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Agarwala A, Satish P, Rifai MA, Mehta A, Cainzos-Achirica M, Shah NS, Kanaya AM, Sharma GV, Dixon DL, Blumenthal RS, Natarajan P, Nasir K, Virani SS, Patel J. Identification and Management of Atherosclerotic Cardiovascular Disease Risk in South Asian Populations in the U.S. JACC. ADVANCES 2023; 2:100258. [PMID: 38089916 PMCID: PMC10715803 DOI: 10.1016/j.jacadv.2023.100258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population.
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Affiliation(s)
- Anandita Agarwala
- Center for Cardiovascular Disease Prevention, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, Texas, USA
| | - Priyanka Satish
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Mahmoud Al Rifai
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
| | - Anurag Mehta
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Miguel Cainzos-Achirica
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
- Institut Hospital del Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
- Hospital del Mar, Parc Salut Mar, Barcelona, Spain
| | - Nilay S. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alka M. Kanaya
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Garima V. Sharma
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
| | - Dave L. Dixon
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
| | - Pradeep Natarajan
- Cardiovascular Disease Initiative Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cardiovascular Research Center Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
- Center for Outcomes Research, Houston Methodist, Houston, Texas, USA
| | - Salim S. Virani
- Aga Khan University, Karachi, Pakistan
- Texas Heart Institute, Baylor College of Medicine, Houston, Texas, USA
| | - Jaideep Patel
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, South Asian Cardiovascular Health Initiative (SACHI), Baltimore, Maryland, USA
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Wong ND, Budoff MJ, Ferdinand K, Graham IM, Michos ED, Reddy T, Shapiro MD, Toth PP. ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK ASSESSMENT: An American Society for Preventive Cardiology Clinical Practice Statement. Am J Prev Cardiol 2022; 10:100335. [PMID: 35342890 PMCID: PMC8943256 DOI: 10.1016/j.ajpc.2022.100335] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/17/2022] [Accepted: 03/05/2022] [Indexed: 01/08/2023] Open
Abstract
Risk for atherosclerotic cardiovascular disease (ASCVD) shows considerable heterogeneity both in generally healthy persons and in those with known ASCVD. The foundation of preventive cardiology begins with assessing baseline ASCVD risk using global risk scores based on standard office-based measures. Persons at low risk are generally recommended for lifestyle management only and those at highest risk are recommended for both lifestyle and pharmacologic therapy. Additional “risk enhancing” factors, including both traditional risk factors and novel biomarkers and inflammatory factors can be used to further assess ASCVD risk, especially in those at borderline or intermediate risk. There are also female-specific risk enhancers, social determinants of health, and considerations for high-risk ethnic groups. Screening for subclinical atherosclerosis, especially with the use of coronary calcium screening, can further inform the treatment decision if uncertain based on the above strategies. Persons with pre-existing ASCVD also have variable risk, affected by the number of major ASCVD events, whether recurrent events have occurred recently, and the presence of other major risk factors or high-risk conditions. Current guidelines define high to very high risk ASCVD accordingly. Accurate ASCVD risk assessment is crucial for the appropriate targeting of preventive therapies to reduce ASCVD risk. Finally, the clinician-patient risk discussion focusing on lifestyle management and the risks and benefits of evidence-based pharmacologic therapies to best lower ASCVD risk is central to this process. This clinical practice statement provides the preventive cardiology specialist with guidance and tools for assessment of ASCVD risk with the goal of appropriately targeting treatment approaches for prevention of ASCVD events.
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Affiliation(s)
- Nathan D. Wong
- Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine, CA, United States
- Corresponding author.
| | - Matthew J. Budoff
- Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Keith Ferdinand
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA United States
| | - Ian M. Graham
- Department of Cardiology, Trinity College, Dublin, Ireland
| | - Erin D. Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Tina Reddy
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA United States
| | | | - Peter P. Toth
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- CGH Medical Center, Sterling, IL, United States
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Kalra D, Vijayaraghavan K, Sikand G, Desai NR, Joshi PH, Mehta A, Karmally W, Vani A, Sitafalwalla SJ, Puri R, Duell PB, Brown A. Prevention of atherosclerotic cardiovascular disease in South Asians in the US: A clinical perspective from the National Lipid Association. J Clin Lipidol 2021; 15:402-422. [PMID: 33846108 DOI: 10.1016/j.jacl.2021.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/20/2021] [Indexed: 12/24/2022]
Abstract
It is now well recognized that South Asians living in the US (SAUS) have a higher prevalence of atherosclerotic cardiovascular disease (ASCVD) that begins earlier and is more aggressive than age-matched people of other ethnicities. SA ancestry is now recognized as a risk enhancer in the US cholesterol treatment guidelines. The pathophysiology of this is not fully understood but may relate to insulin resistance, genetic and dietary factors, lack of physical exercise, visceral adiposity and other, yet undiscovered biologic mechanisms. In this expert consensus document, we review the epidemiology of ASCVD in this population, enumerate the challenges faced in tackling this problem, provide strategies for early screening and education of the community and their healthcare providers, and offer practical prevention strategies and culturally-tailored dietary advice to lower the rates of ASCVD in this cohort.
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Affiliation(s)
- Dinesh Kalra
- Division of Cardiology, Rush University Medical Center, 1620W. Harrison St, Kellogg Suite 320, Chicago, IL 60612, United States.
| | | | - Geeta Sikand
- University of California Irvine School of Medicine, Irvine, CA, United States
| | - Nihar R Desai
- Yale School of Medicine, New Haven, CT, United States
| | - Parag H Joshi
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Anurag Mehta
- Emory University School of Medicine, Atlanta, GA, United States
| | - Wahida Karmally
- Columbia University Irving Medical Center, New York, NY, United States
| | - Anish Vani
- New York University Langone Health, New York, NY, United States
| | | | - Raman Puri
- Lipid Association of India, New Delhi, India
| | - P Barton Duell
- Oregon Health and Science University, Portland, OR, United States
| | - Alan Brown
- Advocate Lutheran General Hospital, Park Ridge, IL, United States
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Bansal M, Ranjan S, Kasliwal RR. Cardiovascular Risk Calculators and their Applicability to South Asians. Curr Diabetes Rev 2021; 17:e100120186497. [PMID: 33023452 DOI: 10.2174/1573399816999201001204020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Estimation of absolute cardiovascular disease (CVD) risk and tailoring therapies according to the estimated risk is a fundamental concept in the primary prevention of CVD is assessed in this study. Numerous CVD risk scores are currently available for use in various populations but unfortunately, none exist for South Asians who have much higher CVD risk as compared to their western counterparts. METHODS A literature search was done using PubMed and Google search engines to prepare a narrative review on this topic. RESULTS Various currently available CVD risk scores and their pros and cons are summarized. The studies performed in native as well as migrant South Asians evaluating the accuracy of these risk scores for estimation of CVD risk are also summarized. The findings of these studies have generally been inconsistent, but it appears that the British risk scores (e.g. QRISK versions) may be more accurate because of inclusion of migrant South Asians in the derivation of these risk scores. However, the lack of any prospective study precludes our ability to draw any firm conclusions. Finally, the potential solution to these challenges, including the role of recalibration and subclinical atherosclerosis imaging, is also discussed. CONCLUSION This review highlights the need to develop large, representative, prospectively followed databases of South Asians providing information on various CVD risk factors and their contribution to incident CVD. Such databases will not only allow the development of validated CVD risk scores for South Asians but will also enable application of machine-learning approaches to provide personalized solutions to CVD risk assessment and management in these populations.
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Affiliation(s)
- Manish Bansal
- Clinical and Preventive Cardiology, Medanta- The Medicity, Gurgaon, Haryana, India
| | - Shraddha Ranjan
- Department of Cardiology, Medanta- The Medicity, Gurgaon, India
| | - Ravi R Kasliwal
- Clinical and Preventive Cardiology, Medanta- The Medicity, Gurgaon, Haryana, India
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Saeed A, Virani SS, Mulukutla S, Chow CK. Dyslipidemia and Cardiovascular Disease Prevention in South Asians: A Review and Discussion of Causes, Challenges and Management Strategies. Curr Diabetes Rev 2021; 17:e011221190238. [PMID: 33438542 DOI: 10.2174/1573399817999210112192419] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/29/2020] [Accepted: 10/03/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND South Asians are at a significantly increased risk of atherosclerotic cardiovascular disease (ASCVD). For a major portion of the South Asian population, the cardiovascular disease events occur at a relatively younger age, are associated with worse outcomes, and have potentially more severe socioeconomic implications compared to their western counterparts. METHODS The term "South Asian" typically constitutes individuals from India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives, including expatriates as well as their families from these countries. Based on this, South Asians form approximately 25% of the world's population, with a high ASCVD burden in this group. In this review, we discuss the pathophysiological factors underlying ASCVD in South Asians, the dyslipidemia types and management, and discuss approaches to improve the overall ASCVD prevention efforts in this large subset population of the world. Although the pathophysiological mechanisms underlying the excess risk of cardiovascular disease in South Asians are multifactorial, dyslipidemia is a primary risk factor for the incidence and prevalence of this disease. The traditional "South Asian" dyslipidemia pattern includes levels of low-density lipoprotein cholesterol (LDL-C) in the normal range with a high concentration of LDL particles, elevated triglycerides, low levels of high-density lipoprotein cholesterol (HDL-C) with dysfunctional HDL particles, and high levels of lipoprotein(a). CONCLUSION While combined efforts to study the expatriate South Asians in western countries have been able to identify South Asian specific dyslipidemias, causal associations and optimal management remain relatively less explored. Larger scale studies are needed to better quantify the relationship of each lipid parameter with ASCVD risk among South Asians as well as optimal lipid targets and management strategies to reduce morbidity and mortality in this high-risk group.
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Affiliation(s)
- Anum Saeed
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Salim S Virani
- Department of Health Policy, Quality and Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Clara K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Department of Cardiology, Westmead Hospital, The George Institute, Sydney, Australia
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Findlay SG, Kasliwal RR, Bansal M, Tarique A, Zaman A. A comparison of cardiovascular risk scores in native and migrant South Asian populations. SSM Popul Health 2020; 11:100594. [PMID: 32613073 PMCID: PMC7322355 DOI: 10.1016/j.ssmph.2020.100594] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 12/14/2022] Open
Abstract
Background South Asians have increased cardiovascular risk burden but little data exists comparing cardiovascular (CV) risk models in migrant and native South Asians. Our retrospective cohort study in patients presenting with first acute myocardial infarction(MI) compares the predictive value of CV risk scores in native and UK migrant South Asians. Methods Retrospective cohort study of 80 UK-based patients of South Asian origin admitted with first presentation MI, excluding patients with known coronary artery disease. A retrospective 10-year CV risk was calculated for each patient using four cardiovascular risk models: Framingham Risk Score(RiskFRS), World Health Organisation(RiskWHO), American College of Cardiology/American Heart Association(ACC/AHA) (RiskACC/AHA), and 3rdJoint British Societies'(RiskJBS). Our aim was to assess agreement between these risk scores and conduct comparative analysis with native South Asians. Results RiskJBS identified the largest proportion of migrant South Asians as ‘high risk’ with 65% of subjects having an estimated >20% 10-year CV risk. RiskWHO provided the lowest 10-year CV risk estimates for South Asian migrants, identifying 21.25% of the migrant cohort as >20% risk of major CV event. Comparative analysis with the native South Asian cohort demonstrated RiskJBS as the risk model most likely to identify patients as ‘high'(>20%) risk(55.9%; p = 0.224). Conclusions This study represents the first analysis of predictive cardiovascular risk scores comparing migrant and native South Asian populations. Significant variation between the CV risk scores were observed, leading to inaccuracies in patient cardiovascular risk estimation. Given the growing burden of cardiovascular disease in Asian countries and different population characteristics, we highlight the need for population specific CV disease risk models whilst providing stimulus for further large-scale prospective studies. South Asians are at increased risk of premature CV disease compared to the global population. Accurate assessment of CVD risk helps to target risk reduction strategies. We evaluated the agreement between four CV risk scores, by retrospective analysis of data post MI within South Asian populations. We demonstrate that accurately predicting CV risk in South Asian populations remains challenging with marked variations between CV risk prediction models. Our study supports the case for using South Asian specific CV risk scores.
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Affiliation(s)
| | - Ravi R Kasliwal
- Clinical and Preventive Cardiology - Medanta - the Medicity, Sector 38, Gurgaon, 122001, Haryana, India
| | - Manish Bansal
- Medanta - the Medicity, Sector 38, Gurgaon, 122001, Haryana, India
| | - Ahmar Tarique
- Medanta - the Medicity, Sector 38, Gurgaon, 122001, Haryana, India
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Cainzos-Achirica M, Fedeli U, Sattar N, Agyemang C, Jenum AK, McEvoy JW, Murphy JD, Brotons C, Elosua R, Bilal U, Kanaya AM, Kandula NR, Martinez-Amezcua P, Comin-Colet J, Pinto X. Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe. Atherosclerosis 2019; 286:105-113. [PMID: 31128454 DOI: 10.1016/j.atherosclerosis.2019.05.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 01/22/2023]
Abstract
South Asian (SA) individuals represent a large, growing population in a number of European countries. These individuals, particularly first-generation SA immigrants, are at higher risk of developing type 2 diabetes, atherogenic dyslipidaemia, and coronary heart disease than most other racial/ethnic groups living in Europe. SAs also have an increased risk of stroke compared to European-born individuals. Despite a large body of conclusive evidence, SA-specific cardiovascular health promotion and preventive interventions are currently scarce in most European countries, as well as at the European Union level. In this narrative review, we aim to increase awareness among clinicians and healthcare authorities of the public health importance of cardiovascular disease among SAs living in Europe, as well as the need for tailored interventions targeting this group - particularly, in countries where SA immigration is a recent phenomenon. To this purpose, we review key studies on the epidemiology and risk factors of cardiovascular disease in SAs living in the United Kingdom, Italy, Spain, Denmark, Norway, Sweden, and other European countries. Building on these, we discuss potential opportunities for multi-level, targeted, tailored cardiovascular prevention strategies. Because lifestyle interventions often face important cultural barriers in SAs, particularly for first-generation immigrants; we also discuss features that may help maximise the effectiveness of those interventions. Finally, we evaluate knowledge gaps, currently available risk stratification tools such as QRISK-3, and future directions in this important field.
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Affiliation(s)
- Miguel Cainzos-Achirica
- Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Baltimore, MD, USA; School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat Del Vallès, Barcelona, Spain.
| | - Ugo Fedeli
- Department of Epidemiology, Azienda Zero, Veneto Region, Italy
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Charles Agyemang
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anne K Jenum
- General Practice Research Unit (AFE), Department of General Practice, University of Oslo, Institute of Health and Society, Norway
| | - John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Baltimore, MD, USA; National University of Ireland and National Institute for Preventive Cardiology, Galway, Ireland; Division of Cardiology, Department of Medicine, Saolta University Healthcare Group, University College Hospital Galway, Galway, Ireland
| | - Jack D Murphy
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carlos Brotons
- Casernes Primary Care Center, Àmbit D'Atenció Primària Barcelona Ciutat, Barcelona, Spain
| | - Roberto Elosua
- Cardiovascular Epidemiology and Genetics, Mar Institute of Medical Research, Barcelona, Spain; Biomedical Research Network in Cardiovascular Diseases (CIBERCV), Barcelona, Spain; School of Medicine, Universitat de Vic-Central de Catalunya, Vic, Spain
| | - Usama Bilal
- Urban Health Collaborative, Drexel Dornsife School of Public Health, Philadelphia, PA, USA
| | | | - Namratha R Kandula
- Northwestern University, Departments of Medicine and Preventive Medicine, Chicago, IL, USA
| | - Pablo Martinez-Amezcua
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Josep Comin-Colet
- Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; School of Medicine, University of Barcelona, Barcelona, Spain
| | - Xavier Pinto
- School of Medicine, University of Barcelona, Barcelona, Spain; Cardiovascular Risk Unit, Department of Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain; Biomedical Research Network in Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
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Osborn D, Burton A, Walters K, Atkins L, Barnes T, Blackburn R, Craig T, Gilbert H, Gray B, Hardoon S, Heinkel S, Holt R, Hunter R, Johnston C, King M, Leibowitz J, Marston L, Michie S, Morris R, Morris S, Nazareth I, Omar R, Petersen I, Peveler R, Pinfold V, Stevenson F, Zomer E. Primary care management of cardiovascular risk for people with severe mental illnesses: the Primrose research programme including cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2019. [DOI: 10.3310/pgfar07020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Effective interventions are needed to prevent cardiovascular disease (CVD) in people with severe mental illnesses (SMI) because their risk of CVD is higher than that of the general population.
Objectives
(1) Develop and validate risk models for predicting CVD events in people with SMI and evaluate their cost-effectiveness, (2) develop an intervention to reduce levels of cholesterol and CVD risk in SMI and (3) test the clinical effectiveness and cost-effectiveness of this new intervention in primary care.
Design
Mixed methods with patient and public involvement throughout. The mixed methods were (1) a prospective cohort and risk score validation study and cost-effectiveness modelling, (2) development work (focus groups, updated systematic review of interventions, primary care database studies investigating statin prescribing and effectiveness) and (3) cluster randomised controlled trial (RCT) assessing the clinical effectiveness and cost-effectiveness of a new practitioner-led intervention, and fidelity assessment of audio-recorded appointments.
Setting
General practices across England.
Participants
All studies included adults with SMI (schizophrenia, bipolar disorder or other non-organic psychosis). The RCT included adults with SMI and two or more CVD risk factors.
Interventions
The intervention consisted of 8–12 appointments with a practice nurse/health-care assistant over 6 months, involving collaborative behavioural approaches to CVD risk factors. The intervention was compared with routine practice with a general practitioner (GP).
Main outcome measures
The primary outcome for the risk score work was CVD events, in the cost-effectiveness modelling it was quality-adjusted life-years (QALYs) and in the RCT it was level of total cholesterol.
Data sources
Databases studies used The Health Improvement Network (THIN). Intervention development work included focus groups and systematic reviews. The RCT collected patient self-reported and routine NHS GP data. Intervention appointments were audio-recorded.
Results
Two CVD risk score models were developed and validated in 38,824 people with SMI in THIN: the Primrose lipid model requiring cholesterol levels, and the Primrose body mass index (BMI) model with no blood test. These models performed better than published Cox Framingham models. In health economic modelling, the Primrose BMI model was most cost-effective when used as an algorithm to drive statin prescriptions. Focus groups identified barriers to, and facilitators of, reducing CVD risk in SMI including patient engagement and motivation, staff confidence, involving supportive others, goal-setting and continuity of care. Findings were synthesised with evidence from updated systematic reviews to create the Primrose intervention and training programme. THIN cohort studies in 16,854 people with SMI demonstrated that statins effectively reduced levels of cholesterol, with similar effect sizes to those in general population studies over 12–24 months (mean decrease 1.2 mmol/l). Cluster RCT: 76 GP practices were randomised to the Primrose intervention (n = 38) or treatment as usual (TAU) (n = 38). The primary outcome (level of cholesterol) was analysed for 137 out of 155 participants in Primrose and 152 out of 172 in TAU. There was no difference in levels of cholesterol at 12 months [5.4 mmol/l Primrose vs. 5.5 mmol/l TAU; coefficient 0.03; 95% confidence interval (CI) –0.22 to 0.29], nor in secondary outcomes related to cardiometabolic parameters, well-being or medication adherence. Mean cholesterol levels decreased over 12 months in both arms (–0.22 mmol/l Primrose vs. –0.39 mmol/l TAU). There was a significant reduction in the cost of inpatient mental health attendances (–£799, 95% CI –£1480 to –£117) and total health-care costs (–£895, 95% CI –£1631 to –£160; p = 0.012) in the intervention group, but no significant difference in QALYs (–0.011, 95% CI –0.034 to 0.011). A total of 69% of patients attended two or more Primrose appointments. Audiotapes revealed moderate fidelity to intervention delivery (67.7%). Statin prescribing and adherence was rarely addressed.
Limitations
RCT participants and practices may not represent all UK practices. CVD care in the TAU arm may have been enhanced by trial procedures involving CVD risk screening and feedback.
Conclusions
SMI-specific CVD risk scores better predict new CVD if used to guide statin prescribing in SMI. Statins are effective in reducing levels of cholesterol in people with SMI in UK clinical practice. This primary care RCT evaluated an evidence-based practitioner-led intervention that was well attended by patients and intervention components were delivered. No superiority was shown for the new intervention over TAU for level of cholesterol, but cholesterol levels decreased over 12 months in both arms and the intervention showed fewer inpatient admissions. There was no difference in cholesterol levels between the intervention and TAU arms, which might reflect better than standard general practice care in TAU, heterogeneity in intervention delivery or suboptimal emphasis on statins.
Future work
The new risk score should be updated, deployed and tested in different settings and compared with the latest versions of CVD risk scores in different countries. Future research on CVD risk interventions should emphasise statin prescriptions more. The mechanism behind lower costs with the Primrose intervention needs exploring, including SMI-related training and offering frequent support to people with SMI in primary care.
Trial registration
Current Controlled Trials ISRCTN13762819.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 2. See the NIHR Journals Library website for further project information. Professor David Osborn is supported by the University College London Hospital NIHR Biomedical Research Centre and he was also in part supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust.
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Affiliation(s)
- David Osborn
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Alexandra Burton
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Kate Walters
- Department of Primary Care and Population Health, University College London, London, UK
| | - Lou Atkins
- Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, Faculty of Brain Sciences, University College London, London, UK
| | - Thomas Barnes
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Ruth Blackburn
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Thomas Craig
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Hazel Gilbert
- Department of Primary Care and Population Health, University College London, London, UK
| | - Ben Gray
- The McPin Foundation, London, UK
| | - Sarah Hardoon
- Department of Primary Care and Population Health, University College London, London, UK
| | - Samira Heinkel
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Richard Holt
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rachael Hunter
- Department of Primary Care and Population Health, University College London, London, UK
| | - Claire Johnston
- School of Health and Education, Faculty of Professional and Social Sciences, Middlesex University, London, UK
| | - Michael King
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Judy Leibowitz
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK
| | - Susan Michie
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
- Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, Faculty of Brain Sciences, University College London, London, UK
| | - Richard Morris
- Department of Primary Care and Population Health, University College London, London, UK
| | - Steve Morris
- Department of Allied Health Research, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, University College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
| | - Robert Peveler
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Fiona Stevenson
- Department of Primary Care and Population Health, University College London, London, UK
| | - Ella Zomer
- Department of Primary Care and Population Health, University College London, London, UK
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9
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Pai S, Bader GD. Patient Similarity Networks for Precision Medicine. J Mol Biol 2018; 430:2924-2938. [PMID: 29860027 PMCID: PMC6097926 DOI: 10.1016/j.jmb.2018.05.037] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 02/08/2023]
Abstract
Clinical research and practice in the 21st century is poised to be transformed by analysis of computable electronic medical records and population-level genome-scale patient profiles. Genomic data capture genetic and environmental state, providing information on heterogeneity in disease and treatment outcome, but genomic-based clinical risk scores are limited. Achieving the goal of routine precision medicine that takes advantage of these rich genomics data will require computational methods that support heterogeneous data, have excellent predictive performance, and ideally, provide biologically interpretable results. Traditional machine-learning approaches excel at performance, but often have limited interpretability. Patient similarity networks are an emerging paradigm for precision medicine, in which patients are clustered or classified based on their similarities in various features, including genomic profiles. This strategy is analogous to standard medical diagnosis, has excellent performance, is interpretable, and can preserve patient privacy. We review new methods based on patient similarity networks, including Similarity Network Fusion for patient clustering and netDx for patient classification. While these methods are already useful, much work is required to improve their scalability for contemporary genetic cohorts, optimize parameters, and incorporate a wide range of genomics and clinical data. The coming 5 years will provide an opportunity to assess the utility of network-based algorithms for precision medicine.
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Affiliation(s)
- Shraddha Pai
- The Donnelly Centre, University of Toronto, Toronto, Canada
| | - Gary D Bader
- The Donnelly Centre, University of Toronto, Toronto, Canada; Department of Molecular Genetics, University of Toronto, Toronto, Canada; Department of Computer Science, University of Toronto, Toronto, Canada; The Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.
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10
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Battu HS, Bhopal R, Agyemang C. Heterogeneity in blood pressure in UK Bangladeshi, Indian and Pakistani, compared to White, populations: divergence of adults and children. J Hum Hypertens 2018; 32:725-744. [PMID: 30181657 DOI: 10.1038/s41371-018-0095-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/27/2018] [Indexed: 12/21/2022]
Abstract
Blood pressure (BP) and hypertension prevalence differences between UK South Asians (Bangladeshis, Indians and Pakistanis) and White Europeans exist in childhood and adulthood. This meta-analysis sought to quantify these differences. We searched MEDLINE (1946-2017), EMBASE (1974-2017) and GLOBAL HEALTH (1973-2017) for comparative studies and pooled the data with Revman (Cochrane Collaboration). Twenty-two studies were included-fourteen on adults and eight on children. South Asian adults had lower systolic and slightly lower diastolic BP. However, stark heterogeneity existed between South Asian subgroups: Bangladeshis had markedly lower systolic BP (mean difference: -11.7 mmHg in men and women), Indians slightly lower (-2.0 mmHg in men and -4.5 mmHg in women) and Pakistanis intermediately lower (-7.9 mmHg in men and -8.6 mmHg in women), compared to White Europeans. However, South Asian children did not have lower systolic or diastolic BP compared to White children, and their BP was often higher. This intergenerational change in BP difference mirrored the change in body mass index difference, particularly in Bangladeshis. We conclude that ethnicity-related BP differences are heterogeneous and dependent on age, sex and South Asian subgroup. South Asian children do not have lower BP than White Europeans in contrast to their adult counterparts. There is concern that this pattern may continue into adulthood, worsening the already high cardiovascular disease burden in South Asians in future years. Further research is needed to ascertain the causes of this evolving issue.
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Affiliation(s)
- Hartesh S Battu
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.
| | - Raj Bhopal
- Public Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Charles Agyemang
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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11
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Zomer E, Osborn D, Nazareth I, Blackburn R, Burton A, Hardoon S, Holt RIG, King M, Marston L, Morris S, Omar R, Petersen I, Walters K, Hunter RM. Effectiveness and cost-effectiveness of a cardiovascular risk prediction algorithm for people with severe mental illness (PRIMROSE). BMJ Open 2017; 7:e018181. [PMID: 28877952 PMCID: PMC5588956 DOI: 10.1136/bmjopen-2017-018181] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To determine the cost-effectiveness of two bespoke severe mental illness (SMI)-specific risk algorithms compared with standard risk algorithms for primary cardiovascular disease (CVD) prevention in those with SMI. SETTING Primary care setting in the UK. The analysis was from the National Health Service perspective. PARTICIPANTS 1000 individuals with SMI from The Health Improvement Network Database, aged 30-74 years and without existing CVD, populated the model. INTERVENTIONS Four cardiovascular risk algorithms were assessed: (1) general population lipid, (2) general population body mass index (BMI), (3) SMI-specific lipid and (4) SMI-specific BMI, compared against no algorithm. At baseline, each cardiovascular risk algorithm was applied and those considered high risk (> 10%) were assumed to be prescribed statin therapy while others received usual care. PRIMARY AND SECONDARY OUTCOME MEASURES Quality-adjusted life years (QALYs) and costs were accrued for each algorithm including no algorithm, and cost-effectiveness was calculated using the net monetary benefit (NMB) approach. Deterministic and probabilistic sensitivity analyses were performed to test assumptions made and uncertainty around parameter estimates. RESULTS The SMI-specific BMI algorithm had the highest NMB resulting in 15 additional QALYs and a cost saving of approximately £53 000 per 1000 patients with SMI over 10 years, followed by the general population lipid algorithm (13 additional QALYs and a cost saving of £46 000). CONCLUSIONS The general population lipid and SMI-specific BMI algorithms performed equally well. The ease and acceptability of use of an SMI-specific BMI algorithm (blood tests not required) makes it an attractive algorithm to implement in clinical settings.
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Affiliation(s)
- Ella Zomer
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, UK
| | - David Osborn
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
- Camden and Islington National Health Service Foundation Trust, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Ruth Blackburn
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Alexandra Burton
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Sarah Hardoon
- Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Richard Ian Gregory Holt
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael King
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, Faculty of Population Health Sciences, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, Faculty of Mathematical and Physical Sciences, University College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Kate Walters
- Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Rachael Maree Hunter
- Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, UK
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12
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Perini W, Agyemang C, Snijder MB, Peters RJG, Kunst AE. Ethnic disparities in educational and occupational gradients of estimated cardiovascular disease risk: The Healthy Life in an Urban Setting study. Scand J Public Health 2017; 46:204-213. [PMID: 28699411 PMCID: PMC5871022 DOI: 10.1177/1403494817718906] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND European societies are becoming increasingly ethnically diverse. This may have important implications for socio-economic inequalities in health due to the often disadvantaged position of ethnic minority groups in both socio-economic status (SES) and disease, especially cardiovascular disease (CVD). OBJECTIVE The aim of this study was to determine whether the socio-economic gradient of estimated CVD risk differs between ethnic groups. METHODS Using the Healthy Life in an Urban Setting study, we obtained data on SES and CVD risk factors among participants from six ethnic backgrounds residing in Amsterdam. SES was measured using educational level and occupational level. CVD risk was estimated based on the occurrence of CVD risk factors using the Dutch version of the systematic coronary risk evaluation algorithm. Ethnic disparities in socio-economic gradients for estimated CVD risk were determined using the relative index of inequality (RII). RESULTS Among Dutch-origin men, the RII for estimated CVD risk according to educational level was 6.15% (95% confidence interval [CI] 4.35-7.96%), indicating that those at the bottom of the educational hierarchy had a 6.15% higher estimated CVD risk relative than those at the top. Among Dutch-origin women, the RII was 4.49% (CI 2.45-6.52%). The RII was lower among ethnic minority groups, ranging from 0.83% to 3.13% among men and -0.29% to 5.12% among women, indicating weaker associations among these groups. Results were similar based on occupational level. CONCLUSIONS Ethnic background needs to be considered in associations between SES and disease. The predictive value of SES varies between ethnic groups and may be quite poor for some groups.
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Affiliation(s)
- Wilco Perini
- 1 Department of Public Health, Academic Medical Center of the University of Amsterdam, The Netherlands.,2 Department of Cardiology, Academic Medical Center of the University of Amsterdam, The Netherlands
| | - Charles Agyemang
- 1 Department of Public Health, Academic Medical Center of the University of Amsterdam, The Netherlands
| | - Marieke B Snijder
- 1 Department of Public Health, Academic Medical Center of the University of Amsterdam, The Netherlands.,3 Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center of the University of Amsterdam, The Netherlands
| | - Ron J G Peters
- 2 Department of Cardiology, Academic Medical Center of the University of Amsterdam, The Netherlands
| | - Anton E Kunst
- 1 Department of Public Health, Academic Medical Center of the University of Amsterdam, The Netherlands
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13
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Dunkley AJ, Tyrer F, Gray LJ, Bhaumik S, Spong R, Chudasama Y, Cooper SA, Ganghadaran S, Davies M, Khunti K. Type 2 diabetes and glucose intolerance in a population with intellectual disabilities: the STOP diabetes cross-sectional screening study. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2017; 61:668-681. [PMID: 28544066 DOI: 10.1111/jir.12380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 01/31/2017] [Accepted: 03/15/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Adults with intellectual disabilities (ID) may be at increased risk of developing type 2 diabetes and cardiovascular disease, due to lifestyle factors, medications and other diagnosed conditions. Currently, there is lack of evidence on prevalence and prevention in this population. The aim of this study was to conduct a diabetes screening programme to determine prevalence of previously undiagnosed type 2 diabetes and impaired glucose regulation in people with ID. METHODS Screening was conducted in a variety of community settings in Leicestershire, UK. Adults with ID were invited via: general practices; the Leicestershire Learning Disability Register; ID psychiatric services; and some people directly contacted the research team due to publicity about the study. Screening involved collection of anthropometric, biomedical and questionnaire data. Type 2 diabetes and impaired glucose regulation were defined according to (venous) fasting plasma glucose or HbA1c, following current World Health Organisation criteria. RESULTS Nine hundred thirty adults (29% of those approached) participated. Mean age was 43 years, 58% were male and 16% of South Asian ethnicity. Most participants were either overweight or obese (68%). Diabetes status was successfully assessed for 675 (73%) participants: Nine (1.3%, 95% confidence interval 0.6 to 2.5) were found to have undiagnosed type 2 diabetes, and 35 (5.2%, 95% confidence interval 3.6 to 7.1) had impaired glucose regulation. Key factors associated with abnormal glucose regulation included the following: non-white ethnicity and a first degree family history of diabetes. CONCLUSIONS Results from this large multi-ethnic cohort suggest a low prevalence of screen-detected (previously undiagnosed) type 2 diabetes and impaired glucose regulation in adults with ID. However, the high levels of overweight and obesity we found emphasise the need for targeted lifestyle prevention strategies, which are specifically tailored for the needs of people with ID.
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Affiliation(s)
- A J Dunkley
- Diabetes Research Centre, University of Leicester, Leicester Diabetes Centre, Leicester General Hospital, Leicester, LE5 4PW, UK
| | - F Tyrer
- Department of Health Sciences, University of Leicester, Centre for Medicine, University Road, Leicester, LE1 7RH, UK
| | - L J Gray
- Department of Health Sciences, University of Leicester, Centre for Medicine, University Road, Leicester, LE1 7RH, UK
| | - S Bhaumik
- Learning Disabilities Service, Leicestershire Partnership NHS Trust, Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester, LE4 8PQ, UK
| | - R Spong
- Diabetes Research Centre, University of Leicester, Leicester Diabetes Centre, Leicester General Hospital, Leicester, LE5 4PW, UK
| | - Y Chudasama
- Diabetes Research Centre, University of Leicester, Leicester Diabetes Centre, Leicester General Hospital, Leicester, LE5 4PW, UK
| | - S-A Cooper
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XH, UK
| | - S Ganghadaran
- Learning Disabilities Service, Leicestershire Partnership NHS Trust, Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester, LE4 8PQ, UK
| | - M Davies
- Diabetes Research Centre, University of Leicester, Leicester Diabetes Centre, Leicester General Hospital, Leicester, LE5 4PW, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester Diabetes Centre, Leicester General Hospital, Leicester, LE5 4PW, UK
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14
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Dunkley AJ, Tyrer F, Spong R, Gray LJ, Gillett M, Doherty Y, Martin-Stacey L, Patel N, Yates T, Bhaumik S, Chalk T, Chudasama Y, Thomas C, Sadler S, Cooper SA, Gangadharan SK, Davies MJ, Khunti K. Screening for glucose intolerance and development of a lifestyle education programme for prevention of type 2 diabetes in a population with intellectual disabilities: the STOP Diabetes research project. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BackgroundThe prevalence of type 2 diabetes mellitus (T2DM) and of cardiovascular disease (CVD) is believed to be higher among people with intellectual disability (ID) than in the general population. However, research on prevalence and prevention in this population is limited.ObjectivesThe objectives of this programme of work were to establish a programme of research that would significantly enhance the knowledge and understanding of impaired glucose regulation (IGR) and T2DM in people with ID; to test strategies for the early identification of IGR and T2DM in people with ID; and to develop a lifestyle education programme and educator training protocol to promote behaviour change in a population with ID and IGR (or at a high risk of T2DM/CVD).SettingLeicestershire, UK.ParticipantsAdults with ID were recruited from community settings, including residential homes and family homes. Adults with mild to moderate ID who had an elevated body mass index (BMI) of ≥ 25 kg/m2and/or IGR were invited to take part in the education programme.Main outcome measuresThe primary outcome of the screening programme was the prevalence of screen-detected T2DM and IGR. The uptake, feasibility and acceptability of the intervention were assessed.Data sourcesParticipants were recruited from general practices, specialist ID services and clinics, and through direct contact.ResultsA total of 930 people with ID were recruited to the screening programme: 58% were male, 80% were white and 68% were overweight or obese. The mean age of participants was 43.3 years (standard deviation 14.2 years). Bloods were obtained for 675 participants (73%). The prevalence of previously undiagnosed T2DM was 1.3% [95% confidence interval (CI) 0.5% to 2%] and of IGR was 5% (95% CI 4% to 7%). Abnormal IGR was more common in those of non-white ethnicity; those with a first-degree family history of diabetes; those with increasing weight, waist circumference, BMI, diastolic blood pressure or triglycerides; and those with lower high-density lipoprotein cholesterol. We developed a lifestyle educational programme for people with ID, informed by findings from qualitative stakeholder interviews (health-care professionals,n = 14; people with ID,n = 7) and evidence reviews. Subsequently, 11 people with ID (and carers) participated in pilot education sessions (two groups) and five people attended education for the feasibility stage (one group). We found that it was feasible to collect primary outcome measures on physical activity and sedentary behaviour using wrist-worn accelerometers. We found that the programme was relatively costly, meaning that large changes in activity or diet (or a reduction in programme costs) would be necessary for the programme to be cost-effective. We also developed a quality development process for assessing intervention fidelity.LimitationsWe were able to screen only around 30% of the population and involved only a small number in the piloting and feasibility work.ConclusionsThe results from this programme of work have significantly enhanced the existing knowledge and understanding of T2DM and IGR in people with ID. We have developed a lifestyle education programme and educator training protocol to promote behaviour change in this population.Future workFurther work is needed to evaluate the STOP Diabetes intervention to identify cost-effective strategies for its implementation.Trial registrationClinicalTrials.gov NCT02513277.FundingThe National Institute for Health Research Programme Grants for Applied Research programme and will be published in full inHealth Research Programme Grants for Applied Research; Vol. 5, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alison J Dunkley
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Freya Tyrer
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Rebecca Spong
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mike Gillett
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | - Yvonne Doherty
- Leicester Diabetes Centre, University Hospitals of Leicester, Leicester, UK
| | | | - Naina Patel
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Thomas Yates
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Sabyasachi Bhaumik
- Learning Disabilities Service, Leicestershire Partnership NHS Trust, Leicester, UK
| | - Thomas Chalk
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Yogini Chudasama
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Chloe Thomas
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | - Susannah Sadler
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | - Sally-Ann Cooper
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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15
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Ambiguities in the Guidelines for the Management of Arterial Hypertension: Indian Perspective with a Call for Global Harmonization. Curr Hypertens Rep 2017; 19:17. [DOI: 10.1007/s11906-017-0715-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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16
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Benderly M, Chetrit A, Murad H, Abu-Saad K, Gillon-Keren M, Rogowski O, Sela BA, Kanety H, Harats D, Atamna A, Alpert G, Goldbourt U, Kalter-Leibovici O. Cardiovascular health among two ethnic groups living in the same region: A population-based study. Int J Cardiol 2016; 228:23-30. [PMID: 27863357 DOI: 10.1016/j.ijcard.2016.11.079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/05/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Poor cardiovascular health (CVH) among ethnic/racial minorities, studied primarily in the USA, may reflect lower access to healthcare. We examined factors associated with minority CVH in a setting of universal access to healthcare. METHODS AND RESULTS CVH behaviors and factors were evaluated in a random population sample (551 Arabs, 553 Jews) stratified by sex, ethnicity and age. More Jews (10%) than Arabs (3%) had 3 ideal health behaviors. Only one participant had all four. Although ideal diet was rare (≤1.5%) across groups, Arabs were more likely to meet intake recommendations for whole grains, but less likely to meet intake recommendations for fruits/vegetables and fish. Arabs had lower odds of attaining ideal levels for body mass index and physical activity. Smoking prevalence was 57% among Arab men and 6% among Arab women. Having four ideal health factors (cholesterol, blood pressure, glucose, smoking) was observed in 2% and 8% of Arab and Jewish men, respectively, and 13% of Arab and Jewish women. Higher prevalence of ideal total-cholesterol corresponded to lower high-density lipoprotein cholesterol among Arabs. No participant met ideal levels for all 7 metrics and only 1.8% presented with 6. Accounting for age and lower socioeconomic status, Arabs were less likely to meet a greater number of metric goals (odds ratio (95% confidence interval): 0.62 (0.42-0.92) for men, and 0.73 (0.48-1.12) for women). CONCLUSIONS Ideal CVH, rare altogether, was less prevalent among the Arab minority albeit universal access to healthcare. Health behaviors were the main contributors to the CVH disparity.
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Affiliation(s)
- Michal Benderly
- Cardiovascular Epidemiology Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Angela Chetrit
- Cardiovascular Epidemiology Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel
| | - Havi Murad
- Biostatistics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel
| | - Kathleen Abu-Saad
- Cardiovascular Epidemiology Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel
| | - Michal Gillon-Keren
- Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Ori Rogowski
- Internal Medicine, Soraski Medical Center, Tel Aviv, Israel
| | - Ben-Ami Sela
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Chemical Pathology, Sheba Medical Center, Ramat-Gan, Israel
| | - Hannah Kanety
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Endocrinology, Sheba Medical Center, Ramat-Gan, Israel
| | - Dror Harats
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Bert W. Strassburger Lipid Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Ahmed Atamna
- Clalit Health Services, Shomron Administration, Hadera, Israel
| | - Gershon Alpert
- Clalit Health Services, Shomron Administration, Hadera, Israel
| | - Uri Goldbourt
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofra Kalter-Leibovici
- Cardiovascular Epidemiology Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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17
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Brewster LM, van Montfrans GA, Oehlers GP, Seedat YK. Systematic review: antihypertensive drug therapy in patients of African and South Asian ethnicity. Intern Emerg Med 2016; 11:355-74. [PMID: 27026378 PMCID: PMC4820501 DOI: 10.1007/s11739-016-1422-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/22/2016] [Indexed: 02/06/2023]
Abstract
Despite the large differences in the epidemiology of hypertension across Europe, treatment strategies are similar for national populations of white European descent. However, hypertensive patients of African or South Asian ethnicity may require ethnic-specific approaches, as these population subgroups tend to have higher blood pressure at an earlier age that is more difficult to control, a higher occurrence of diabetes, and more target organ damage with earlier cardiovascular mortality. Therefore, we systematically reviewed the evidence on antihypertensive drug treatment in South Asian and African ethnicity patients. We used the Cochrane systematic review methodology to retrieve trials in electronic databases including CENTRAL, PubMed, and Embase from their inception through November 2015; and with handsearch. We retrieved 4596 reports that yielded 35 trials with 7 classes of antihypertensive drugs in 25,540 African ethnicity patients. Aside from the well-known blood pressure efficacy of calcium channel blockers and diuretics, with lesser effect of ACE inhibitors and beta-blockers, nebivolol was not more effective than placebo in reducing systolic blood pressure levels. Trials with morbidity and mortality outcomes indicated that lisinopril and losartan-based therapy were associated with a greater incidence of stroke and sudden death. Furthermore, 1581 reports yielded 16 randomized controlled trials with blood pressure outcomes in 1719 South Asian hypertensive patients. In contrast with the studies in African ethnicity patients, there were no significant differences in blood pressure lowering efficacy between drugs, and no trials available with mortality outcomes. In conclusion, in patients of African ethnicity, treatment initiated with ACE inhibitor or angiotensin II receptor blocker monotherapy was associated with adverse cardiovascular outcomes. We found no evidence of different efficacy of antihypertensive drugs in South Asians, but there is a need for trials with morbidity and mortality outcomes. Screening for cardiovascular risk at a younger age, treating hypertension at lower thresholds, and new delivery models to find, treat and follow hypertensives in the community may help reduce the excess cardiovascular mortality in these high-risk groups.
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Affiliation(s)
- Lizzy M Brewster
- Department of Vascular Medicine, F4-222, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Gert A van Montfrans
- Department of Vascular Medicine, F4-222, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Glenn P Oehlers
- Department of Cardiology, Academic Hospital of Paramaribo, Paramaribo, Suriname
| | - Yackoob K Seedat
- Nelson R Mandela School of Medicine, Faculty of Health Sciences, University of KwaZulu Natal, Private Bag. 7, Congella, 4013, Durban, South Africa
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18
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Cardiovascular risk models for South Asian populations: a systematic review. Int J Public Health 2015; 61:525-34. [PMID: 26361963 DOI: 10.1007/s00038-015-0733-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 08/18/2015] [Accepted: 08/20/2015] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To review existing cardiovascular risk models applicable to South Asian populations. METHODS A systematic review of the literature using a combination of search terms for "South Asian", "cardiovascular", "risk"/"score" and existing risk models for inclusion. South Asian was defined as those residing in or with ancestry belonging to the Indian subcontinent. RESULTS The literature search including MEDLINE and EMBASE identified 7560 papers. After full-text review, 4 papers met the inclusion criteria. Only 1 reported formal measures of model performance. In that study, both a modified Framingham model and QRISK2 showed similar good discrimination with AUROCs of 0.73-0.77 with calibration also reasonable in men (0.71-0.93) but poor in women (0.43-0.52). CONCLUSIONS Considering the number of South Asians and prevalence of cardiovascular disease, very few studies have reported performance of risk scores in South Asian populations. Furthermore, it was difficult to make comparisons, as many did not provide measures of discrimination, accuracy and calibration. There is a need for further research to evaluate risk models in South Asians, and ideally derive and validate cardiovascular risk models within South Asian populations.
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Francis DK, Bennett NR, Ferguson TS, Hennis AJM, Wilks RJ, Harris EN, MacLeish MMY, Sullivan LW. Disparities in cardiovascular disease among Caribbean populations: a systematic literature review. BMC Public Health 2015; 15:828. [PMID: 26310793 PMCID: PMC4551768 DOI: 10.1186/s12889-015-2166-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 08/18/2015] [Indexed: 11/24/2022] Open
Abstract
Background Cardiovascular diseases (CVD) are the predominant cause of death globally. The large health disparities in the distribution of the burden of disease seen in developed and developing countries are of growing concern. Central to this concern is the poor outcome which is seen disproportionately in socially disadvantaged groups and racial/ethnic minorities. The aim of the study was to conduct a systematic literature review to investigate the nature of cardiovascular disease health disparities among Afro-Caribbean origin populations and identify current knowledge gaps. Methods A systematic literature review including a detailed search strategy was developed to search MEDLINE and other research databases. Using an a priori protocol peer-reviewed publications and grey literature articles were retrieved and screened and relevant data extracted by two independent review authors. Thematic analysis was done according to CVD outcomes and measures of disparity including age, sex, ethnicity and socioeconomic status. Results The search retrieved 665 articles of which 22 met the inclusion criteria. Most studies were conducted in the United Kingdom and centered on the prevalence of CVD by ethnicity, age and sex. An important sub-theme identified was the disparities in health service utilization/hospital admission. Coronary Heart Disease (CHD) and Peripheral Arterial Disease (PAD) were less prevalent among Afro-Caribbeans compared to Caucasian and South East Asian ethnic groups. The prevalence of CHD ranged from 0–7 % in Afro-Caribbean to 2–22 % in Caucasians. Strokes were more common among Afro-Caribbeans. There are inadequate data on morbidity and mortality from CVD, particularly across the socio-economic gradient, in Afro-Caribbean populations. Conclusions There are important differences in morbidity and mortality from CVD across ethnic groups. Important knowledge gaps remain in understanding the social determinants of these disparities in CVD. More research exploring these gaps by varying disparity indicators needs to be undertaken. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-2166-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Damian K Francis
- Epidemiology Research Unit, Tropical Medicine Research Institute, The University of the West Indies, Kingston, West Indies, Jamaica.
| | - Nadia R Bennett
- Epidemiology Research Unit, Tropical Medicine Research Institute, The University of the West Indies, Kingston, West Indies, Jamaica.
| | - Trevor S Ferguson
- Epidemiology Research Unit, Tropical Medicine Research Institute, The University of the West Indies, Kingston, West Indies, Jamaica.
| | - Anselm J M Hennis
- Chronic Disease Research Centre, Tropical Medicine Research Institute, The University of the West Indies, Bridgetown, West Indies, Barbados.
| | - Rainford J Wilks
- Epidemiology Research Unit, Tropical Medicine Research Institute, The University of the West Indies, Kingston, West Indies, Jamaica.
| | - E Nigel Harris
- The University of the West Indies, Kingston, West Indies, Jamaica.
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Bansal D, Nayakallu RSR, Gudala K, Vyamasuni R, Bhansali A. Agreement between Framingham Risk Score and United Kingdom Prospective Diabetes Study Risk Engine in Identifying High Coronary Heart Disease Risk in North Indian Population. Diabetes Metab J 2015; 39:321-7. [PMID: 26301194 PMCID: PMC4543196 DOI: 10.4093/dmj.2015.39.4.321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 11/26/2014] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The aim of the study is to evaluate the concurrence between Framingham Risk score (FRS) and United Kingdom Prospective Diabetes Study (UKPDS) risk engine in identifying coronary heart disease (CHD) risk in newly detected diabetes mellitus patients and to explore the characteristics associated with the discrepancy between them. METHODS A cross-sectional study involving 489 subjects newly diagnosed with type 2 diabetes mellitus was conducted. Agreement between FRS and UKPDS in classifying patients as high risk was calculated using kappa statistic. Subjects with discrepant scores between two algorithms were identified and associated variables were determined. RESULTS The FRS identified 20.9% subjects (range, 17.5 to 24.7) as high-risk while UKPDS identified 21.75% (range, 18.3 to 25.5) as high-risk. Discrepancy was observed in 17.9% (range, 14.7 to 21.7) subjects. About 9.4% had high risk by UKPDS but not FRS, and 8.6% had high risk by FRS but not UKPDS. The best agreement was observed at high-risk threshold of 20% for both (κ=0.463). Analysis showed that subjects having high risk on FRS but not UKPDS were elderly females having raised systolic and diastolic blood pressure. Patients with high risk on UKPDS but not FRS were males and have high glycosylated hemoglobin. CONCLUSION The FRS and UKPDS (threshold 20%) identified different populations as being at high risk, though the agreement between them was fairly good. The concurrence of a number of factors (e.g., male sex, low high density lipoprotein cholesterol, and smoking) in both algorithms should be regarded as increasing the CHD risk. However, longitudinal follow-up is required to form firm conclusions.
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Affiliation(s)
- Dipika Bansal
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, India
| | - Ramya S. R. Nayakallu
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, India
| | - Kapil Gudala
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, India
| | - Rajavikram Vyamasuni
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Malik MO, Govan L, Petrie JR, Ghouri N, Leese G, Fischbacher C, Colhoun H, Philip S, Wild S, McCrimmon R, Sattar N, Lindsay RS. Ethnicity and risk of cardiovascular disease (CVD): 4.8 year follow-up of patients with type 2 diabetes living in Scotland. Diabetologia 2015; 58:716-25. [PMID: 25669630 DOI: 10.1007/s00125-015-3492-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/22/2014] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Potential differences in cardiovascular risk by ethnicity remain uncertain. We evaluated the association of ethnicity with cardiovascular disease (CVD) incidence in a large cohort of people with type 2 diabetes living in Scotland. METHODS Data from Scottish Care Information-Diabetes (SCI-Diabetes) were linked to Scottish Morbidity Records (SMR01) and National Records of Scotland data for mortality for dates between 2005 and 2011. Of 156,991 people with type 2 diabetes with coded ethnicity, 121,535 (77.4%) had no CVD at baseline (White: 114,461; Multiple Ethnic: 2,554; Indian: 797; Other Asian: 319; Pakistani: 2,250; Chinese: 387; African-Caribbean: 301 and Other: 466) and were followed up (mean ± SD: 4.8 ± 2.3 years) for the development of fatal and non-fatal CVD. RESULTS During follow-up, 16,265 (13.4%) patients developed CVD (ischaemic heart or cerebrovascular diseases). At baseline, Pakistanis were younger and had developed diabetes earlier, had higher HbA1c and longer duration of diabetes, but had lower BP, BMI, creatinine, proportion of smokers and proportion on antihypertensive therapy than whites. The age and sex adjusted HRs for CVD were HR 1.31 (CI 1.17, 1.47), p < 0.001 in Pakistanis and HR 0.66 (CI 0.47, 0.92), p = 0.014 in Chinese compared with whites. Adjusting additionally for an area measure of deprivation, duration of diabetes, conventional CVD and other risk factors, the HR for Pakistanis (HR 1.45 [CI 1.14, 1.85], p = 0.002) was significantly higher, and that for Chinese (HR = 0.58 [CI 0.24, 1.40], p = 0.228) lower, compared with whites. CONCLUSIONS/INTERPRETATION Compared with whites with type 2 diabetes, those of Pakistani ethnicity in Scotland were at increased risk of CVD, whereas Chinese were at lower risk, with these differences unexplained by known risk factors.
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Affiliation(s)
- Muhammad Omar Malik
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow, Cardiovascular Research Centre, University of Glasgow, 126 University Place, G12 8TA, Glasgow, UK
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22
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Jones CA, Ross L, Surani N, Dharamshi N, Karmali K. Framingham ten-year general cardiovascular disease risk: agreement between BMI-based and cholesterol-based estimates in a South Asian convenience sample. PLoS One 2015; 10:e0119183. [PMID: 25781949 PMCID: PMC4364600 DOI: 10.1371/journal.pone.0119183] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 01/17/2015] [Indexed: 11/18/2022] Open
Abstract
The goal of this analysis was to determine the agreement between body mass index-based and cholesterol-based ten-year Framingham general cardiovascular disease risk scores among a convenience sample of 773 South Asian Canadian adults attending community-based screening clinics. Scores were calculated using age, systolic blood pressure, antihypertensive use, current smoking, diabetes, and total cholesterol and high density lipoprotein (for cholesterol-based risk) or height and weight (for body mass index-based risk). Mean risk score differences (body mass index-based risk minus cholesterol-based risk) were estimated using paired t-tests. Bland-Altman plots were used to assess agreement between scores. Finally, agreement across risk categories (low [<10%], moderate [10% to <20%], high [> = 20%]) was examined using the kappa statistic. Average agreement between the two risk scores was quite good overall (mean differences of 0.6% for men and 0.5% for women), but increased to about 3% among participants 60-74 years of age. However, Bland-Altman plots revealed that the differences between the two scores and the variability of the differences increased with increasing average 10-year risk. In terms of clinical importance, the limits of agreement were reasonable for women < 60 years (95% confidence interval: -3.2% to 3.1%), but of concern for women 60-74 years (95% confidence interval: -6.0% to 12.3%), men < 60 years (95% confidence interval: -7.1% to 7.3%) and men 6-074 years (95% confidence interval: -13.8% to 18.8%). Agreement across categories was moderate for most sex and age groups examined (kappa values: 0.51 for women < 60 years, 0.50 for women 60-74 years, 0.65 for men < 60 years), except for men 60-74 years, where agreement was only fair (kappa = 0.26). In light of these disagreements, evaluation of a participant's change in cardiovascular disease risk over time will necessitate use of the same risk score (i.e., either body mass index-based or cholesterol-based) at all screening sessions.
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Affiliation(s)
- Charlotte A. Jones
- Department of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, AB, Canada
- Faculty of Medicine, Southern Medical Program, University of British Columbia—Okanagan, Kelowna, BC, Canada
- * E-mail:
| | - Leanne Ross
- Department of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, AB, Canada
- Faculty of Medicine, Southern Medical Program, University of British Columbia—Okanagan, Kelowna, BC, Canada
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Modesti PA, Perruolo E, Parati G. Need for better blood pressure measurement in developing countries to improve prevention of cardiovascular disease. J Epidemiol 2014; 25:91-8. [PMID: 25420484 PMCID: PMC4310869 DOI: 10.2188/jea.je20140146] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Hypertension is now the foremost cause of disability and is responsible for the highest percentage of attributable death among risk factors. These global changes are mainly due to the increase in the prevalence of hypertension in most low- and middle-income countries (LMICs) as a consequence of relevant socioeconomic changes occurring during the last decades. Implementation of global prevention efforts urgently needs to be accelerated because of the increasing incidence of haemorrhagic stroke, renal failure, and hypertensive heart disease in developing countries. Blood pressure (BP) measurement has different implications in epidemiological studies performed in low-resource settings. First, the frequency of blood pressure measurement is a simple but reliable indicator of access to healthcare in epidemiological studies, which may disclose the favourable effects of urbanization; the opportunity to have BP measured increases hypertension awareness, facilitates drug treatment, and leads to better achievement of BP control. Second, BP measurement is a key element in cardiovascular risk stratification, focusing solely on the preferred strategy in low-resource settings where costs of biochemical tests might be less sustainable. Third, the issue of obtaining reliable estimation of BP values is crucial to achieve sound data on the burden of hypertension in LMICs, and some aspects of BP measurement, such as the use of reliable automated devices, the number of measurements/visits to achieve a consistent diagnosis of hypertension, and the possible confounding effect of environmental factors, must be closely considered.
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Modesti PA, Agostoni P, Agyemang C, Basu S, Benetos A, Cappuccio FP, Ceriello A, Del Prato S, Kalyesubula R, O’Brien E, Kilama MO, Perlini S, Picano E, Reboldi G, Remuzzi G, Stuckler D, Twagirumukiza M, Van Bortel LM, Watfa G, Zhao D, Parati G. Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings. J Hypertens 2014; 32:951-60. [PMID: 24577410 PMCID: PMC3979828 DOI: 10.1097/hjh.0000000000000125] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 01/09/2014] [Accepted: 01/09/2014] [Indexed: 02/06/2023]
Abstract
The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on 'Hypertension and Cardiovascular risk in low resource settings', which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs.
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Affiliation(s)
- Pietro A. Modesti
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | | | - Charles Agyemang
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanjay Basu
- University of California, San Francisco, California, USA
| | - Athanase Benetos
- INSERM UMR S1116, Université de Lorraine, Vandoeuvre-les-Nancy, Nancy, France
| | - Francesco P. Cappuccio
- University of Warwick, Warwick Medical School, and University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Antonio Ceriello
- Institut d’Investigacions Biomèdiques August Pi i Sunyer IDIBAPS, and Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
| | - Stefano Del Prato
- Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Eoin O’Brien
- The Conway Institute, University College Dublin, Dublin, Ireland
| | | | | | | | | | - Giuseppe Remuzzi
- IRCCS-Istituto di Ricerche Farmacologiche ‘Mario Negri’, Bergamo, Italy
| | - David Stuckler
- Department of Sociology, University of Oxford, Oxford, UK
| | - Marc Twagirumukiza
- Faculty of Medicine and Health Sciences, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Luc M. Van Bortel
- Faculty of Medicine and Health Sciences, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | | | - Dong Zhao
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Gianfranco Parati
- Department of Health Sciences, University of Milano-Bicocca
- Department of Cardiology, S. Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
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25
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Goh LG, Dhaliwal SS, Welborn TA, Thompson PL, Maycock BR, Kerr DA, Lee AH, Bertolatti D, Clark KM, Naheed R, Coorey R, Della PR. Cardiovascular disease risk score prediction models for women and its applicability to Asians. Int J Womens Health 2014; 6:259-67. [PMID: 24648770 PMCID: PMC3956733 DOI: 10.2147/ijwh.s55225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Although elevated cardiovascular disease (CVD) risk factors are associated with a higher risk of developing heart conditions across all ethnic groups, variations exist between groups in the distribution and association of risk factors, and also risk levels. This study assessed the 10-year predicted risk in a multiethnic cohort of women and compared the differences in risk between Asian and Caucasian women. METHODS Information on demographics, medical conditions and treatment, smoking behavior, dietary behavior, and exercise patterns were collected. Physical measurements were also taken. The 10-year risk was calculated using the Framingham model, SCORE (Systematic COronary Risk Evaluation) risk chart for low risk and high risk regions, the general CVD, and simplified general CVD risk score models in 4,354 females aged 20-69 years with no heart disease, diabetes, or stroke at baseline from the third Australian Risk Factor Prevalence Study. Country of birth was used as a surrogate for ethnicity. Nonparametric statistics were used to compare risk levels between ethnic groups. RESULTS Asian women generally had lower risk of CVD when compared to Caucasian women. The 10-year predicted risk was, however, similar between Asian and Australian women, for some models. These findings were consistent with Australian CVD prevalence. CONCLUSION In summary, ethnicity needs to be incorporated into CVD risk assessment. Australian standards used to quantify risk and treat women could be applied to Asians in the interim. The SCORE risk chart for low-risk regions and Framingham risk score model for incidence are recommended. The inclusion of other relevant risk variables such as obesity, poor diet/nutrition, and low levels of physical activity may improve risk estimation.
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Affiliation(s)
- Louise Gh Goh
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Satvinder S Dhaliwal
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | | | - Peter L Thompson
- Sir Charles Gairdner Hospital, Nedlands, Perth, WA, Australia ; School of Population Health, University of Western Australia, Perth, WA, Australia ; Harry Perkins Institute for Medical Research, Perth, WA, Australia
| | - Bruce R Maycock
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Deborah A Kerr
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Andy H Lee
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Dean Bertolatti
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Karin M Clark
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Rakhshanda Naheed
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Ranil Coorey
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Phillip R Della
- School of Nursing and Midwifery, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
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Tillin T, Hughes AD, Whincup P, Mayet J, Sattar N, McKeigue PM, Chaturvedi N. Ethnicity and prediction of cardiovascular disease: performance of QRISK2 and Framingham scores in a U.K. tri-ethnic prospective cohort study (SABRE--Southall And Brent REvisited). Heart 2014; 100:60-7. [PMID: 24186564 PMCID: PMC4869829 DOI: 10.1136/heartjnl-2013-304474] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To evaluate QRISK2 and Framingham cardiovascular disease (CVD) risk scores in a tri-ethnic U.K. population. DESIGN Cohort study. SETTING West London. PARTICIPANTS Randomly selected from primary care lists. Follow-up data were available for 87% of traced participants, comprising 1866 white Europeans, 1377 South Asians, and 578 African Caribbeans, aged 40-69 years at baseline (1998-1991). MAIN OUTCOME MEASURES First CVD events: myocardial infarction, coronary revascularisation, angina, transient ischaemic attack or stroke reported by participant, primary care or hospital records or death certificate. RESULTS During follow-up, 387 CVD events occurred in men (14%) and 78 in women (8%). Both scores underestimated risk in European and South Asian women (ratio of predicted to observed risk: European women: QRISK2: 0.73, Framingham: 0.73; South Asian women: QRISK2: 0.52, Framingham: 0.43). In African Caribbeans, Framingham over-predicted in men and women and QRISK2 over-predicted in women. Framingham classified 28% of participants as high risk, predicting 54% of all such events. QRISK2 classified 19% as high risk, predicting 42% of all such events. Both scores performed poorly in identifying high risk African Caribbeans; QRISK2 and Framingham identified as high risk only 10% and 24% of those who experienced events. CONCLUSIONS Neither score performed consistently well in all ethnic groups. Further validation of QRISK2 in other multi-ethnic datasets, and better methods for identifying high risk African Caribbeans and South Asian women, are required.
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Affiliation(s)
- Therese Tillin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Alun D Hughes
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Peter Whincup
- Division of Population Health Sciences and Education, St George’s University of London, London, UK
| | - Jamil Mayet
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow School of Medicine, Glasgow, UK
| | - Paul M McKeigue
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Nish Chaturvedi
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK
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Ainsworth H, Shah S, Ahmed F, Amos A, Cameron I, Fairhurst C, King R, Mir G, Parrott S, Sheikh A, Torgerson D, Thomson H, Siddiqi K. Muslim communities learning about second-hand smoke (MCLASS): study protocol for a pilot cluster randomised controlled trial. Trials 2013; 14:295. [PMID: 24034853 PMCID: PMC3847687 DOI: 10.1186/1745-6215-14-295] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 09/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the UK, 40% of Bangladeshi and 29% of Pakistani men smoke cigarettes regularly compared to the national average of 24%. As a consequence, second-hand smoking is also widespread in their households which is a serious health hazard to non-smokers, especially children. Smoking restrictions in households can help reduce exposure to second-hand smoking. This is a pilot trial of 'Smoke Free Homes', an educational programme which has been adapted for use by Muslim faith leaders, in an attempt to find an innovative solution to encourage Pakistani- and Bangladeshi-origin communities to implement smoking restrictions in their homes. The primary objectives for this pilot trial are to establish the feasibility of conducting such an evaluation and provide information to inform the design of a future definitive study. METHODS/DESIGN This is a pilot cluster randomised controlled trial of 'Smoke Free Homes', with an embedded preliminary health economic evaluation and a qualitative analysis. The trial will be carried out in around 14 Islamic religious settings. Equal randomisation will be employed to allocate each cluster to a trial arm. The intervention group will be offered the Smoke Free Homes package (Smoke Free Homes: a resource for Muslim religious teachers), trained in its use, and will subsequently implement the package in their religious settings. The remaining clusters will not be offered the package until the completion of the study and will form the control group. At each cluster, we aim to recruit around 50 households with at least one adult resident who smokes tobacco and at least one child or a non-smoking adult. Households will complete a household survey and a non-smoking individual will provide a saliva sample which will be tested for cotinine. All participant outcomes will be measured before and after the intervention period in both arms of the trial. In addition, a purposive sample of participants and religious leaders/teachers will take part in interviews and focus groups. DISCUSSION The results of this pilot study will inform the protocol for a definitive trial. TRIAL REGISTRATION Current Controlled Trials ISRCTN03035510.
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Affiliation(s)
- Hannah Ainsworth
- York Trials Unit, Department of Health Sciences, University of York, York, North Yorkshire YO10 5DD, England
| | - Sarwat Shah
- Department of Health Sciences, University of York, York, North Yorkshire YO10 5DD, England
| | - Faraz Ahmed
- Cambridge Centre for Health Services Research, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge CB2 0SR, England
| | - Amanda Amos
- UKCTCS, Centre for Population Health Sciences, University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG, Scotland
| | - Ian Cameron
- Leeds City Council, Civic Hall, Calverley Street, Leeds LS1 1UR, England
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, York, North Yorkshire YO10 5DD, England
| | - Rebecca King
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds LS2 9LJ, England
| | - Ghazala Mir
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds LS2 9LJ, England
| | - Steve Parrott
- Department of Health Sciences, University of York, York, North Yorkshire YO10 5DD, England
| | - Aziz Sheikh
- Allergy & Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG, Scotland
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, North Yorkshire YO10 5DD, England
| | - Heather Thomson
- Leeds City Council, Civic Hall, Calverley Street, Leeds LS1 1UR, England
| | - Kamran Siddiqi
- Department of Health Sciences, University of York, York, North Yorkshire YO10 5DD, England
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D'Agostino RB, Pencina MJ, Massaro JM, Coady S. Cardiovascular Disease Risk Assessment: Insights from Framingham. Glob Heart 2013; 8:11-23. [PMID: 23750335 PMCID: PMC3673738 DOI: 10.1016/j.gheart.2013.01.001] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Cardiovascular disease (CVD) is among the leading causes of death and disability worldwide. Since its beginning, the Framingham study has been a leader in identifying CVD risk factors. Clinical trials have demonstrated that when the modifiable risk factors are treated and corrected, the chances of CVD occurring can be reduced. The Framingham study also recognized that CVD risk factors are multifactorial and interact over time to produce CVD. In response, Framingham investigators developed the Framingham Risk Functions (also called Framingham Risk Scores) to evaluate the chance or likelihood of developing CVD in individuals. These functions are multivariate functions (algorithms) that combine the information in CVD risk factors such as sex, age, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, smoking behavior, and diabetes status to produce an estimate (or risk) of developing CVD or a component of CVD (such as coronary heart disease, stroke, peripheral vascular disease, or heart failure) over a fixed time, for example, the next 10 years. These estimates of CVD risk are often major inputs in recommending drug treatments such as cholesterol-lowering drugs.
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Affiliation(s)
- Ralph B D'Agostino
- Mathematics and Statistics Department, Boston University, Boston, MA, USA ; Framingham Study, Framingham, MA, USA ; Biostatistics Department, Boston University, Boston, MA, USA
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Khunti K, Morris DH, Weston CL, Gray LJ, Webb DR, Davies MJ. Joint prevalence of diabetes, impaired glucose regulation, cardiovascular disease risk and chronic kidney disease in South Asians and White Europeans. PLoS One 2013; 8:e55580. [PMID: 23383233 PMCID: PMC3559442 DOI: 10.1371/journal.pone.0055580] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/03/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Multiple vascular risk factors may confer very high risk, but the degree of commonality between risk factors is unclear, particularly among ethnic minorities. Furthermore, it is unknown what impact this commonality will have on the UK-based NHS Health Check Programme; a vascular disease prevention programme that screens individuals aged 40-74 years. We estimated the joint prevalence of diabetes, impaired glucose regulation (IGR), high cardiovascular disease (CVD) risk and chronic kidney disease (CKD) among White Europeans and South Asians who would be eligible for the Programme. METHODS Cross-sectional data were analysed for 3707 participants (23.6% South Asian) in a screening study set in Leicestershire, UK. Diabetes and IGR were screen-detected. CKD may have been diagnosed previously. IGR was defined as impaired fasting glucose and/or impaired glucose tolerance, and high CVD risk as 10 year risk greater than 20%. RESULTS Among males, South Asians had higher prevalence than White Europeans of diabetes (9.0% vs. 3.9%, respectively, p<0.001), IGR (12.5% vs. 9.2%, p = 0.06), and high CVD risk (39.1% vs. 33.1%, p = 0.03), but lower prevalence of CKD (1.5% vs. 4.6%, p<0.01). Among females, South Asians had higher prevalence than White Europeans of diabetes (7.4% vs. 3.3%, p<0.001), but lower prevalence of CKD (3.7% vs. 13.0%, p <0.001) and CVD risk (2.4% vs. 4.6%, p = 0.03), and a non-significant difference in IGR prevalence. At least one risk factor was diagnosed in 34% of participants, and all of them in 0.4%, suggesting that 723,589-734,589 more individuals each year will require monitoring following implementation of the Health Check Programme. CONCLUSIONS The collective prevalence of risk factors for vascular disease in this population was high, but there was little overlap between the risk factors, and prevalence differed by ethnicity. This has implications for service delivery and resources, and should be considered when planning screening and intervention programmes.
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Affiliation(s)
- Kamlesh Khunti
- Department of Health Sciences, University of Leicester, Leicester Diabetes Centre, Leicester General Hospital, Leicester, Leicestershire, United Kingdom.
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Ekwunife OI, Okafor CE, Ezenduka CC, Udeogaranya PO. Cost-utility analysis of antihypertensive medications in Nigeria: a decision analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2013; 11:2. [PMID: 23343250 PMCID: PMC3567962 DOI: 10.1186/1478-7547-11-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 01/17/2013] [Indexed: 01/16/2023] Open
Abstract
Background Many drugs are available for control of hypertension and its sequels in Nigeria but some are not affordable for majority of the populace. This serious pharmacoeconomic question has to be answered by the nation’s health economists. The objective of this study was to evaluate the cost-effectiveness of drugs from 4 classes of antihypertensive medications commonly used in Nigeria in management of hypertension without compelling indication to use a particular antihypertensive drug. Methods The study employed decision analytic modeling. Interventions were obtained from a meta-analysis. The Markov process model calculated clinical outcomes and costs during a life cycle of 30 years of 1000 hypertensive patients stratified by 3 cardiovascular risk groups, under the alternative intervention scenarios. Quality adjusted life year (QALY) was used to quantify clinical outcome. The average cost of treatment for the 1000 patient was tracked over the Markov cycle model of the alternative interventions and results were presented in 2010 US Dollars. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability frontiers. Expected value of perfect information (EVPI) and expected value of parameter perfect information (EVPPI) analyses were also conducted for the hypothetical population. Results Thiazide diuretic was the most cost-effective option across the 3 cardiovascular risk groups. Calcium channel blocker was the second best for Moderate risk and high risk with a willingness to pay of at least 2000$/QALY. The result was robust since it was insensitive to the parameters alteration. Conclusions The result of this study showed that thiazide diuretic followed by calcium channel blocker could be a feasible strategy in order to ensure that patients in Nigeria with hypertension are better controlled.
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Affiliation(s)
- Obinna Ikechukwu Ekwunife
- Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, University of Nigeria Nsukka, 410001, Enugu, Nigeria.
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Wierzbicki AS. New directions in cardiovascular risk assessment: the role of secondary risk stratification markers. Int J Clin Pract 2012; 66:622-30. [PMID: 22698414 DOI: 10.1111/j.1742-1241.2012.02956.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Cardiovascular disease (CVD) risk screening is performed by multivariate methods relying on calculators derived from the Framingham study, other epidemiological studies or primary care records. However, it only identifies 70% of individuals at risk for CVD events and there has been interest in adding other risk factors to improve its predictive capacity. The addition of a family history of premature CVD is well established and there is evidence for adding lipoprotein (a) in some populations and possibly C-reactive protein may be suitable for general use in CVD risk assessment. Most new biochemical and imaging markers have been assessed in the context of improving risk classification in intermediate-risk groups rather than in the general population. There is evidence that N-terminal pro-B-type natriuretic peptide and coronary artery calcium score add significantly to risk prediction. The data for carotid intima-media thickness, ankle-brachial index are less strong and high sensitivity troponins look promising, but have had only limited data to date. Large scale meta-analyses ideally of pooled primary patient data will be required to determine the best additional markers to add to conventional risk prediction and in what groups to apply them.
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Affiliation(s)
- A S Wierzbicki
- Consultant in Metabolic Medicine/Chemical Pathology, St. Thomas' Hospital Campus, Lambeth Palace Road, London SE1 7EH, UK.
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Burton JO, Gray LJ, Webb DR, Davies MJ, Khunti K, Crasto W, Carr SJ, Brunskill NJ. Association of anthropometric obesity measures with chronic kidney disease risk in a non-diabetic patient population. Nephrol Dial Transplant 2011; 27:1860-6. [PMID: 21965589 DOI: 10.1093/ndt/gfr574] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Obesity is a risk factor for both chronic kidney disease (CKD) and cardiovascular disease. The association of simple indices of obesity with CKD remains poorly understood. Evidence suggests that measures of central obesity such as waist circumference (WC) and waist-to-hip ratio (WHR) are more accurate predictors of morbidity and cardiovascular risk than body mass index (BMI). This study aimed to investigate the association of BMI, WC and WHR with CKD risk in a population screened for type 2 diabetes. METHODS Data were drawn from a population-based screening programme of 6475 volunteers without pre-existing diabetes. A number of investigations and cardiovascular health-related assessments were performed. Participants were categorized into two groups: those with an estimated glomerular filtration rate (eGFR) ≥60 and <60 mL/min/1.73m(2). Participants were also categorized as low, medium and high risk according to each anthropometric variable. RESULTS CKD was independently associated with higher WC and BMI (P < 0.01) but not WHR (P = 0.47). Increasing obesity measured by BMI and WC was associated with a reduction in eGFR for both men and women (P < 0.001). Increasing risk categories for BMI and WC were also associated with lower eGFR in men and women (P < 0.001). Combining anthropometric measures provided no additional measure of risk for underlying CKD. CONCLUSIONS WC may be a simple and reliable clinical tool for the detection of underlying CKD within primary care. Given the complex interaction between adiposity and uraemia, a combined screening tool using BMI and WC or WHR is unlikely to provide any additional benefit to risk analysis.
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Affiliation(s)
- James O Burton
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK.
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Marques-Vidal P, Vollenweider P, Waeber G, Paccaud F. The prevalence and management of cardiovascular risk factors in immigrant groups in Switzerland. Int J Public Health 2011; 57:63-77. [PMID: 21901332 DOI: 10.1007/s00038-011-0297-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 08/02/2011] [Accepted: 08/16/2011] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To compare the prevalence and management of cardiovascular risk factors (CVRFs) between immigrant groups and Swiss nationals. METHODS The Swiss Health Surveys (SHS, N = 49,245) and CoLaus study (N = 6,710) were used. Immigrant groups from France, Germany, Italy, Portugal, Spain, former Yugoslavia, other European and other countries were defined. RESULTS Immigrants from Italy, France, Portugal, Spain and former Yugoslavia presented a higher prevalence of smoking than Swiss nationals. Immigrants reported less hypertension than Swiss nationals, but the differences were reduced when blood pressure measurements were used. The prevalence of dyslipidaemia was similar between immigrants and Swiss nationals in the SHS. When eligibility for statin treatment was assessed, immigrants from Italy were more frequently eligible than Swiss nationals. Immigrants from former Yugoslavia presented a lower prevalence of diabetes in the SHS, but a higher prevalence in the CoLaus study. Most differences between immigrant groups and Swiss nationals disappeared after adjusting for age, leisure-time physical activity, being overweight/obesity and education. CONCLUSIONS Most CVRFs are unevenly distributed among immigrant groups in Switzerland, but these differences are due to disparities in age, leisure-time physical activity, being overweight/obesity and education.
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Affiliation(s)
- Pedro Marques-Vidal
- Institute of Social and Preventive Medicine, University Hospital and University of Lausanne, Epalinges, Switzerland.
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Abstract
During the past 2 decades, life-course social-ecological frameworks have emerged across health, developmental, social, behavioral, and public health disciplines as useful models for explaining how health trajectories develop over an individual's lifetime and how this knowledge can guide and inform new approaches to clinical and public health practice, multilevel policies, and research. Viewed from this perspective, and with emphasis on global cardiovascular health promotion and prevention of cardiovascular disease (CVD), this article summarizes evidence on the early origins and progression of CVD processes across the life course of individuals and diverse populations. Current evidence-based guidelines for CVD prevention are summarized, and recommendations for future research are suggested.
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Stronks K, van Valkengoed IGM. How can we realise the potentially large public health benefit of screening for type 2 diabetes mellitus in south Asians? Diabetologia 2011; 54:2214-6. [PMID: 21769508 PMCID: PMC3149662 DOI: 10.1007/s00125-011-2258-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 06/13/2011] [Indexed: 11/21/2022]
Affiliation(s)
- K Stronks
- Department of Public Health, Academic Medical Center, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands.
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Webb DR, Gray LJ, Khunti K, Srinivasan B, Taub N, Campbell S, Barnett J, Farooqi A, Echouffo-Tcheugui JB, Griffin SJ, Wareham NJ, Davies MJ. Screening for diabetes using an oral glucose tolerance test within a western multi-ethnic population identifies modifiable cardiovascular risk: the ADDITION-Leicester study. Diabetologia 2011; 54:2237-46. [PMID: 21638133 DOI: 10.1007/s00125-011-2189-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 03/17/2011] [Indexed: 11/27/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to determine the frequency of undiagnosed glucose abnormalities and the burden of cardiovascular disease (CVD) risk among south Asians and white Europeans attending a systematic screening programme for type 2 diabetes (ADDITION-Leicester) and to estimate the achievable risk reduction in individuals identified with glucose disorders. METHODS Random samples of individuals (n = 66,320) from 20 general practices were invited for a 75 g OGTT and CVD risk assessment. Ten-year CVD risk among screen-detected people with diabetes or impaired glucose regulation (IGR) (impaired fasting glycaemia and/or impaired glucose tolerance [IGT]) was computed using the Framingham-based ETHRISK engine and achievable risk reduction was predicted using relative reductions for treatments extracted from published trials. RESULTS A total of 6,041 participants (48% male, 22% south Asian) aged 40-75 years inclusive were included. Undiagnosed glucose disorders occurred more frequently in south Asians than white Europeans; age and sex adjusted odds ratios were 1.74 (95% CI 1.42-2.13) and 2.30 (95% CI 1.68-3.16) for IGT and diabetes respectively. Prevalence of any undetected glucose disorder was 17.5% in the whole cohort. Adjusted 10-year risk was similar in screen-detected people with IGR and diabetes (18.3% vs 21.6%), and was higher in south Asians across the glucose spectrum. Absolute CVD risk reductions of up to 13% in those with screen-detected type 2 diabetes and 6% in IGR are achievable using existing cardioprotective therapies. CONCLUSIONS/INTERPRETATION Population screening with an OGTT identifies a significant burden of modifiable CVD risk, especially within south Asian groups. Strategies enticing this population to consider screening programmes are urgently needed as significant risk reduction is possible once a glucose abnormality is identified. TRIAL REGISTRATION ClinicalTrials.gov NCT00318032. FUNDING The project is funded for support and treatment costs by NHS Department of Health Support for Science and project grants.
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Affiliation(s)
- D R Webb
- Vascular Research Group, Department of Cardiovascular Sciences, Victoria Building, Leicester Royal Infirmary, London Road, Leicester LE1 5WW, UK.
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Manzur F, España H, Dueñas C. Variables asociadas a mortalidad por infarto del miocardio en adultos mayores de 75 años en Cartagena de Indias, Colombia: un estudio piloto. REVISTA COLOMBIANA DE CARDIOLOGÍA 2011. [DOI: 10.1016/s0120-5633(11)70186-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Jeemon P, Prabhakaran D, Huffman MD, Ramakrishnan L, Goenka S, Thankappan KR, Mohan V, Joshi PP, Mohan BVM, Ahmed F, Ramanathan M, Ahuja R, Chaturvedi V, Lloyd-Jones DM, Reddy KS. Distribution of 10-year and lifetime predicted risk for cardiovascular disease in the Indian Sentinel Surveillance Study population (cross-sectional survey results). BMJ Open 2011; 1:e000068. [PMID: 22021747 PMCID: PMC3191418 DOI: 10.1136/bmjopen-2011-000068] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 03/25/2011] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Cardiovascular disease (CVD) prevention guidelines recommend lifetime risk stratification for primary prevention of CVD, but no such risk stratification has been performed in India to date. METHODS The authors estimated short-term and lifetime predicted CVD risk among 10,054 disease-free, adult Indians in the 20-69-year age group who participated in a nationwide risk factor surveillance study. The study population was then stratified into high short-term (≥ 10% 10-year risk or diabetes), low short-term (<10%)/high lifetime and low short-term/low lifetime CVD risk groups. RESULTS The mean age (SD) of the study population (men=63%) was 40.8 ± 10.9 years. High short-term risk for coronary heart disease was prevalent in more than one-fifth of the population (23.5%, 95% CI 22.7 to 24.4). Nearly half of individuals with low short-term predicted risk (48.2%, 95% CI 47.1 to 49.3) had a high predicted lifetime risk for CVD. While the proportion of individuals with all optimal risk factors was 15.3% (95% CI 14.6% to 16.0%), it was 20.6% (95% CI 18.7% to 22.6%) and 8.8% (95% CI 7.7% to 10.5%) in the highest and lowest educational groups, respectively. CONCLUSION Approximately one in two men and three in four women in India had low short-term predicted risks for CVD in this national study, based on aggregate risk factor burden. However, two in three men and one in two women had high lifetime predicted risks for CVD, highlighting a key limitation of short-term risk stratification.
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Affiliation(s)
- Panniyammakal Jeemon
- Centre for Chronic Disease Control, New Delhi, India
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Public Health Foundation of India, New Delhi, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, New Delhi, India
- Center of Excellence, Center for Cardio-metabolic Risk Reduction in South Asia, New Delhi, India
| | - Mark D Huffman
- Centre for Chronic Disease Control, New Delhi, India
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | | | - K R Thankappan
- Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala
| | - V Mohan
- Madras Diabetes Research Foundation, Chennai, India
| | | | - B V M Mohan
- Narayana Hrudayalaya Institute of Medical Sciences, Bangalore, India
| | - F Ahmed
- KPC Medical College, Jadavpur, Kolkata, India
| | | | - R Ahuja
- King George Medical College, Lucknow, India
| | | | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Webb DR, Gray LJ, Khunti K, Campbell S, Dallosso H, Davies MJ. Contrasting cardiovascular risk profiles and prescribed cardio-protective therapies in newly-diagnosed type 2 diabetes identified through screening and standard practice. Diabetes Res Clin Pract 2011; 91:280-5. [PMID: 21194777 DOI: 10.1016/j.diabres.2010.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 11/16/2010] [Indexed: 10/18/2022]
Abstract
AIMS Screening for Type 2 diabetes mellitus (T2DM) may improve long-term outcomes by managing cardiovascular risk at an earlier stage of the disease. The cardiovascular risk profile of screen-detected (SD) T2DM is ill defined and has not been compared to conventional newly diagnosed (CD) cases. METHODS Baseline data from SD (n=337) and CD (n=824) cohorts were compared. SD adopted mixed approaches to screening, population based (n=214) and cardiovascular-risk factor targeted (n=123). CD reflected UK primary care practice with cases referred within four weeks of diagnosis. RESULTS People with SD T2DM were leaner, had a lower HbA1c(%) and lower triglyceride but were more hypertensive compared to people with CD T2DM. Fewer SD were on blood pressure lowering (46% vs. 60%, p<0.0001), statin (30% vs. 41%, p<0.0001) or anti-platelet (15% vs. 27%, p<0.0001) therapies. Modelled 10 year cardiovascular disease (CVD) risk was actually greater in the SD group compared to CD (CVD: 20.8 vs. 17.2, p=0.0001). CONCLUSION Individuals with SD T2DM are at high risk of CVD as a result of untreated hyperglycaemia, hypertension and dyslipidaemia. Those prescribed antihypertensive or lipid-lowering therapies frequently still had inadequate control. Identifying vascular risk by screening for latent glucose disease provides therapeutic opportunities for earlier intervention.
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Affiliation(s)
- D R Webb
- Department of Cardiovascular Sciences, University of Leicester, UK.
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Mostafa SA, Khunti K, Srinivasan BT, Webb D, Gray LJ, Davies MJ. The potential impact and optimal cut-points of using glycated haemoglobin, HbA1c, to detect people with impaired glucose regulation in a UK multi-ethnic cohort. Diabetes Res Clin Pract 2010; 90:100-8. [PMID: 20633944 DOI: 10.1016/j.diabres.2010.06.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 06/02/2010] [Accepted: 06/07/2010] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Recommended diagnostic cut-points to detect impaired glucose regulation (IGR, also termed prediabetes: impaired fasting glucose and/or impaired glucose tolerance based on WHO 1999 criteria) are HbA1c 6.0-6.4% and 5.7-6.4% from an International Expert Committee and American Diabetes Association, respectively. We investigated the impact on prevalence/phenotype from using these criteria compared to IGR detected on oral glucose tolerance testing (OGTT) and determined optimal HbA1c cut-points for IGR in a multi-ethnic cohort. METHODS Analysis of 8696 participants in the LEADER study of primary care individuals aged 40-75 years without diabetes, in Leicestershire (UK) who underwent OGTT and had HbA1c measured. RESULTS Use of OGTT detected less people with IGR (n=1407, 16.2%) compared to HbA1c 6.0-6.4% (n=1610, 18.5%) and HbA1c 5.7-6.4%(n=3904, 44.9%), a 1.1- and 2.8-fold increase in prevalence, respectively. There were 930 (10.7%) and 534 (6.1%) people with IGR on OGTT not detected using HbA1c 6.0-6.4% and 5.7-6.4%, respectively. From ROC curve analysis, the optimal cut-point for detecting IGR in white Europeans was HbA1c>or=5.8%, sensitivity/specificity 61.5%/67.9%, but in south Asians HbA1c>or=6.0%, sensitivity/specificity 63.8%/69.4%. CONCLUSION Recommended HbA1c cut-points to detect IGR significantly increase numbers detected, however introduce a change in people identified. Using HbA1c 6.0-6.4% lacks sensitivity in white Europeans, but is a reasonable option in south Asians.
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Affiliation(s)
- Samiul A Mostafa
- Division of Diabetes and Endocrinology, Department of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, UK.
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Hobbs FDR, Jukema JW, Da Silva PM, McCormack T, Catapano AL. Barriers to cardiovascular disease risk scoring and primary prevention in Europe. QJM 2010; 103:727-39. [PMID: 20685842 DOI: 10.1093/qjmed/hcq122] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The prevalence and burden of cardiovascular disease (CVD) is high, and it remains the leading cause of death worldwide. Unfortunately, many individuals who are at high risk for CVD are not recognized and/or treated. Therefore, programs are available to ensure individuals at risk for CVD are identified through appropriate risk classification and offered optimal preventative interventions. The use of algorithms to determine a global risk score may help to achieve these goals. Such global risk-scoring algorithms takes into account the synergistic effects between individual risk factors, placing increases in individual risk factors into context relative to the overall disease, allowing for a continuum of disease risk to be expressed, and identifying patients most likely to derive benefit from an intervention. The predictive value of risk scoring such as using the Framingham equation is reasonable, analogous to cervical screening, with area under the receiver operated characteristic curve a little over 70%. However, limitations do exist, and as they are identified adjustments can be made to the global risk-scoring algorithms. Limitations include patient-specific issues, such as variations in lifetime risk level, ethnicity or socio-economic strata, and algorithm-specific issues, such as discrepancies between different algorithms arising from varying risk factors evaluated. The use of currently developed algorithms is low in general practice, in part, because of the belief that the assessment may oversimplify the risk and/or lead to medication overuse. Additional hindrances to the use of risk scoring include government or local health policy, patient compliance issues and lack of time. A thorough, easy-to-use, and standardized tool for risk estimation would allow for improvements in the primary prevention of CVD.
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Affiliation(s)
- F D R Hobbs
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, UK.
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Debar S, Kumarapeli P, Kaski JC, de Lusignan S. Addressing modifiable risk factors for coronary heart disease in primary care: an evidence-base lost in translation. Fam Pract 2010; 27:370-8. [PMID: 20418224 DOI: 10.1093/fampra/cmq025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Risk factors for cardiovascular disease can be modified in primary care. Electronic patient record (EPR) systems include embedded cardiovascular risk factor calculators and should facilitate this process. OBJECTIVE To observe how the evidence base for assessing and managing cardiovascular risk is implemented in practice. METHOD We compared the different risk calculators promoted for calculating cardiovascular risk in primary care using four test cases. We looked to see how these calculators were implemented in primary care EPR systems. We explored through a workshop which risk factors GPs thought were important and felt motivated to address as part of clinical care. RESULTS The risk calculators reviewed use different sets of risk factors and the levels of risk calculated for the same test patient profiles vary by up to 100%. The risk factor calculators embedded within UK computer systems all include the Framingham equation though there is variation in interface, default values and patient groups included. GPs showed consensus around the importance of managing smoking, blood pressure, obesity (body mass index), diabetes and cholesterol but also stressed the importance of providing personalized care and exercising professional judgement. CONCLUSIONS There appears to be an evidence-base lost in translation. Different guidelines calculate risk differently, and even when the same guideline is used, variation in implementation leads to further variation. Education and development of improved risk calculators should enable the most appropriate calculator to be used for an individual patient; accreditation of implementation could be achieved through the use of a standard set of test cases.
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Affiliation(s)
- Safia Debar
- Division of Community Health Sciences, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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Aboud M, Elgalib A, Pomeroy L, Panayiotakopoulos G, Skopelitis E, Kulasegaram R, Dimian C, C Lampe F, Duncan A, Wierzbicki AS, Peters BS. Cardiovascular risk evaluation and antiretroviral therapy effects in an HIV cohort: implications for clinical management: the CREATE 1 study. Int J Clin Pract 2010; 64:1252-9. [PMID: 20653801 PMCID: PMC2913108 DOI: 10.1111/j.1742-1241.2010.02424.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIMS The aim of this study is to determine the cardiovascular disease (CVD) risk profile of a large UK HIV cohort and how highly active antiretroviral therapy (HAART) affects this. METHODS It is a cross-sectional study within a large inner city hospital and neighbouring district hospital. A total of 1021 HIV positive outpatients representative of the complete cohort and 990 who had no previous CVD were included in CVD risk analysis. We recorded demographics, HAART history and CVD risk factors. CVD and coronary heart disease (CHD) risks were calculated using the Framingham (1991) algorithm adjusted for family history. RESULTS The non-CVD cohort (n = 990) was 74% men, 51% Caucasian and 73.1% were on HAART. Mean age was 41 +/- 9 years, systolic blood pressure 120 +/- 14 mmHg, total cholesterol 4.70 +/- 1.05 mmol/l, high-density lipoprotein-C 1.32 +/- 0.48 mmol/l and 37% smoked. Median CVD risk was 4 (0-56) % in men and 1.4 (0-37) % in women; CHD risks were 3.5 (0-36) % and 0.6 (0-16) %. CVD risk was > 20% in 6% of men and 1% of women and > 10% in 12% of men and 4% of women. CVD risk was higher in Caucasians than other ethnicities; the risk factor contributing most was raised cholesterol. For patients on their first HAART, increased CHD risk (26.2% vs. 6.5%; odds ratio 4.03, p < 0.001) was strongly related to the duration of therapy. CONCLUSIONS Modifiable risk factors, especially cholesterol, and also duration of HAART, were key determinants of CVD risk. DISCUSSION Regular CHD and/or CVD risk assessment should be performed on patients with HIV, especially during HAART therapy. The effect of different HAART regimens on CHD risk should be considered when selecting therapy.
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Affiliation(s)
- M Aboud
- HIV Medicine, Guy's & St Thomas' Hospitals, London, UK
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Affiliation(s)
- Marie Therese Cooney
- From the Department of Cardiology (M.T.C., A.D., I.M.G.), Adelaide Meath Hospital incorporating the National Children’s Hospital Tallaght, Dublin, Ireland, and Mathematics and Statistics Department (R.D.), Boston University, Boston, Mass
| | - Alexandra Dudina
- From the Department of Cardiology (M.T.C., A.D., I.M.G.), Adelaide Meath Hospital incorporating the National Children’s Hospital Tallaght, Dublin, Ireland, and Mathematics and Statistics Department (R.D.), Boston University, Boston, Mass
| | - Ralph D'Agostino
- From the Department of Cardiology (M.T.C., A.D., I.M.G.), Adelaide Meath Hospital incorporating the National Children’s Hospital Tallaght, Dublin, Ireland, and Mathematics and Statistics Department (R.D.), Boston University, Boston, Mass
| | - Ian M. Graham
- From the Department of Cardiology (M.T.C., A.D., I.M.G.), Adelaide Meath Hospital incorporating the National Children’s Hospital Tallaght, Dublin, Ireland, and Mathematics and Statistics Department (R.D.), Boston University, Boston, Mass
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Mostafa SA, Davies MJ, Webb D, Gray LJ, Srinivasan BT, Jarvis J, Khunti K. The potential impact of using glycated haemoglobin as the preferred diagnostic tool for detecting Type 2 diabetes mellitus. Diabet Med 2010; 27:762-9. [PMID: 20636956 DOI: 10.1111/j.1464-5491.2010.03015.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS There are calls to simplify the diagnosis of Type 2 diabetes mellitus (T2DM) to reduce the burden of undiagnosed disease. Glycated haemoglobin (HbA(1c)) is therefore being considered as a preferred diagnostic tool to replace the need for an oral glucose tolerance test (OGTT), considered by many as cumbersome and inconvenient. The aim of this study was to examine the potential impact of the preferred use of HbA(1c) as a diagnostic tool on the prevalence and phenotype of T2DM. METHODS Analysis of the Leicester Ethnic Atherosclerosis and Diabetes Risk (LEADER) cohort for previously undiagnosed individuals between 40 and 75 years of age who had OGTT, repeated if within the diabetes range, and HbA(1c) results. We compared the prevalence and phenotype of subjects with T2DM based on either HbA(1c)> or =6.5% or OGTT using 1999 World Health Organization criteria. RESULTS From the total population of 8696, we detected 291 (3.3%) with T2DM from using an OGTT, and 502 (5.8%) had HbA(1c)> or =6.5%. Of those diagnosed with T2DM by OGTT, 93 (1.2%) had HbA(1c) <6.5% and therefore would not have been classified as having T2DM using proposed criteria. Using HbA(1c) criteria resulted in 304 (3.5%) additional cases of T2DM, approximately doubling the prevalence. Of these 304 additional people, 172 (56.7%) had impaired glucose tolerance/impaired fasting glycaemia according to 1999 World Health Organization criteria. Using HbA(1c) criteria there was an increase of 2.2- and 1.4-fold in south Asians and white Europeans detected, respectively. CONCLUSIONS Within this multi-ethnic cohort, we found that introducing HbA(1c)> or =6.5% as the preferred diagnostic test to diagnose T2DM significantly increased numbers detected with T2DM; however, some people were no longer detected as having T2DM.
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Affiliation(s)
- S A Mostafa
- Division of Diabetes and Endocrinology, Department of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, UK.
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Dent THS. Predicting the risk of coronary heart disease I. The use of conventional risk markers. Atherosclerosis 2010; 213:345-51. [PMID: 20637467 DOI: 10.1016/j.atherosclerosis.2010.06.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 06/04/2010] [Accepted: 06/07/2010] [Indexed: 12/14/2022]
Abstract
This is the first of two articles reviewing recent findings about the risk of coronary heart disease. This paper is concerned with conventional risk factors; the second will review novel molecular biomarkers, genetic markers of risk and the future of risk prediction. Predicting exactly the future occurrence of coronary heart disease (CHD) is not possible, but the risk can be estimated with models based on cohort studies. Most existing models are based on long-standing research on the residents of Framingham, Massachusetts. The findings from Framingham yield inaccurate results when applied to contemporary populations elsewhere. In particular, they may exacerbate health inequalities. This is because the incidence of and mortality from CHD have fallen recently, the Framingham cohort differs from many groups to which findings from it have been applied, important risk factors such as ethnicity, socio-economic deprivation and family history are absent from the Framingham equations and susceptibility to risk factors varies between populations. Attempts to recalibrate or adjust the Framingham equations to improve their performance have not been shown to overcome these problems. SCORE, QRISK, PROCAM and ASSIGN are risk prediction models that have been developed based on different cohorts. The group developing NICE's guideline on lipid modification was uncertain about which risk prediction model to recommend for use in the NHS. Eventually they selected a modified version of the Framingham equation. However, QRISK appears to offer the best long-term promise.
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Affiliation(s)
- T H S Dent
- PHG Foundation, 2 Worts Causeway, Cambridge CB1 8RN, United Kingdom.
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Cooney MT, Dudina AL, Graham IM. Value and limitations of existing scores for the assessment of cardiovascular risk: a review for clinicians. J Am Coll Cardiol 2009; 54:1209-27. [PMID: 19778661 DOI: 10.1016/j.jacc.2009.07.020] [Citation(s) in RCA: 254] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 07/13/2009] [Accepted: 07/20/2009] [Indexed: 10/20/2022]
Abstract
Atherosclerotic cardiovascular diseases (CVDs) are the biggest causes of death worldwide. In most people, CVD is the product of a number of causal risk factors. Several seemingly modest risk factors may, in combination, result in a much higher risk than an impressively raised single factor. For this reason, risk estimation systems have been developed to assist clinicians to assess the effects of risk factor combinations in planning management strategies. In this article, the performances of the major risk estimation systems are reviewed. Most perform usably well in populations that are similar to the one used to derive the system, and in other populations if calibrated to allow for different CVD mortality rates and different risk factor distributions. The effect of adding "new" risk factors to age, sex, smoking, lipid status, and blood pressure is usually small, but may help to appropriately reclassify some of those patients who are close to a treatment threshold to a more correct "treat/do not treat" category. Risk estimation in the young and old needs more research. Quantification of the hoped-for benefits of the multiple risk estimation approach in terms of improved outcomes is still needed. But, it is likely that the widespread use of such an approach will help to address the issues of both undertreatment and overtreatment.
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Paramsothy P, Knopp R, Bertoni AG, Tsai MY, Rue T, Heckbert SR. Combined hyperlipidemia in relation to race/ethnicity, obesity, and insulin resistance in the Multi-Ethnic Study of Atherosclerosis. Metabolism 2009; 58:212-9. [PMID: 19154954 PMCID: PMC2677914 DOI: 10.1016/j.metabol.2008.09.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 09/16/2008] [Indexed: 10/21/2022]
Abstract
We have asked whether the prevalence of combined hyperlipidemia (CHL) differs by race/ethnicity, obesity, and insulin resistance in a contemporary, multiethnic, US cohort. We determined the prevalence and adjusted odds of CHL in a cohort of 5923 men and women free of clinically recognized cardiovascular disease and diabetes according to race/ethnicity (white, Chinese, African American, and Hispanic), obesity, and insulin resistance. Untreated lipid values were imputed for those on lipid-lowering therapy. Combined hyperlipidemia was defined using age- and sex-specific greater than or equal to 75th percentile cut points for low-density lipoprotein cholesterol and triglycerides obtained from a predominantly white North American population study. Compared with whites, adjusted odds ratios for CHL were 0.48 in African Americans (95% confidence interval [CI], 0.30-0.75), 1.33 in Hispanics (95% CI, 0.93-1.91), and 1.06 in Asians (95% CI, 0.62-1.82). Within the entire population, the adjusted odds of CHL were over 2-fold higher in overweight and obese participants compared with normal-weight participants and more than 4-fold higher in quartiles 2 through 4 of insulin resistance compared with quartile 1. African Americans had lower odds for CHL than whites despite higher body mass index and abdominal adiposity. Hispanics had a nonsignificantly higher trend, and Asians had no significantly different odds than whites. Modest increases in weight and insulin resistance were associated with significantly higher odds of CHL in a multiethnic US population. Further research is needed to determine the most efficacious diet, exercise, and drug management to decrease the risk of CHL and coronary heart disease among racial/ethnic groups in the United States.
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Affiliation(s)
- Pathmaja Paramsothy
- Department of Internal Medicine/Division of Cardiology, University of Washington, Seattle, WA 98105, USA.
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Martin CJ, Taylor P, Potts HWW. Construction of an odds model of coronary heart disease using published information: the Cardiovascular Health Improvement Model (CHIME). BMC Med Inform Decis Mak 2008; 8:49. [PMID: 18976488 PMCID: PMC2601038 DOI: 10.1186/1472-6947-8-49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Accepted: 10/31/2008] [Indexed: 11/10/2022] Open
Abstract
Background There is a need for a new cardiovascular disease model that includes a wider range of relevant risk factors, in particular lifestyle factors, to aid targeting of interventions and improve population models of the impact of cardiovascular disease and preventive strategies. The model needs to be applicable to a wider population including different ethnic groups, different countries and to those with and without cardiovascular disease. This paper describes the construction of the Cardiovascular Health Improvement Model that aims to meet these requirements. Method An odds model is used. Information was taken from 2003 mortality statistics for England and Wales, the Health Survey for England 2003 and published data on relative risk in those with and without CVD and mean blood pressure values in hypertensives. The odds ratios used were taken from the INTERHEART study. Results A worked example is given calculating the 10-year coronary heart disease risk for a 57 year-old non-diabetic male with no personal or family history of cardiovascular disease, who smokes 30 cigarettes a day and has a systolic blood pressure of 137 mmHg, a total cholesterol (TC) of 6.2 mmol/l, a high density lipoprotein (HDL) of 1.3 mol/l, and a body mass index of 21. He neither drinks regularly nor exercises. He can give no reliable information about his mental health or fruit and vegetable intake. His 10-year risk of CHD death is 2.47%. Conclusion This paper demonstrates a method for developing a CHD risk model. Further improvements could be made to the model with additional information. The method is applicable to other causes of death.
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Affiliation(s)
- Christopher J Martin
- Centre for Health Informatics and Multiprofessional Education, University College London, Archway Campus, Highgate Hill, London, N19 5LW, UK.
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