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Identification of patients for clinical risk assessment by prediction of cardiovascular risk using default risk factor values
Tom Marshall
BMC Public Health , 2008, DOI: 10.1186/1471-2458-8-25
Abstract: Prior estimates of Framingham cardiovascular risk were derived in a population obtained from the Health Survey for England 2003. Receiver operating characteristics curves were constructed for using a prior estimate of cardiovascular risk to identify patients at greater than 20% ten-year cardiovascular risk. This was compared to strategies using age, or diabetic and antihypertensive treatment status to identify high risk patients.The area under the curve for a prior estimate of cardiovascular risk calculated using minimum data (0.933, 95% CI: 0.925 to 0.941) is significantly greater than for a selection strategy based on age (0.892, 95% CI: 0.882 to 0.902), or diabetic and hypertensive status (0.608, 95% CI: 0.584 to 0.632).Using routine data held on primary care databases it is possible to identify a population at high risk of cardiovascular disease. Information technology to help primary care prioritise patients for cardiovascular disease prevention may improve the efficiency of cardiovascular risk assessment.Because they are at high risk of cardiovascular events, patients with cardiovascular disease are the highest priority for preventive interventions. Some patients without cardiovascular disease are also at high risk and are the next priority for prevention. In patients without cardiovascular disease, the Framingham cardiovascular equation is widely used to determine probability of a cardiovascular event [1]. UK guidelines recommend treatment at a ten-year Framingham cardiovascular (CVD) risk of 20% [2]. Calculating Framingham cardiovascular risk requires knowledge of a patient's age, sex, diabetic status, smoking status, total cholesterol, HDL cholesterol and whether or not they have existing cardiovascular disease. Risk factor assessment requires patient time, staff time and laboratory tests. Furthermore, not all patients assessed are eligible for treatment. To make best use of resources for identification of patients eligible for preventive treatments it woul
Indications for and utilization of angiotensin receptor II blockers in patients at high cardiovascular risk  [cached]
Farsang C
Vascular Health and Risk Management , 2011,
Abstract: Csaba FarsangCardiometabolic Center, Department of Internal Medicine, St Imre Hospital, Budapest, HungaryAbstract: The worldwide burden of cardiovascular disease is growing. In addition to lifestyle changes, pharmacologic agents that can modify cardiovascular disease processes have the potential to reduce cardiovascular events. Antihypertensive agents are widely used to reduce the risk of cardiovascular events partly beyond that of blood pressure-lowering. In particular, the angiotensin II receptor blockers (ARBs), which antagonize the vasoconstrictive and proinflammatory/pro-proliferative effects of angiotensin II, have been shown to be cardio vascularly protective and well tolerated. Although the eight currently available ARBs are all indicated for the treatment of hypertension, they have partly different pharmacology, and their pharmacokinetic and pharmacodynamic properties differ. ARB trials for reduction of cardiovascular risk can be broadly categorized into those in patients with/without hypertension and additional risk factors, in patients with evidence of cardiovascular disease, and in patients with severe cardiovascular disease, such as heart failure. These differences have led to their indications in different populations. For hypertensive patients with left ventricular hypertrophy, losartan was approved to have an indication for stroke prevention, while for most patients at high-risk for cardiovascular events, telmisartan is an appropriate therapy because it has a cardiovascular preventive indication. Other ARBs are indicated for narrowly defined high-risk patients, such as those with hypertension or heart failure. Although in one analysis a possible link between ARBs and increased risks of cancer has surfaced, several meta-analyses, using the most comprehensive data available, have found no link between any ARB, or the class as a whole, and cancer. Most recently, the US Food and Drug Administration completed a review of the potential risk of cancer and concluded that treatment with an ARB medication does not increase the risk of developing cancer. This review discusses the clinical evidence supporting the different indications for each of the ARBs and the outstanding safety of this drug class.Keywords: angiotensin II receptor blocker, cardiovascular disease, cardiometabolic risk, cardiovascular prevention
Experience of ramipril (Hartil) usage in patients with high cardiovascular risk (the OPTIMIST study  [cached]
I.A. Velizhanina,L.I. Gapon,E.S. Velizhanina,M.I. Shupina
Rational Pharmacotherapy in Cardiology , 2009,
Abstract: Aim. To evaluate efficacy and safety of ramipril (Hartil, Egis) in treatment of patients with different cardiovascular risk (according to arterial hypertension (HT) risk stratification) in real clinical practice.Material and methods. 998 patients (424 men and 574 women; aged 57,4 }0,4 y.o.) with HT; with combination of HT and ischemic heart disease; with ischemic heart disease and high normal blood pressure (BP) were included in the open non-control non-comparative multicenter phase IV study. The anamnesis data collection, physical examination, evaluation of risk factors, the target organ damage, the associated cardiovascular diseases, total cardiovascular risk, previous therapy, and also BP measurement were performed.All patients received ramipril within 8 weeks additionally to previous antihypertensive therapy. The BP measurement was performed initially, after 4 and 8 weeks of therapy. Achievement of target BP level (BP<140/90 or <130/80 mm Hg in patients of high or very high cardiovascular risk) was used as efficacy criterion.Results. 790 (82,1%) hypertensive patients used antihypertensive therapy before the study. 675 (85,4%) patients received ACE inhibitors, 435 (55%) patients - beta-blockers, 230 (29,1%) patients - calcium channel blockers, 420 (53,2%) patients – diuretics and 28 (3,5%) patients - angiotensin II receptor blockers. Ramipril additionally to previous therapy provided achievement of target BP in 69,4% of patients with high and in 64,8% of patients with very high cardiovascular risk.Conclusion. Addition of a ramipril to the treatment of patients with high and very high cardiovascular risk increases efficacy of the therapy.
Indications for and utilization of angiotensin receptor II blockers in patients at high cardiovascular risk
Farsang C
Vascular Health and Risk Management , 2011, DOI: http://dx.doi.org/10.2147/VHRM.S23468
Abstract: dications for and utilization of angiotensin receptor II blockers in patients at high cardiovascular risk Review (4414) Total Article Views Authors: Farsang C Published Date September 2011 Volume 2011:7 Pages 605 - 622 DOI: http://dx.doi.org/10.2147/VHRM.S23468 Csaba Farsang Cardiometabolic Center, Department of Internal Medicine, St Imre Hospital, Budapest, Hungary Abstract: The worldwide burden of cardiovascular disease is growing. In addition to lifestyle changes, pharmacologic agents that can modify cardiovascular disease processes have the potential to reduce cardiovascular events. Antihypertensive agents are widely used to reduce the risk of cardiovascular events partly beyond that of blood pressure-lowering. In particular, the angiotensin II receptor blockers (ARBs), which antagonize the vasoconstrictive and proinflammatory/pro-proliferative effects of angiotensin II, have been shown to be cardio vascularly protective and well tolerated. Although the eight currently available ARBs are all indicated for the treatment of hypertension, they have partly different pharmacology, and their pharmacokinetic and pharmacodynamic properties differ. ARB trials for reduction of cardiovascular risk can be broadly categorized into those in patients with/without hypertension and additional risk factors, in patients with evidence of cardiovascular disease, and in patients with severe cardiovascular disease, such as heart failure. These differences have led to their indications in different populations. For hypertensive patients with left ventricular hypertrophy, losartan was approved to have an indication for stroke prevention, while for most patients at high-risk for cardiovascular events, telmisartan is an appropriate therapy because it has a cardiovascular preventive indication. Other ARBs are indicated for narrowly defined high-risk patients, such as those with hypertension or heart failure. Although in one analysis a possible link between ARBs and increased risks of cancer has surfaced, several meta-analyses, using the most comprehensive data available, have found no link between any ARB, or the class as a whole, and cancer. Most recently, the US Food and Drug Administration completed a review of the potential risk of cancer and concluded that treatment with an ARB medication does not increase the risk of developing cancer. This review discusses the clinical evidence supporting the different indications for each of the ARBs and the outstanding safety of this drug class.
Improving Blood Pressure Control in Patients with Diabetes Mellitus and High Cardiovascular Risk  [PDF]
Henry L. Elliott,Suzanne M. Lloyd,Ian Ford,Peter A. Meredith
International Journal of Hypertension , 2010, DOI: 10.4061/2010/490769
Abstract: Patients with diabetes mellitus and symptomatic coronary artery disease are also likely to be hypertensive and, overall, are at very high cardiovascular (CV) risk. This paper reports the findings of a posthoc analysis of the 1113 patients with diabetes mellitus in the ACTION trial: ACTION itself showed that outcomes in patients with stable angina and hypertension were significantly improved when a long-acting calcium channel blocking drug (nifedipine GITS) was added to their treatment regimens. This further analysis of the ACTION database in those patients with diabetes has identified a number of practical therapeutic issues which are still relevant because of potential outcome benefits, particularly in relation to BP control. For example, despite background CV treatment and, specifically, despite the widespread use of ACE Inhibitor drugs, the addition of nifedipine GITS was associated with significant benefits: improvement in BP control by an average of 6/3 mmHg and significant improvements in outcome. In summary, this retrospective analysis has identified that the addition of nifedipine GITS resulted in improved BP control and significant outcome benefits in patients with diabetes who were at high CV risk. There is evidence to suggest that these findings are of direct relevance to current therapeutic practice.
Improving Blood Pressure Control in Patients with Diabetes Mellitus and High Cardiovascular Risk  [PDF]
Henry L. Elliott,Suzanne M. Lloyd,Ian Ford,Peter A. Meredith
International Journal of Hypertension , 2010, DOI: 10.4061/2010/490769
Abstract: Patients with diabetes mellitus and symptomatic coronary artery disease are also likely to be hypertensive and, overall, are at very high cardiovascular (CV) risk. This paper reports the findings of a posthoc analysis of the 1113 patients with diabetes mellitus in the ACTION trial: ACTION itself showed that outcomes in patients with stable angina and hypertension were significantly improved when a long-acting calcium channel blocking drug (nifedipine GITS) was added to their treatment regimens. This further analysis of the ACTION database in those patients with diabetes has identified a number of practical therapeutic issues which are still relevant because of potential outcome benefits, particularly in relation to BP control. For example, despite background CV treatment and, specifically, despite the widespread use of ACE Inhibitor drugs, the addition of nifedipine GITS was associated with significant benefits: improvement in BP control by an average of 6/3?mmHg and significant improvements in outcome. In summary, this retrospective analysis has identified that the addition of nifedipine GITS resulted in improved BP control and significant outcome benefits in patients with diabetes who were at high CV risk. There is evidence to suggest that these findings are of direct relevance to current therapeutic practice. 1. Introduction The optimal management of patients with type 2 diabetes mellitus requires a multiplicity of drug treatments: not only for glycaemic control but also for nephroprotection and for reducing cardiovascular (CV) risk. Since CV disease, particularly coronary artery disease (CAD), accounts for around 60% of deaths in people with type 2 diabetes mellitus, “cardioprotective” drugs are obviously of fundamental importance [1, 2]. Furthermore, since many of these patients with diabetes also have hypertension and since there is good evidence that “tight” blood pressure (BP) control significantly reduces CV morbidity and mortality in diabetic, hypertensive patients (usually by means of combination drug treatment), optimal antihypertensive treatment is central to the overall therapeutic strategy [3, 4]. Although it is recommended that the antihypertensive treatment regimen includes drugs which block the renin-angiotensin system (RAS blockade) (mainly because of the evidence suggestive of nephroprotection) [5–7], it is important to remember that RAS blockade has no direct antianginal activity. Thus, there is not yet agreement on the “best practice” antihypertensive/antianginal treatment combination for patients with diabetes, hypertension, and
Benefits of statin therapy and compliance in high risk cardiovascular patients  [cached]
Joel A Lardizabal,Prakash C Deedwania
Vascular Health and Risk Management , 2010,
Abstract: Joel A Lardizabal1, Prakash C Deedwania21Division of Cardiology, Department of Medicine, University of California in San Francisco (Fresno-MEP), Fresno, CA, USA; 2University of California in San Francisco, Chief of Cardiology, Veterans Affairs Central California System, Fresno, CA, USAAbstract: Cardiovascular disease (CVD) remains the top cause of global mortality. There is considerable evidence that supports the mortality and morbidity benefit of statin therapy in coronary heart disease (CHD) and stroke, both in primary and secondary prevention settings. Data also exist pointing to the advantage of statin treatment in other high-risk CVD conditions, such as diabetes, CKD, CHF, and PVD. National and international clinical guidelines in the management of these CVD conditions all advocate for the utilization of statin therapy in appropriate patients. However, overall compliance to statin therapy remains suboptimal. Patient-, physician-, and economic-related factors all play a role. These factors need to be considered in devising approaches to enhance adherence to guideline-based therapies. To fully reap the benefits of statin therapy, interventions which improve long-term treatment compliance in real-world settings should be encouraged.Keywords: cardiovascular disease, statin therapy, coronary heart disease, long-term treatment compliance
Benefits of statin therapy and compliance in high risk cardiovascular patients
Joel A Lardizabal, Prakash C Deedwania
Vascular Health and Risk Management , 2010, DOI: http://dx.doi.org/10.2147/VHRM.S9474
Abstract: enefits of statin therapy and compliance in high risk cardiovascular patients Review (8844) Total Article Views Authors: Joel A Lardizabal, Prakash C Deedwania Published Date September 2010 Volume 2010:6 Pages 843 - 853 DOI: http://dx.doi.org/10.2147/VHRM.S9474 Joel A Lardizabal1, Prakash C Deedwania2 1Division of Cardiology, Department of Medicine, University of California in San Francisco (Fresno-MEP), Fresno, CA, USA; 2University of California in San Francisco, Chief of Cardiology, Veterans Affairs Central California System, Fresno, CA, USA Abstract: Cardiovascular disease (CVD) remains the top cause of global mortality. There is considerable evidence that supports the mortality and morbidity benefit of statin therapy in coronary heart disease (CHD) and stroke, both in primary and secondary prevention settings. Data also exist pointing to the advantage of statin treatment in other high-risk CVD conditions, such as diabetes, CKD, CHF, and PVD. National and international clinical guidelines in the management of these CVD conditions all advocate for the utilization of statin therapy in appropriate patients. However, overall compliance to statin therapy remains suboptimal. Patient-, physician-, and economic-related factors all play a role. These factors need to be considered in devising approaches to enhance adherence to guideline-based therapies. To fully reap the benefits of statin therapy, interventions which improve long-term treatment compliance in real-world settings should be encouraged.
Risk of Cardiovascular Disease among Diabetic Patients in Manipur, Northeast India  [PDF]
Mary Grace Tungdim,T. Ginzaniang,G. Poufullung Kabui,Deepali Verma,Satwanti Kapoor
Journal of Anthropology , 2014, DOI: 10.1155/2014/421439
Abstract: Atherosclerotic cardiovascular disease is the major cause of premature mortality in patients with type 2 diabetes. The present study was conducted to assess cardiovascular risk among diabetic patients of Northeast India. The present cross-sectional study included 81 diabetic patients (39 males and 42 females) aged 36–74 years from the district Imphal of Manipur, Northeast India. Sex-specific Framingham general cardiovascular risk prediction equations were used to calculate the 10-year risk for cardiovascular disease. The probable risk factors were determined by cross-tabulation of cardiometabolic parameters with the 10-year cardiovascular risk level. Males were found to be at higher risk of developing CVD in the future as compared to females with a discernible accumulation of adverse cardiovascular risk factors among them. 38.3% patients were at high risk, 37.0% at moderate risk and 24.7% at low risk for developing CVD in the next 10 years. Systolic blood pressure, total cholesterol, triglyceride, and smoking contributed significantly to high degree of cardiovascular risk. Presence of cardiovascular risk factors among diabetic patients at diagnosis accentuates the need of intensive management of cardiovascular complications, taking into consideration the traditional dietary pattern of the population. 1. Introduction Changes in the human environment, behaviour, and lifestyle are contributing to the upsurge in the incidence of diabetes. However, better management has resulted in a longer survival of patients with diabetes, but it is accompanied by long-term chronic complications due to hyperglycemia [1]. Individuals with diabetes most often die of cardiovascular disease (CVD) rather than from a cause uniquely related to diabetes, such as ketoacidosis or hypoglycemia [2]. Diabetic patients have a twofold to sixfold higher incidence of cardiovascular disease than nondiabetic population [3]. Furthermore, diabetic patients with CVD sustain a worse prognosis for survival than CVD patients without diabetes and their quality of life also depreciates. Therefore, diabetes has been considered as having a risk equivalent to a nondiabetic patient with preexisting heart disease [4]. Identification of patients at risk for CVD could felicitate the prevention or retardation of cardiovascular events. Lifetime risk estimates provide a simple conceptual basis for estimating the absolute risk of developing disease over the remaining lifespan [5]. Presence of several risk factors among diabetic patients suffering from cardiovascular disease stresses on the assessment of the
Cardiovascular risk factor treatment targets and renal complications in high risk vascular patients: a cohort study
Sharmini Selvarajah, Yolanda vD Graaf, Frank LJ Visseren, Michiel L Bots, the SMART study group
BMC Cardiovascular Disorders , 2011, DOI: 10.1186/1471-2261-11-40
Abstract: This was a cohort study. Participants in Utrecht, The Netherlands either at risk of, or had cardiovascular disease were recruited. Cardiovascular treatment targets were achievement of control in systolic and diastolic blood pressure, total and low-density cholesterol, and treatment of albuminuria. Outcome measures were time to development of end stage renal failure or symptomatic renal atherosclerotic disease requiring intervention.The cohort consisted of 7,208 participants; 1,759 diabetics and 4,859 with clinically manifest vascular disease. The median age was 57 years and 67% were male. Overall, 29% of the cohort achieved the treatment target for systolic blood pressure, 39% for diastolic blood pressure, 28% for total cholesterol, 31% for LDL cholesterol and 78% for albuminuria. The incidence rate for end stage renal failure and renal atherosclerotic disease reduced linearly with each additional treatment target achieved (p value less than 0.001). Achievement of any two treatment targets reduced the risk of renal complications, hazard ratio 0.46 (95% CI 0.26-0.82). For patients with clinically manifest vascular disease and diabetes, the hazard ratios were 0.56 (95% CI 0.28 - 1.12) and 0.28 (95%CI 0.10 - 0.79) respectively.Clinical guidelines for cardiovascular disease management do reduce risk of renal complications in high risk patients. Benefits are seen with attainment of any two treatment targets.Current clinical practice guidelines for the management of patients with diabetes, hypertension and other atherosclerotic risk factors are geared to the prevention of cardiovascular disease and its complications [1-3]. However, cardiovascular diseases are not the only complications that can arise. Renal complications such as renal atherosclerotic disease [4] and end stage renal failure (ESRF) are of equal importance [5-9] though not as common.There are few studies looking at the effects of combined cardiovascular treatment targets on renal complications; most are aime
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