Chronic kidney disease in the type 2 diabetic patients: prevalence and associated variables in a random sample of 2642 patients of a Mediterranean area.

BACKGROUND: Kidney disease is associated with an increased total mortality and cardiovascular morbimortality in the general population and in patients with Type 2 diabetes. The aim of this study is to determine the prevalence of kidney disease and different types of renal disease in patients with type 2 diabetes (T2DM). METHODS: Cross-sectional study in a random sample of 2,642 T2DM patients cared for in primary care during 2007. Studied variables: demographic and clinical characteristics, pharmacological treatments and T2DM complications (diabetic foot, retinopathy, coronary heart disease and stroke). Variables of renal function were defined as follows: 1) Microalbuminuria: albumin excretion rate & 30 mg/g or 3.5 mg/mmol, 2) Macroalbuminuria: albumin excretion rate & 300 mg/g or 35 mg/mmol, 3) Kidney disease (KD): glomerular filtration rate according to Modification of Diet in Renal Disease < 60 ml/min/1.73 m2 and/or the presence of albuminuria, 4) Renal impairment (RI): glomerular filtration rate < 60 ml/min/1.73 m2, 5) Nonalbuminuric RI: glomerular filtration rate < 60 ml/min/1.73 m2 without albuminuria and, 5) Diabetic nephropathy (DN): macroalbuminuria or microalbuminuria plus diabetic retinopathy. RESULTS: The prevalence of different types of renal disease in patients was: 34.1% KD, 22.9% RI, 19.5% albuminuria and 16.4% diabetic nephropathy (DN). The prevalence of albuminuria without RI (13.5%) and nonalbuminuric RI (14.7%) was similar. After adjusting per age, BMI, cholesterol, blood pressure and macrovascular disease, RI was significantly associated with the female gender (OR 2.20; CI 95% 1.86-2.59), microvascular disease (OR 2.14; CI 95% 1.8-2.54) and insulin treatment (OR 1.82; CI 95% 1.39-2.38), and inversely associated with HbA1c (OR 0.85 for every 1% increase; CI 95% 0.80-0.91). Albuminuria without RI was inversely associated with the female gender (OR 0.27; CI 95% 0.21-0.35), duration of diabetes (OR 0.94 per year; CI 95% 0.91-0.97) and directly associated with HbA1c (OR 1.19 for every 1% increase; CI 95% 1.09-1.3). CONCLUSIONS: One-third of the sample population in this study has KD. The presence or absence of albuminuria identifies two subgroups with different characteristics related to gender, the duration of diabetes and metabolic status of the patient. It is important to determine both albuminuria and GFR estimation to diagnose KD.

Lipid-lowering drugs in ischaemic heart disease: a quasi-experimental uncontrolled before-and-after study of the effectiveness of clinical practice guidelines.

BACKGROUND: Cardiovascular diseases(CVD), specifically ischaemic heart disease(IHD), are the main causes of death in industrialized countries. Statins are not usually prescribed in the most appropriate way. To ensure the correct prescription of these drugs, it is necessary to develop, disseminate and implement clinical practice guidelines(CPGs), and subsequently evaluate them. The main objective of this study is to evaluate the effectiveness of the implementation of consensual Lipid-lowering drugs (LLD) prescription guidelines in hospital and primary care settings, to improve the control of Low-Density Lipoprotein Cholesterol (LDL-C) levels in patients with IHD in the Terres de l'Ebre region covered by the Catalonian Health Institute. Secondary objectives are to assess the improvement of the prescription profile of these LLDs, to assess cardiovascular morbimortality and the professional profile and participant centre characteristics that govern the control of LDL-C. DESIGN: Quasi-experimental uncontrolled before and after study. The intervention consists of the delivery of training strategies for guideline implementation (classroom clinical sessions and on-line courses) aimed at primary care and hospital physicians. The improvement in the control of LDL-C levels in the 3,402 patients with IHD in our territory is then assessed. SCOPE: Primary care physicians from 11 basic health areas(BHAs) and two hospital services (internal medicine and cardiology). SAMPLE: 3,402 patients registered with IHD in the database of the Catalan Institute of Health(E-cap) before December 2008 and patients newly diagnosed during 2009-2010. VARIABLES: Percentage of patients achieving good control of LDL-C, measured in milligrams per decilitre. The aim of the intervention is to achieve levels of LDL-C < 100 mg/dl in patients with IHD. Secondary variables measure type and time of diagnosis of IHD, type and dose of prescribed cholesterol-lowering drugs, level of physician participation in training activities and their professional profile. DISCUSSION: The development of prescription guidelines previously agreed by various medical specialists involved in treating IHD patients have usually improved drug prescription. The guideline presented in this study aims to improve the control of LDL-C by training physicians through presential and on-line courses on the dissemination of this guideline, and by providing feedback on their personal results a year after this training intervention.

Randomized clinical trial to assess the efficacy of a comprehensive programme of secondary prevention of cardiovascular disease in general practice: the PREseAP study.

INTRODUCTION AND OBJECTIVES: To assess the efficacy of a comprehensive program of secondary prevention of cardiovascular disease in general practice. METHODS: A cluster randomized clinical trial was carried out in a regular general practice setting. Male and female patients aged under 86 years with a diagnosis of ischemic heart disease, stroke or peripheral artery disease were recruited between January 2004 and May 2005. Study participants were seen at 42 health centers throughout the whole of Spain. The primary endpoint was the combination of all-cause mortality and hospital cardiovascular readmission at 3-year follow-up. RESULTS: In total, 1224 patients were recruited: 624 in the intervention group and 600 in the control group. The primary endpoint was observed in 29.9% (95% confidence interval [CI], 25.5-34.8%) in the intervention group and 25.6% (22.3-29.2%) in the control group (P=.15). At the end of follow-up, 8.5% (6.3-11.3%) in the intervention group and 11% (7.4-16%) in the control group were smokers (P=.07). The mean waist circumference of patients in the intervention and control groups was 100.44 cm (95% CI, 98.97-101.91 cm) and 102.58 cm (95% CI, 100.96-104.21 cm), respectively (P=.07). Overall, 20.9% (15.6-27.7%) of patients in the intervention group and 29.6% (23.9-36.1%) in the control group suffered from anxiety (P=.05), and 29.6% (22.4-37.9%) in the intervention group and 41.4% (35.8-47.3%) in the control group had depression (P=.02). CONCLUSIONS: A comprehensive program of secondary prevention of cardiovascular disease in general practice was not effective in reducing cardiovascular morbidity and mortality. However, some factors associated with a healthy lifestyle were improved and anxiety and depression were reduced.

Ensayo clínico aleatorizado para evaluar la eficacia de un programa integral de prevención secundaria de las enfermedades cardiovasculares en atención primaria: estudio PREseAP / Randomized clinical trial to assess the efficacy of a comprehensive programme of secondary prevention of cardiovascular disease in general practice: the PREseAP study

Introducción y objetivos. Evaluar la eficacia de un programa integral de prevención secundaria de las enfermedades cardiovasculares en atención primaria. Métodos.Ensayo clínico aleatorizado, pragmático, por conglomerados realizado en atención primaria. Eran pacientes elegibles varones y mujeres menores de 86 años, diagnosticados de cardiopatía isquémica, accidente cerebrovascular o enfermedad arterial periférica entre enero de 2004 y mayo de 2005. Participaron en el estudio pacientes visitados en 42 centros de salud de todo el estado español. La variable de resultado fue la combinación de la mortalidad total y los reingresos hospitalarios por causa cardiovascular a los 3 años de seguimiento. Resultados. Se reclutó a 1.224 pacientes, 624 en el grupo intervención y 600 en el grupo control. La variable principal de resultado se observó en el 29,9% (intervalo de confianza del 95%, 25,5-34,8) en el grupo intervención y en el 25,6% (22,3-29,2) en el grupo control (p=0,15). Al final del seguimiento un 8,5% (6,3-11,3) del grupo intervención y un 11% (7,4-16) del grupo control eran fumadores (p=0,07). El perímetro abdominal del grupo intervención fue 100,44 (98,97-101,91) cm y el del grupo control, 102,58 (100,96-104,21) cm (p=0,07). El 20,9% (15,6-27,7) de los pacientes del grupo intervención y el 29,6% de los pacientes del grupo control (23,9-36,1) tenían ansiedad (p=0,05), y el 29,6% (22,4-37,9) del grupo intervención y el 41,4% (35,8-47,3) del grupo control tenían depresión (p=0,02). Conclusiones. Un programa integral de prevención secundaria no es eficaz para reducir la morbimortalidad cardiovascular, pero sí en mejorar algunos aspectos relacionados con los hábitos saludables y en reducir la ansiedad y la depresión (AU)

Introduction and objectives: To assess the efficacy of a comprehensive programof secondary prevention of cardiovascular disease in general practice. Methods: A cluster randomized clinical trial was carried out in a regular general practice setting. Male and female patients aged under 86 years with a diagnosis of ischemic heart disease, stroke or peripheral artery disease were recruited between January 2004 and May 2005. Study participants were seen at 42 health centers throughout the whole of Spain. The primary endpoint was the combination of all-cause mortality and hospital cardiovascular readmission at 3-year follow-up. Results: In total, 1224 patients were recruited: 624 in the intervention group and 600 in the control group. The primary endpoint was observed in 29.9% (95% confidence interval [CI], 25.5–34.8%) in the intervention group and 25.6% (22.3–29.2%) in the control group (P = .15). At the end of follow-up, 8.5% (6.3–11.3%) in the intervention group and 11% (7.4–16%) in the control group were smokers (P = .07). The mean waist circumference of patients in the intervention and control groups was 100.44 cm (95% CI, 98.97–101.91 cm) and 102.58 cm (95% CI, 100.96–104.21 cm), respectively (P = .07). Overall, 20.9% (15.6–27.7%) of patients in the intervention group and 29.6% (23.9–36.1%) in the control group suffered from anxiety (P = .05), and 29.6% (22.4–37.9%) in the intervention group and 41.4% (35.8–47.3%) in the control group had depression (P = .02). Conclusions: A comprehensive program of secondary prevention of cardiovascular disease in general practice was not effective in reducing cardiovascular morbidity and mortality. However, some factors associated with a healthy lifestyle were improved and anxiety and depression were reduced (AU)

[Factors affecting the control of blood pressure and lipid levels in patients with cardiovascular disease: the PREseAP Study]. / Determinantes del control de la presión arterial y los lípidos en pacientes con enfermedad cardiovascular (estudio PREseAP).

The aim of this observational study was to identify factors influencing the control of blood pressure (i.e., <140/90 mmHg, or <130/80 mmHg in diabetic patients) and low-density lipoprotein (LDL) cholesterol level (<100 mg/dL) in 1223 patients with cardiovascular disease. Overall, 70.2% of patients were men, and their mean age was 66.4 years. Blood pressure was poorly controlled in 50.9% (95% confidence interval [CI], 46.9%-54.8%) and the LDL cholesterol level was poorly controlled in 60.1% (95% CI, 56.3%-63.9%). Determinants of poor blood pressure control were diabetes, hypertension, no previous diagnosis of heart failure, previous diagnosis of peripheral artery disease or stroke, obesity, and no lipid-lowering treatment. Determinants of poor LDL cholesterol control were no lipid-lowering treatment, no previous diagnosis of ischemic heart disease, no antihypertensive treatment, and dyslipidemia. The factors affecting blood pressure control were different from those affecting LDL cholesterol control, an observation that should be taken into account when implementing treatment recommendations for achieving therapeutic objectives in secondary prevention.

Determinantes del control de la presión arterial y los lípidos en pacientes con enfermedad cardiovascular (estudio PREseAP) / Factors affecting the control of blood pressure and lipid levels in patients with cardiovascular disease: the PREseAP study

Estudio observacional para identificar los determinantes del control de la presión arterial (< 140/90 o < 130/80 mmHg si diabetes) y el colesterol de las lipoproteínas de baja densidad (cLDL < 100 mg/dl) en 1.223 pacientes diagnosticados de enfermedad cardiovascular. El 70,2% eran varones con una media de edad de 66,4 años. El 50,9% (intervalo de confianza [IC] del 95%, 46,9%-54,8%) mostró mal control de la presión arterial y el 60,1% (IC del 95%, 56,3%-63,9%), del cLDL. Determinantes de mal control de la presión arterial fueron: diabetes, hipertensión arterial, no tener diagnóstico previo de insuficiencia cardiaca, diagnóstico de enfermedad arterial periférica o ictus, obeso y no recibir tratamiento hipolipemiante. Determinantes de mal control del cLDL fueron: no recibir tratamiento hipolipemiante, no tener diagnóstico de cardiopatía isquémica, no recibir tratamiento antihipertensivo y dislipemia. Los determinantes de mal control de presión arterial difieren de los del cLDL, resultado que considerar al aplicar las recomendaciones para alcanzar los objetivos terapéuticos en prevención secundaria

The aim of this observational study was to identify factors influencing the control of blood pressure (i.e., <140/90 mmHg, or <130/80 mmHg in diabetic patients) and low-density lipoprotein (LDL) cholesterol level (<100 mg/dL) in 1223 patients with cardiovascular disease. Overall, 70.2% of patients were men, and their mean age was 66.4 years. Blood pressure was poorly controlled in 50.9% (95% confidence interval [CI], 46.9%­54.8%) and the LDL cholesterol level was poorly controlled in 60.1% (95% CI, 56.3%­63.9%). Determinants of poor blood pressure control were diabetes, hypertension, no previous diagnosis of heart failure, previous diagnosis of peripheral artery disease or stroke, obesity, and no lipid-lowering treatment. Determinants of poor LDL cholesterol control were no lipid-lowering treatment, no previous diagnosis of ischemic heart disease, no antihypertensive treatment, and dyslipidemia. The factors affecting blood pressure control were different from those affecting LDL cholesterol control, an observation that should be taken into account when implementing treatment recommendations for achieving therapeutic objectives in secondary prevention

La normativa europea y el futuro de los esfigmomanómetros de mercurio en las consultas / European regulations and the future of mercury sphygmomanometers in the clinical setting

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