Peripheral arterial disease: Changes in clinical outcomes and therapeutic strategies in two cohorts, from 2002 to 2008 and from 2008 to 2014. A population-based study.

Background The aim of our study was to evaluate whether treatments for peripheral artery disease changed in two different cohorts identified in 2002 and 2008, and whether this had an impact on mortality and major clinical outcomes after six years of follow-up. Methods Using administrative health databases of the largest region in Northern Italy, we identified patients admitted to hospital for peripheral artery disease in 2002 and 2008. Both cohorts were followed for six years. All cause death, acute coronary syndrome, stroke and major amputations, cardiovascular prevention drugs and revascularization procedures were collected. Incidence of events was plotted using adjusted cumulative incidence function estimates. The risk, for each outcome, was compared between 2002-2008 and 2008-2014 using a multivariable Fine and Gray's semiparametric proportional subdistribution hazards model. Results In 2002 and 2008, 2885 and 2848 patients were identified. Adjusting for age, sex, Charlson comorbidity index and severity of peripheral artery disease we observed a significant reduction (in 2008 vs. 2002) in the risk of acute coronary syndrome (28%), stroke (27%) and major amputation (17%). No change was observed in the risk of death. The percentages of patients with peripheral artery revascularizations, during the hospital stay, increased: 43.8% in 2002 vs. 49.0% in 2008, p < 0.001. From 2002 to 2008 there was a significant absolute increase in the prescription of lipid-lowering drugs (+18%), antiplatelets (+7.2%) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (+11.8%), p < 0.001. Conclusions In six years of follow-up we observed a reduction in risk of major cardiovascular events in 2008-2014 in comparison with the 2002-2008 cohort. Increasing use of revascularization interventions and cardiovascular prevention drugs could have contributed to the better prognosis.

Are all people with diabetes and cardiovascular risk factors or microvascular complications at very high risk? Findings from the Risk and Prevention Study.

AIMS: To verify whether it is possible, in people with diabetes mellitus (DM) considered at very high cardiovascular (CV) risk, stratify this risk better and identify significant modifiable risk factor (including lifestyle habits) to help patients and clinicians improve CV prevention. METHODS: People with DM and microvascular diseases or one or more CV risk factors (hypertension, hyperlipidemia, smoking, poor dietary habits, overweight, physical inactivity) included in the Risk and Prevention study were selected. We considered the combined endpoint of non-fatal acute myocardial infarction and stroke and CV death. A multivariate Cox proportional analysis was carried out to identify relevant predictors. We also used the RECPAM method to identify subgroups of patients at higher risk. RESULTS: In our study, the rate of major CV events was lower than expected (5 % in 5 years). Predictors of CV events were age, male, sex, heart failure, previous atherosclerotic disease, atrial fibrillation, insulin treatment, high HbA1c, heart rate and other CV diseases while being physically active was protective. RECPAM analysis indicated that history of atherosclerotic diseases and a low BMI defined worse prognosis (HR 4.51 95 % CI 3.04-6.69). Among subjects with no previous atherosclerotic disease, men with HbA1c more than 8 % were at higher CV risk (HR 2.77; 95 % CI 1.86-4.14) with respect to women. CONCLUSIONS: In this population, the rate of major CV events was lower than expected. This prediction model could help clinicians identify people with DM at higher CV risk and support them in achieving goals of physical activity and HbA1c.

Improving cardiovascular prevention in general practice: Results of a comprehensive personalized strategy in subjects at high risk.

BACKGROUND: Although high cardiovascular risk patients should be the main target of preventive strategies, modifiable risk factors are often inadequately controlled. AIM: To assess feasibility and results of a comprehensive personalized method for cardiovascular prevention in high risk patients followed by their general practitioner. METHODS: Between 2004 and 2007, 12,513 patients (mean age 64.0 ± 9.5 years; 61.5% males) with multiple cardiovascular risk factors or history of atherosclerotic disease were identified and followed for five years. If control of major modifiable cardiovascular risk factors (hypertension, hypercholesterolaemia, diabetes, obesity, smoking, unhealthy diet, physical inactivity) was sub-optimal, at baseline and yearly thereafter general practitioners planned with patients, with the help of a brief checklist, preventive interventions to improve the global risk profile. Main outcome was the control of the seven major modifiable cardiovascular risk factors during follow-up. Secondary outcome was the incidence of cardiovascular deaths and hospitalization for cardiovascular reasons according to the improvement in global cardiovascular risk profile during the first year. RESULTS: Control of all major modifiable risk factors except physical inactivity improved gradually and significantly (p < 0.0001) during follow-up.The improvement in the global cardiovascular risk profile during the first year was independently and significantly associated with a lower rate of major cardiovascular events in the following years (hazard ratio 0.939; 95% confidence interval 0.887-0.994, p = 0.03). CONCLUSIONS: Our comprehensive, personalized method for cardiovascular risk prevention in people at high risk appears feasible in general practice. The improvement in the global cardiovascular risk profile was associated with a better prognosis.

[Effectiveness of a nurse-led educational intervention for patients admitted for acute coronary syndrome]. / Efficacia di un intervento educativo infermieristico in pazienti ricoverati per una sindrome coronarica acuta.

OBJECTIVE: To assess the effectiveness of a nurse-led class with phone follow-up, to help patients achieve lifestyle changes after an acute coronary syndrome (ACS). METHODS: Each patient < or = 75 years, admitted to a intensive cardiac care unit (ICCU) for ACS from September 2003 to December 2004, who attended the education class (case) was matched with two patients paired for age, sex and admission time, admitted for ACS to ICCUs in the other hospitals in the same area (controls). One year later the two groups were blindly interviewed on the phone, using a structured questionnaire about their lifestyles. RESULTS: One-hundred-nineteen cases and 238 controls were phoned and 84% cases and 61% controls completed the interview. Cases reported a more correct lifestyle: they ate > or = 4 portions/day of fruit or vegetables (55% vs. 36%, p = 0.003) and > or = 2 portions/week of fish (48% vs. 32%, p = 0.010), reported > or = 30 min/day of physical activity (67% vs. 59%, p = 0.262) and stopped smoking (82% vs. 71% of previous smokers, p = 0.264). CONCLUSION: An educational intervention led by cardiology nurses, with a group meeting and personal phone follow-up, improved lifestyle habits one year after an ACS.

Diagnostic evaluation of people with hypertension in low income country: cohort study of "essential" method of risk stratification.

OBJECTIVES: To explore the predictive power of a risk stratification method for people with hypertension based on "essential" procedures (that is, available in economically less developed areas of the world), comparing it in the same population with the results given by the method suggested by the 1999 World Health Organization-International Society of Hypertension (WHO-ISH) guidelines. DESIGN: Prospective cohort study of outcomes according to cardiovascular risk profile at baseline. SETTING: Primary care in a poor rural area of the Ecuadorian forest. PARTICIPANTS: 504 people with hypertension prospectively monitored for a mean of 6.7 (SD 2.3) years. INTERVENTIONS: Essential data included blood pressure, medical history, smoking, age, sex, and diagnosis of diabetes; the WHO-ISH methods additionally included measurement of fasting blood glucose, total cholesterol, and creatinine, urinalysis, and electrocardiography. MAIN OUTCOME MEASURES: Cardiovascular events and total deaths. RESULTS: With both methods there was a highly significant association between the level of predicted risk and the incidence of cardiovascular events and of total deaths: up to three quarters of all cardiovascular events and two thirds of all deaths were reported among people classified as at high or very high risk with either method. The predictive discrimination of the essential method is comparable with the WHO-ISH with C statistics (95% confidence interval) of 0.788 (0.721 to 0.855) and 0.744 (0.673 to 0.815), respectively, for cardiovascular events and 0.747 (0.678 to 0.816) and 0.705 (0.632 to 0.778) for total mortality. CONCLUSIONS: The risk stratification of patients with hypertension with an essential package of variables (that is, available and practicable even in the economically less developed areas of the world) serves at least as well as the more comprehensive method proposed by WHO-ISH.

[Knowledge and lifestyles of patients: a survey on patients admitted with acute coronary syndrome in the CCU of an Italian hospital]. / Le conoscenze e gli still di vita dei pazienti: indagine sui pazienti ricoverati per sindrome coronarica acuta nell'Unità Coronarica dell'Ospedale di Desio.

AIM AND METHODS: The lifestyles before hospital admission, knowledge on their illness and lifestyles after the acute coronary event were analysed with questionnaires, in three different samples of patients: a. all the patients admitted for acute coronary event from may 2003 to may 2005 to explore lifestyles before acute coronary event (416 patients) b. all the patients admitted from may 2003 to april 2004 (before the start of health information meetings organised by nurses), to explore the knowledge of the illness and its causes (132 patients) c. a sample of 83 patients followed in day hospital, to explore the lifestyles after the acute coronary event. RESULTS: Lifestyles before the event. Most patients have incorrect lifestyles: 50% eat cheese every day and never exercise for at least 30 minutes everyday. Even after the acute coronary event, some incorrect lifestyles are still present. Seventy-five percent of patients have incorrect or insufficient knowledge on illness and risk factors at discharge and only 50% is willing to increase the amount of fruit and vegetables in their diet. CONCLUSIONS: Although confirmed by other studies, these results are worrying and call for the systematic adoption of secondary prevention strategies with effective interventions aimed at increasing knowledge and modifying lifestyles.

[An health education program for patients admitted to CCU for an acute coronary event]. / Organizzazione di un incontro di educazione alla salute dedicato ai pazienti ricoverati per sindrome coronarica acuta: l'esperienza degli infermieri dell'ospedale di Desio.

UNLABELLED: In spite of the broad recognition of the importance of health education, time for structured one-to -one initiatives of health education during the hospital stay is limited. The organization of an health education meeting for patients admitted to CCU for an acute coronary event is described. METHODS: The planning and implementation of the initiative lasted two years and involved 7 nurses and one doctor. The organization required efforts related to the event itself (preparation of training aids, identification or contents and methods for delivery) but also organizative changes. Dietitians in fact had to be involved because the healthy diet recommended was different from the hospital diet. The assessment of the effectiveness of the health education was also planned: administration of a questionnaire to explore lifestyles and knowledge of the illness before and after the meeting; phone interviews after 3, 6 and 12 months from the meeting. RESULTS: Since may 2003, in the first 3 years 74 meetings have been organised, involving 507 patients and 329 relatives. Each meeting lasts 2 hours and contents delivered encompass the coronary event, risk factors and their modification, healthy lifestyles. Initial preliminary results on the impact of the meeting on lifestyle changes are promising. Initiatives are ongoing to include this activity among officially recognised nursing activities.

Appropriate use of antiplatelets: is prescription in daily practice influenced by the global cardiovascular risk?

OBJECTIVE: To evaluate the appropriate prescription of antiplatelets according to patients' global cardiovascular risk level in everyday practice. METHODS: In a cross-sectional study, general practitioners (GPs) identified a random sample of 10% of patients at cardiovascular risk among all subjects coming to the surgery and collected data on cardiovascular risk factors and history of atherosclerotic cardiovascular diseases (CVD). GPs were asked to do a physical examination and record the results of laboratory tests to define the global cardiovascular risk. The use of antiplatelet drugs in patients with established CVD and in healthy subjects at high risk of developing symptomatic atherosclerotic disease was evaluated. RESULTS: A total of 162 GPs from all over Italy recruited 3,120 subjects (51% female, mean age 64 years). Of the 949 with an indication for antiplatelet treatment for secondary prevention of CVD, 442 (47%) were receiving it. Among the 2,071 without CVD, 11% were taking an antiplatelet drug. In this group, antiplatelets were prescribed in 6, 10, 16 and 23%, respectively, of patients perceived by GPs to be at mild, moderate, high and very high cardiovascular risk. CONCLUSIONS: Prescription of antiplatelets still seems to be far from what is recommended in virtually all patients with a history of CVD. In subjects with cardiovascular risk factors but without CVD antiplatelet prescription increases in relation to global cardiovascular risk but is still low in patients at high or very high risk of cardiovascular events.

How general practitioners perceive and grade the cardiovascular risk of their patients.

BACKGROUND: Although risk assessment charts have been proposed to identify patients at high cardiovascular risk, in everyday practice general practitioners (GPs) often use their knowledge of the patients to estimate the risk subjectively. DESIGN: A cross-sectional study aimed to describe how GPs perceive, qualify and grade cardiovascular risk in everyday practice. METHODS: General practitioners had to identify in a random sample of 10% of their contacts the first 20 consecutive patients perceived as being at cardiovascular risk. For each patient essential data were collected on clinical history, physical examination and laboratory tests, for the qualification of risk. At the end of the process GPs subjectively estimated the overall patient's level of risk. General practitioners grading was compared with the risk estimate from a reference chart. RESULTS: Over a mean time of 25 days 3120 patients perceived as being at cardiovascular risk were enrolled. According to the inclusion scheme each GP had contact with more than 200 patients at cardiovascular risk every month. Thirty percent of these patients had atherosclerotic diseases. Up to 72% of patients without any history of atherosclerotic diseases but perceived to be at risk could be classified according to a reference chart as being at moderate to very high risk. Comparing GPs' grading of risk with a chart estimate there was agreement in 42% of the cases. Major determinants of GPs' underestimation of risk were age, sex and smoking habits, while obesity and family history were independently associated with overestimation. CONCLUSIONS: On the basis of their perception GPs properly identify patients at cardiovascular risk in the majority of cases. General practitioners subjective grading of risk level only partially agreed with that given by a chart.

[Community participation as a strategy of hypertension control in a health district of Ecuador]. / Una comunità del sud del mondo partecipa al controllo dell'ipertensione arteriosa: i protagonisti raccontano.

The results of a program for the treatment and control of arterial hypertension in a rural community of the northern area of Ecuador are reported through the voices and the posters used for patients education, by nurses and health promoters (non professional representatives of the community, with a nursing role) of the district. The steps of the program, from the awareness of the problem because of its high impact on mortality; to the organization of the screening for hypertension of 4284 adults (half of the local adult population); to the systematic collection of data on mortality are described. One of the strategies adopted is the discussion of patients' stories with the local communities: the death of a young patient who refused the treatment and died had a strong influence in convincing at risk patients to enter the program. Treatments were available for 1 dollar a month. Nurses and community health promoters have a pivotal role in guaranteeing pressure control and in identifying at risk patients with the help of community adapted risk tables. From the analysis of data of the first 18 months of follow-up some improvements can be observed: grade II hypertensive patients shifted from 34% to 25%; grade III from 35% to 29%. Lack of compliance with the drug therapy is still one of the main problems.

Primary prevention of cardiovascular events with low-dose aspirin and vitamin E in type 2 diabetic patients: results of the Primary Prevention Project (PPP) trial.

OBJECTIVE: We investigated in general practice the efficacy of antiplatelets and antioxidants in primary prevention of cardiovascular events in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: The Primary Prevention Project (PPP) is a randomized, open trial with a two-by-two factorial design aimed to investigate low-dose aspirin (100 mg/day) and vitamin E (300 mg/day) in the prevention of cardiovascular events in patients with one or more cardiovascular risk factors. The primary end point was a composite end point of cardiovascular death, stroke, or myocardial infarction. A total of 1,031 people with diabetes in the PPP, aged >/=50 years, without a previous cardiovascular event were enrolled by 316 general practitioners and 14 diabetes outpatient clinics. RESULTS: The PPP trial was prematurely stopped (after a median of 3.7 years) by the independent data safety and monitoring board because of a consistent benefit of aspirin compared with the control group in a population of 4,495 patients with one or more major cardiovascular risk factors. In diabetic patients, aspirin treatment was associated with a nonsignificant reduction in the main end point (relative risk [RR] = 0.90, 95% CI 0.50-1.62) and in total cardiovascular events (0.89, 0.62-1.26) and with a nonsignificant increase in cardiovascular deaths (1.23, 0.69-2.19). In nondiabetic subjects, RRs for the main end point, total cardiovascular events, and cardiovascular deaths were 0.59 (0.37-0.94), 0.69 (0.53-0.90), and 0.32 (0.14-0.72), respectively. No significant reduction in any of the end points considered could be found with vitamin E in either diabetic or nondiabetic subjects. CONCLUSIONS: Our data suggest a lower effect of primary prevention of cardiovascular disease (CVD) with low-dose aspirin in diabetic patients as opposed to subjects with other cardiovascular risk factors. If confirmed, these findings might indicate that the antiplatelet effects of aspirin in diabetic patients are overwhelmed by aspirin-insensitive mechanisms of platelet activation and thrombus formation, thus making the balance between benefits and harms of aspirin treatment unfavorable. Further large-scale trials investigating the role of aspirin in the primary prevention of CVD in diabetic patients are urgently needed.