Comparison of estimates and calculations of risk of coronary heart disease by doctors and nurses using different calculation tools in general practice: cross sectional study

OBJECTIVE: To assess the effect of using different risk calculation tools on how general practitioners and practice nurses evaluate the risk of coronary heart disease with clinical data routinely available in patients' records. DESIGN: Subjective estimates of the risk of coronary heart disease and results of four different methods of calculation of risk were compared with each other and a reference standard that had been calculated with the Framingham equation; calculations were based on a sample of patients' records, randomly selected from groups at risk of coronary heart disease. SETTING: General practices in central England. PARTICIPANTS: 18 general practitioners and 18 practice nurses. MAIN OUTCOME MEASURES: Agreement of results of risk estimation and risk calculation with reference calculation; agreement of general practitioners with practice nurses; sensitivity and specificity of the different methods of risk calculation to detect patients at high or low risk of coronary heart disease. RESULTS: Only a minority of patients' records contained all of the risk factors required for the formal calculation of the risk of coronary heart disease (concentrations of high density lipoprotein (HDL) cholesterol were present in only 21%). Agreement of risk calculations with the reference standard was moderate (kappa=0.33-0.65 for practice nurses and 0.33 to 0.65 for general practitioners, depending on calculation tool), showing a trend for underestimation of risk. Moderate agreement was seen between the risks calculated by general practitioners and practice nurses for the same patients (kappa=0.47 to 0.58). The British charts gave the most sensitive results for risk of coronary heart disease (practice nurses 79%, general practitioners 80%), and it also gave the most specific results for practice nurses (100%), whereas the Sheffield table was the most specific method for general practitioners (89%). CONCLUSIONS: Routine calculation of the risk of coronary heart disease in primary care is hampered by poor availability of data on risk factors. General practitioners and practice nurses are able to evaluate the risk of coronary heart disease with only moderate accuracy. Data about risk factors need to be collected systematically, to allow the use of the most appropriate calculation tools.

Abnormal retinal vascular reactivity in individuals with impaired glucose tolerance:a preliminary study

To investigate the relationship between vascular function parameters measured at the retinal and systemic level and known markers for cardiovascular risk in patients with impaired glucose tolerance (IGT). Sixty age- and gender- matched White-European adults (30 IGT and 30 normal glucose tolerance -NGT) were recruited for the study. Fasting plasma glucose, lipids and 24-hour blood pressure (BP) was measured in all subjects. Systemic vascular and endothelial function was assessed using carotid-artery intimal media thickness (cIMT) and flow mediated dilation (FMD). Retinal vascular reactivity was assessed by the Dynamic Retinal Vessel Analyser (DVA). Additionally, blood glutathione (GSH, GSSG and tGSH) and plasma von-Willebrand (vWF) factor levels were also measured. Individuals with IGT demonstrated higher BP values (p<0.001), fasting TG and TG:HDL ratios (p<0.001) than NGT subjects. Furthermore, Total:HDL-C ratios and Framingham scores were raised (p=0.010 and p<0.001 respectively). Blood glutathione levels (GSH, GSSG and tGSH) were lower (p<0.001, p=0.039 and p<0.001 respectively) while plasma vWF was increased (p=0.014) in IGT subjects compared to controls. IGT individuals also demonstrated higher IMT in right and left carotid arteries (p=0.017 and p=0.005, respectively) alongside larger brachial artery diameter (p=0.015), lower FMD% (p=0.026) and GTN induced dilation (GID) (p=0.012) than healthy controls. At the retinal arterial level, the IGT subjects showed higher baseline fluctuations (BDF) (p=0.026), longer reaction time (RT) (p=0.032) and reduced baseline-corrected flicker response (bFR) (p=0.045). In IGT subjects retinal BDF correlated with and Total:HDL (p= 0.003) and HDL-C (p= 0.004). Arterial RT also correlated with FMD (p=0.017) in IGT but not NGT subjects. In IGT individuals there is a relationship between macro- and microvascular function, as well as a direct correlation between the observed retinal microcirculatory changes and established plasma markers for CVD. Multifactorial preventive interventions to decrease vascular risk in these individuals should be considered.

Premature cardiovascular events and mortality in south Asians with type 2 diabetes in the United Kingdom Asian Diabetes Study - effect of ethnicity on risk

Background/Aim - People of south Asian origin have an excessive risk of morbidity and mortality from cardiovascular disease. We examined the effect of ethnicity on known risk factors and analysed the risk of cardiovascular events and mortality in UK south Asian and white Europeans patients with type 2 diabetes over a 2 year period. Methods - A total of 1486 south Asian (SA) and 492 white European (WE) subjects with type 2 diabetes were recruited from 25 general practices in Coventry and Birmingham, UK. Baseline data included clinical history, anthropometry and measurements of traditional risk factors – blood pressure, total cholesterol, HbA1c. Multiple linear regression models were used to examine ethnicity differences in individual risk factors. Ten-year cardiovascular risk was estimated using the Framingham and UKPDS equations. All subjects were followed up for 2 years. Cardiovascular events (CVD) and mortality between the two groups were compared. Findings - Significant differences were noted in risk profiles between both groups. After adjustment for clustering and confounding a significant ethnicity effect remained only for higher HbA1c (0.50 [0.22 to 0.77]; P?=?0.0004) and lower HDL (-0.09 [-0.17 to -0.01]; P?=?0.0266). Baseline CVD history was predictive of CVD events during follow-up for SA (P?

Statin use in rheumatoid arthritis in relation to actual cardiovascular risk:evidence for substantial undertreatment of lipid-associated cardiovascular risk?

Background Cardiovascular disease (CVD) is partially attributed to traditional cardiovascular risk factors, which can be identified and managed based on risk stratification algorithms (Framingham Risk Score, National Cholesterol Education Program, Systematic Cardiovascular Risk Evaluation and Reynolds Risk Score). We aimed to (a) identify the proportion of at risk patients with rheumatoid arthritis (RA) requiring statin therapy identified by conventional risk calculators, and (b) assess whether patients at risk were receiving statins. Methods Patients at high CVD risk (excluding patients with established CVD or diabetes) were identified from a cohort of 400 well characterised patients with RA, by applying risk calculators with or without a ×1.5 multiplier in specific patient subgroups. Actual statin use versus numbers eligible for statins was also calculated. Results The percentage of patients identified as being at risk ranged significantly depending on the method, from 1.6% (for 20% threshold global CVD risk) to 15.5% (for CVD and cerebrovascular morbidity and mortality) to 21.8% (for 10% global CVD risk) and 25.9% (for 5% CVD mortality), with the majority of them (58.1% to 94.8%) not receiving statins. The application of a 1.5 multiplier identified 17% to 78% more at risk patients. Conclusions Depending on the risk stratification method, 2% to 26% of patients with RA without CVD have sufficiently high risk to require statin therapy, yet most of them remain untreated. To address this issue, we would recommend annual systematic screening using the nationally applicable risk calculator, combined with regular audit of whether treatment targets have been achieved.

Systemic circulatory influences on retinal microvascular function in middle-age individuals with low to moderate cardiovascular risk

Purpose: To investigate the relationship between retinal microvascular reactivity, circulatory markers for CVD risk and systemic antioxidative defence capacity in healthy middle-aged individuals with low to moderate risk of CVD. Methods: Retinal vascular reactivity to flickering light was assessed in 102 healthy participants (46-60 years) by means of dynamic retinal vessel analysis (DVA). Other vascular assessments included carotid intima-media thickness (C-IMT) and blood pressure (BP) measurements. Total cholesterol (CHOL), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and blood glutathione levels in its reduced (GSH) and oxidized (GSSG) forms were also determined for each participant, along with Framingham risk scores (FRS). Results: Retinal arterial baseline diameter fluctuation (BDF) was independently, significantly and negatively influenced by LDL-C levels (β = -0.53, p = 0.027). Moreover, the arterial dilation slope (SlopeAD) was independently, significantly and positively associated with redox index (GSH: GSSG ratio, β = 0.28, p = 0.016), while the arterial constriction slope (SlopeAC) was significantly and negatively influenced by blood GSH levels (β = -0.20, p = 0.042), and positively associated with FRS (β = 0.25, p = 0.009). Venous BDF and dilation amplitude (DA) were also negatively influenced by plasma LDL-C levels (β = -0.83, p = 0.013; and β = -0.22, p = 0.028, respectively). Conclusions: In otherwise healthy individuals with low to moderate cardiovascular risk, retinal microvascular dilation and constriction responses to stress levels are influenced by systemic antioxidant capacity, and circulating markers for cardiovascular risk.

Ageing effect on flicker-induced diameter changes in retinal microvessels of healthy individuals

Purpose: To compare flicker-induced retinal vessel diameter changes in varying age groups with low cardiovascular risk. Methods: Retinal vascular reactivity to flicker light was assessed by means of dynamic retinal vessel analysis in 57 participants aged 19-30 years, 75 participants aged 31-50 years and 62 participants aged 51-70 years participants. Other assessments included carotid intima-media thickness (c-IMT), augmentation index (AIx), blood pressure profiles, blood lipid metabolism markers and Framingham risk scores (FRS). Results: Retinal arterial dilation amplitude (DA) and postflicker percentage constriction (MC%) were significantly decreased in the oldest group compared to the middle-aged (p = 0.028; p = 0.021) and youngest group (p = 0.003; p = 0.026). The arterial constriction slope (SlopeAC) was also decreased in the oldest group compared to the youngest group (p = 0.027). On the venous side, MC% was decreased in the middle-aged and oldest groups in comparison with the youngest group (p = 0.015; p = 0.010, respectively). Additionally, men exhibited increased arterial DA (p = 0.007), and percentage dilation (MD%, p < 0.001) in comparison with women, but only in the youngest age group. Both AIx and c-IMT scores increased with age (both p < 0.001); however, no correlations were found between the observed differences in the measured retinal vascular function and systemic parameters. Conclusion: In individuals with low cardiovascular risk, there are age-related differences in flicker-induced retinal vessel diameter changes throughout the entire functional response curve for arteries and veins. Gender differences mainly affect the arterial dilatory phase and are only present in young individuals.

Proteína C reactiva, índice de conicidad y factores de riesgo cardiovascular en pacientes con diabetes tipo 2

La Diabetes tipo 2, forma parte del clúster de componentes que integran el Síndrome metabólico, y constituye una enfermedad tremendamente prevalente en el mundo, con disfunciones metabólicas que incrementan la morbimortalidad. Objetivo. Con la finalidad de definir las características de una población amplia de pacientes diabéticos de la Comunidad de Madrid diagnosticados por el Hospital Infanta Leonor de Madrid, su contribución al síndrome metabólico, tipo de tratamiento, años de evolución y riesgo cardiovascular, se procedió a realizar un estudio transversal en una población de 735 diabéticos, seleccionados de una base de datos de 1135 diabéticos del Servicio de Endocrinología del Hospital de los que se disponían de datos sobre edad, género, parámetros antropométricos, glucosa, hemoglobina glicosilada, lípidos, lipoproteínas, consumo de tabaco, alcohol y actividad física. En muchos de ellos también se disponía de marcadores emergentes de afectaciones relacionadas con la diabetes y la enfermedad cardiovascular como PCR-us, microalbuminuria y fibrinógeno. Descripción de la muestra. La selección se realizó garantizando confidencialidad y que todos tuvieran datos de edad, sexo, y de los marcadores clásicos, y de la mayoría de los nuevos marcadores emergentes. Como quiera que contar absolutamente con todos los marcadores en el mismo individuo supondría perder en tal selección un número no despreciable de pacientes, se procedió a respetar la selección de 735 en donde 716 tenía información de la mayoría de los marcadores. A partir de los datos primarios se calcularon los cocientes colesterol/total /HDL-c, LDL-c/HDL-c que informan del riesgo cardiovascular, el cociente molar TG/HDL-c indicativo del tamaño de las LDL, y la relación de triglicérido- glucosa como marcador de resistencia a la insulina y riesgo de síndrome metabólico. Se procedió a calcular el riesgo cardiovascular según los algoritmos del estudio Framingham...

Factores de riesgo cardiovascular en personas mayores de 45 años de edad que consultan en la Unidad Comunitaria de Salud Familiar El Divisadero, departamento de Morazán

Los Factores de Riesgo Cardiovascular son aquellos que aumentan las probabilidades de sufrir un evento cardiovascular a largo plazo, los cuales pueden ser modificados o eliminados cambiando el estilo de vida. El objetivo de la investigación fue identificar factores de riesgo cardiovascular en personas mayores de 45 años de edad que consultan en la Unidad Comunitaria de Salud Familiar El Divisadero, Departamento de Morazán. La Metodología fue de tipo prospectivo, transversal, descriptivo, de campo y de laboratorio. La población estaba constituida por 85 personas que consultaron en el período de ejecución y que cumplieron con los criterios de inclusión a quienes se les realizaron las siguientes pruebas de laboratorio: Glucosa, Colesterol total, Triglicéridos, Colesterol HDL, Colesterol LDL y se les aplicó una cédula de entrevista que permitió recolectar información importante sobre los factores de riesgo cardiovascular, la cual constaba de 8 preguntas. Se utilizó la escala de Framingham para calcular riesgo cardiovascular y la categoría en que se presentó. Los Resultados obtenidos en las pruebas de laboratorio las más alteradas para toda la población fueron Colesterol HDL bajo con un 58.8% y Triglicéridos con un 29.4% y otros factores de riesgo predisponentes fueron Sobrepeso y obesidad con un 72.9%, Presión arterial alta con 43.5% y Tabaquismo con 23.5%. Conclusión: El 56.5% del total de la población presentó 3 o más factores de riesgo, para el sexo masculino un 19.2% presentó riesgo alto en personas mayores de 66 años, un 15.4% riesgo moderado en la edad de 45- 55 y 56- 66 años respectivamente, en cuanto al sexo femenino el 18.6% presentó riesgo moderado en la edad de 45- 55 años y el 16.9% en mayores de 66 años respectivamente.

The need for a marker predicting benefit following cardiovascular disease risk reduction treatment

Developing a robust method to study characteristics of vascular flow using ultrasound may be useful to assess endothelial function and vasodilatation. There are four stages in this proposal. 1.The first stage is to standardise and validate the methodology to enable computational risk flow data and other flow characteristics to be used clinically. (Current Study). Further development of fluid modelling methods will enable particulate haemodynamics to be investigated, and incorporate detailed endothelial structure together with cellular pathways. 2. This should be followed up by studies in different patient groups investigating the association between the derived values and estimated risk (using other methods such as Framingham risk score). 3. Then, associated with underlying cardiovascular risk, prospective studies would be made to establish whether computational flow dynamic data can predict outcome. If successful it could prove to be a very useful marker of benefit following treatment in a clinical setting.

Función endotelial y lipemia postprandial en adultos normolipídicos: Efecto del estado nutricional

El objetivo del presente estudio fue cuantificar la contribución del sobrepeso en la magnitud de la lipemia posprandial en sujetos normolipídicos. Se incluyeron 33 adultos normolipídicos en dos grupos (n=20, sobrepeso y (n=13 eutróficos, 66% hombres, edad media 31,2±7,6 años). Se midió la vasodilatación mediada por flujo (VMF), la velocidad de onda de pulso (VOP), el perfil lipídico, el cociente Log TG/c-HDL, la glucosa y presión arterial tras una ingesta estándar con alto contenido de grasa (79% Kcal/grasa). Se calculó, el Z-score de riesgo cardiovascular a partir de la suma de los residuos tipificados (Z) de las variables de riesgo cardiovascular. El estado de lipemia posprandial se midió en ayuno (0 min) y a los (60, 120, 180, y 240 min) posprandiales. El valor basal de la VMF y la VOP fue de 6,9±5,9% y 7.0±0.8 m/s, respectivamente. Se identificó que la lipemia posprandial reducía la WMF en 19,2% a los 60 min (5,9±1,5%) y a los 240 min (3,7±1,2%) (p<0,04), respectivamente. Este hallazgo se acompañó con un aumento en la VOP (p<0,05). Al dividir los sujetos en dos grupos según el IMC, los participantes en sobrepeso muestran cifras más elevadas en el Z-score de riesgo cardiovascular, la VOP, el Log TG/c-HDL y el Δ-VOP, (p<0,001). En conclusión los sujetos clasificados en sobrepeso muestran un perfil cardiometabolico asociado con un mayor riesgo cardiovascular.

Determinación del comportamiento del riesgo cardiovascular en paciente postrasplante hepatico en Fundacion Cardioinfantil

El trasplante hepático es una opción terapéutica para enfermedad hepática avanzada cada vez más frecuente en Colombia. La sobrevida del 80% a 5 años conlleva a un aumento del riesgo cardiovascular y de eventos cardiovasculares, por esta razón esta investigación determina el comportamiento del riesgo cardiovascular en los pacientes con trasplante hepático de la Fundación Cardioinfantil, realizado en 3 años de seguimiento . Lo encontrado en esta investigación es que existe un aumento del riesgo cardiovascular a tres años en pacientes post trasplante hepático, estadísticamente significativo, principalmente secundario a hipertensión, diabetes e hipertrigliceridemia. El aumento es mayor a lo descrito en la población general, y similar a otros pacientes trasplantados, en un periodo de 5 años