Predicting Coronary Artery Disease in Primary Care: Development and Validation of a Diagnostic Risk Score for Major Ethnic Groups in Southeast Asia.

BACKGROUND: Coronary artery disease (CAD) risk prediction tools are useful decision supports. Their clinical impact has not been evaluated amongst Asians in primary care. OBJECTIVE: We aimed to develop and validate a diagnostic prediction model for CAD in Southeast Asians by comparing it against three existing tools. DESIGN: We prospectively recruited patients presenting to primary care for chest pain between July 2013 and December 2016. CAD was diagnosed at tertiary institution and adjudicated. A logistic regression model was built, with validation by resampling. We validated the Duke Clinical Score (DCS), CAD Consortium Score (CCS), and Marburg Heart Score (MHS). MAIN MEASURES: Discrimination and calibration quantify model performance, while net reclassification improvement and net benefit provide clinical insights. KEY RESULTS: CAD prevalence was 9.5% (158 of 1658 patients). Our model included age, gender, type 2 diabetes mellitus, hypertension, smoking, chest pain type, neck radiation, Q waves, and ST-T changes. The C-statistic was 0.808 (95% CI 0.776-0.840) and 0.815 (95% CI 0.782-0.847), for model without and with ECG respectively. C-statistics for DCS, CCS-basic, CCS-clinical, and MHS were 0.795 (95% CI 0.759-0.831), 0.756 (95% CI 0.717-0.794), 0.787 (95% CI 0.752-0.823), and 0.661 (95% CI 0.621-0.701). Our model (with ECG) correctly reclassified 100% of patients when compared with DCS and CCS-clinical respectively. At 5% threshold probability, the net benefit for our model (with ECG) was 0.063. The net benefit for DCS, CCS-basic, and CCS-clinical was 0.056, 0.060, and 0.065. CONCLUSIONS: PRECISE (Predictive Risk scorE for CAD In Southeast Asians with chEst pain) performs well and demonstrates utility as a clinical decision support for diagnosing CAD among Southeast Asians.

Blood pressure goal attainment in multi-ethnic Asian patients with hypertension and dyslipidaemia in primary care.

INTRODUCTION: Hypertension and dyslipidaemia are major risk factors for cardiovascular diseases and achieving treatment goals mitigates such risks. This study determined demographic and medication-related factors associated with blood pressure (BP) goal attainment in patients with concomitant hypertension and dyslipidaemia. METHODS: This paper is a sub-analysis of the Lipid HEALTH study, a questionnaire survey focusing on adult Asian patients with both dyslipidaemia and hypertension. An interviewer-administered questionnaire was used to obtain demographic and clinical information. Laboratory and prescription data was retrieved from electronic health records. BP goals were defined by international guidelines. Data was audited and analysed, and logistic regression analysis was used to identify factors determining BP goal attainment. RESULTS: Among the 851 included patients, 49.7% attained their BP goals. 37.0% were on monotherapy, 57.6% on ≥ 2 BP-lowering medications, and 5.4% had no pharmacologic treatment. Among those on pharmacotherapy, 51.2% failed to achieve BP goals. Calcium channel blockers were the most frequently prescribed medications. Attainment of BP goals was significantly associated with: not having Type 2 diabetes mellitus (odds ratio [OR] 2.27, 95% confidence interval [CI] 1.61-3.13); attaining low-density lipoprotein cholesterol goal (OR 2.02, 95% CI 1.45-2.81); being solely on dietary control (OR 2.19, 95% CI 1.09-4.39); and receiving monotherapy (OR 1.71, 95% CI 1.18-2.48). CONCLUSION: BP treatment goals were attained by half of the patients with dyslipidaemia and hypertension, and half of those on pharmacotherapy. Type 2 diabetes mellitus and low-density lipoprotein cholesterol control were significantly associated with BP goal attainment.

Asian patients with dyslipidemia in an urban population: Effect of ethnicity on their LDL-cholesterol treatment goals.

BACKGROUND: Dyslipidemia is the primary risk factor for arthrosclerosis. It is the most common chronic disease among the multiethnic Asian population in Singapore. Local national health survey has shown ethnic variability in achieving control of dyslipidemia. OBJECTIVES: This study aimed to determine the proportion of patients in primary care, who achieved their low-density lipoprotein (LDL)-cholesterol treatment goals, stratified by the local major ethnic groups. It also evaluated the factors that affected their dyslipidemia control, including diet, exercise and medication usage. METHODS: Research assistants administered questionnaires on adult patients with physician-diagnosed dyslipidemia to determine their views on diet, exercise, and medications in this cross-sectional study in 2 local primary care clinics. Their lipid profiles were retrieved from their laboratory reports in their electronic health records. Chi-square and Fisher exact tests were used for the categorical demographics and questionnaire variables, (P < .05: statistically significant). Logistic regression was performed using these significant variables to determine the adjusted odds of the ethnic groups. RESULTS: A total of 1093 eligible patients completed the questionnaires. The proportion of Chinese, Malay, and Indian patients who achieved LDL-cholesterol goals was 78.3%, 67.9%, and 68.5%, respectively. Among those who self-reported taking their favorite cholesterol-rich food occasionally when their cholesterol became controlled, 35.8% Indians failed to achieve treatment goals, compared to 20.1% Chinese and 30.9% Malay patients. Regular medication adherence was associated with 81.8% Chinese, 69.0% Malay, and 69.7% Indian reaching treatment goals. CONCLUSIONS: More Chinese met LDL-cholesterol treatment goals compared to Malays and Indians. Lipid-lowering medications enabled but smoking hindered their achievement of these treatment goals.