Systematic review of the effect of diet and exercise lifestyle interventions in the secondary prevention of coronary heart disease.

The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease(CHD)remains unclear.This systematic review aimed to determine their effectiveness and included randomized controlled trials of lifestyle interventions, in primary care or community settings, with a minimum follow-up of three months, published since 1990. 21 trials with 10,799 patients were included; the interventions were multifactorial (10), educational (4), psychological (3), dietary (1), organisational (2), and exercise(1). The overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes but no overall effect on smoking outcomes. In trials that examined mortality and morbidity,significant benefits were reported for total mortality (in 4 of 6 trials;overall risk ratio(RR) 0.75 (95%confidence intervals (CI) 0.65, 0.87)), cardiovascular mortality (3 of 8 trials; overall RR 0.63(95%CI 0.47, 0.84)), and nonfatal cardiac events(5 of 9 trials; overall RR 0.68(95%CI 0.55, 0.84)). The heterogeneity between trials and generally poor quality of trials make any concrete conclusions difficult. However, the beneficial effects observed in this review are encouraging and should stimulate further research.

Effect of a pharmacist-led multicomponent intervention focussing on the medication monitoring phase to prevent potential adverse drug events in nursing homes

OBJECTIVES: To determine the extent to which the use of a clinical informatics tool that implements prospective monitoring plans reduces the incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

DESIGN: Randomized cluster trial.

SETTING: Twenty-five nursing homes serviced by two long-term care pharmacies.

PARTICIPANTS: Residents living in nursing homes during 2003 (1,711 in 12 intervention; 1,491 in 13 usual care) and 2004 (1,769 in 12 intervention; 1,552 in 13 usual care).

INTERVENTION: The pharmacy automatically generated Geriatric Risk Assessment MedGuide (GRAM) reports and automated monitoring plans for falls and delirium within 24 hours of admission or as part of the normal time frame of federally mandated drug regimen review.

MEASUREMENTS: Incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

RESULTS: GRAM triggered monitoring plans for 491 residents. Newly admitted residents in the intervention homes experienced a lower rate of potential delirium onset than those in usual care homes (adjusted hazard ratio (HR)=0.42, 95% confidence interval (CI)=0.35–0.52), overall hospitalization (adjusted HR=0.89, 95% CI=0.72–1.09), and mortality (adjusted HR=0.88, 95% CI=0.66–1.16). In longer stay residents, the effects of the intervention were attenuated, and all estimates included unity.

CONCLUSION: Using health information technology in long-term care pharmacies to identify residents who might benefit from the implementation of prospective medication monitoring care plans when complex medication regimens carry potential risks for falls and delirium may reduce adverse effects associated with appropriate medication use.

Large-scale association analysis identifies 13 new susceptibility loci for coronary artery disease

We performed a meta-analysis of 14 genome-wide association studies of coronary artery disease (CAD) comprising 22,233 individuals with CAD (cases) and 64,762 controls of European descent followed by genotyping of top association signals in 56,682 additional individuals. This analysis identified 13 loci newly associated with CAD at P < 5 x 10(-8) and confirmed the association of 10 of 12 previously reported CAD loci. The 13 new loci showed risk allele frequencies ranging from 0.13 to 0.91 and were associated with a 6% to 17% increase in the risk of CAD per allele. Notably, only three of the new loci showed significant association with traditional CAD risk factors and the majority lie in gene regions not previously implicated in the pathogenesis of CAD. Finally, five of the new CAD risk loci appear to have pleiotropic effects, showing strong association with various other human diseases or traits.

Optimal glycaemic control, pre-eclampsia and gestational hypertension in women with type 1 diabetes in the Diabetes and Pre-Eclampsia Intervention Trial

OBJECTIVE
To assess the relationship between glycemic control, pre-eclampsia, and gestational hypertension in women with type 1 diabetes.

RESEARCH DESIGN AND METHODS
Pregnancy outcome (pre-eclampsia or gestational hypertension) was assessed prospectively in 749 women from the randomized controlled Diabetes and Pre-eclampsia Intervention Trial (DAPIT). HbA1c (A1C) values were available up to 6 months before pregnancy (n = 542), at the first antenatal visit (median 9 weeks) (n = 721), at 26 weeks’ gestation (n = 592), and at 34 weeks’ gestation (n = 519) and were categorized as optimal (<6.1%: referent), good (6.1–6.9%), moderate (7.0–7.9%), and poor (=8.0%) glycemic control, respectively.

RESULTS
Pre-eclampsia and gestational hypertension developed in 17 and 11% of pregnancies, respectively. Women who developed pre-eclampsia had significantly higher A1C values before and during pregnancy compared with women who did not develop pre-eclampsia (P < 0.05, respectively). In early pregnancy, A1C =8.0% was associated with a significantly increased risk of pre-eclampsia (odds ratio 3.68 [95% CI 1.17–11.6]) compared with optimal control. At 26 weeks’ gestation, A1C values =6.1% (good: 2.09 [1.03–4.21]; moderate: 3.20 [1.47–7.00]; and poor: 3.81 [1.30–11.1]) and at 34 weeks’ gestation A1C values =7.0% (moderate: 3.27 [1.31–8.20] and poor: 8.01 [2.04–31.5]) significantly increased the risk of pre-eclampsia compared with optimal control. The adjusted odds ratios for pre-eclampsia for each 1% decrement in A1C before pregnancy, at the first antenatal visit, at 26 weeks’ gestation, and at 34 weeks’ gestation were 0.88 (0.75–1.03), 0.75 (0.64–0.88), 0.57 (0.42–0.78), and 0.47 (0.31–0.70), respectively. Glycemic control was not significantly associated with gestational hypertension.

CONCLUSIONS
Women who developed pre-eclampsia had significantly higher A1C values before and during pregnancy. These data suggest that optimal glycemic control both early and throughout pregnancy may reduce the risk of pre-eclampsia in women with type 1 diabetes.

Coronary heart disease: health knowledge and behaviour

Objective To determine the current level of knowledge and understanding of CHD in the general public in Northern Ireland and to identify factors that are associated with higher knowledge levels. Setting Six provincial centres in Northern Ireland. Methods The data in the present study were collected using an interview administered questionnaire. 1,000 members of the general public were interviewed face-to-face. CHD knowledge was computed as a continuous variable, i.e. higher score represents better CHD knowledge. Main outcome measure CHD knowledge in the general public in Northern Ireland. Results Study respondents displayed limited knowledge and understanding of CHD. Study respondents who achieved higher CHD knowledge scores were more likely to report: exercising for 30 min three times or more per week, paying attention to their diet, being overweight, having a family history of CHD, living in a higher socioeconomic area (according to postcode) and having attended tertiary education. Respondents in the present study while recognising the role that community pharmacists had to play in helping patients manage their prescribed medicines, did not recognise the community pharmacists' role in other aspects of CHD detection or management. Conclusion The deficit in CHD knowledge could translate into inadequate preventative behaviour patterns and suboptimal clinical outcomes. If community pharmacists wish to become increasingly involved in public health delivery relating to CHD they need to develop effective and accessible services and promote these to the public who at present do not recognise this role of the community pharmacist.