Articles include the following
Cardiovascular Horizon Scanning Volume 3 Issue 2
Multiple risk factor interventions for primary prevention of coronary heart disease
Exercise on prescription: changes in physical activity and health-related quality of life
Efficacy of quantified home-based exercise and supervised exercise
Improving cardiovascular health at population level
NHS failing to screen for deadly heart condition
Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease
Parental history and myocardial infarction
The association of breast arterial calcification and coronary heart disease
Conventional versus automated measurement of blood pressure in primary care
Early life socioeconomic adversity is associated in adult life with chronic inflammation, carotid artherosclerosis, poorer lung function and decreased cognitive performance: a cross-sectional, population-based study
Further dissemination
Cardiovascular Horizon Scanning Volume 3 Issue 2
Posted: 14 Feb 2011 07:50 AM PST
Filed under: Cardiovascular diseases, Volume 3 Issue 2
Multiple risk factor interventions for primary prevention of coronary heart disease
Posted: 11 Feb 2011 09:37 AM PST
Source: Cochrane Database of Systematic Reviews 2011, issue 1
Follow this link for fulltext
Date of publication: January 2011
Publication type: Systematic review
In a nutshell: The evidence from this Cochrane systematic review suggests that multiple risk factor interventions using counselling and educational methods to change behaviour do not reduce coronary heart disease (CHD) mortality and morbidity. However, they may be effective in reducing mortality in high-risk hypertensive and diabetic populations. It concludes that health promotion interventions have limited use in general populations.
Length of publication: 175 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Volume 3 Issue 2 Tagged: behaviour change, CHD, health promotion, risk factors
Exercise on prescription: changes in physical activity and health-related quality of life
Posted: 11 Feb 2011 07:06 AM PST
Source: European Journal of Public Health, 2011, 21 (1), p. 56-62
Follow this link for fulltext
Date of publication: January 2011
Publication type: Research
In a nutshell: This study analysed changes in physical activity among participants of five Exercise on Prescription (EoP) programmes in Denmark. EoP helped to contribute to improved levels of physical activity and health-related quality of life.
Length of publication: 7 pages
Some important notes: You will need an NHS Athens username and password to access this article. Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Physical activity, Volume 3 Issue 2 Tagged: behaviour change, Exercise, lifestyle
Efficacy of quantified home-based exercise and supervised exercise
Posted: 10 Feb 2011 09:49 AM PST
Source: Circulation, 2011, 123 (5) p. 491-498
Follow this link for fulltext
Date of publication: February 2011
Publication type: Research
In a nutshell: This clinical trial compared home-based and supervised exercise programmes among peripheral artery disease patients. The results of the study found that a home-based exercise programme had high adherence and was effective in improving claudication measures and increasing daily ambulatory activity.
Length of publication: 8 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.
Acknowledgement: American Heart AssociationFiled under: Cardiovascular diseases, Volume 3 Issue 2 Tagged: claudication, peripheral artery disease, Physical activity
Improving cardiovascular health at population level
Posted: 10 Feb 2011 09:25 AM PST
Source: BMJ 2011; 342:d442 (Online First)
Follow this link for fulltext
Date of publication: February 2011
Publication type: Research
In a nutshell: The Cardiovascular Health Awareness Program (CHAP) was implemented as an intervention to reduce morbidity from cardiovascular disease among older adults in 39 communities in Canada. This collaborative, community-based health promotion and prevention programme was found to reduce cardiovascular morbidity at a population level.
Length of publication: 8 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Canada, Cardiovascular diseases, Prevention, Volume 3 Issue 2 Tagged: community-based programmes, education, health promotion, Risk assessment
NHS failing to screen for deadly heart condition
Posted: 10 Feb 2011 09:16 AM PST
Source: National Institute for Health and Clinical Excellence
Follow this link for fulltext
Date of publication: January 2011
Publication type: Press release
In a nutshell: 100.000 people are at risk of developing familial hypercholesterolaemia (FH) as trusts fail to act on NICE guidelines which call for early diagnosis. A UK-wide audit found that very few families were systematically genetically screened for the inherited condition.
Length of publication: 1 webpage
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Diagnosis, Volume 3 Issue 2 Tagged: familial hypercholesterolaemia, family history, genetics, screening
Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease
Posted: 10 Feb 2011 07:30 AM PST
Source: The Cochrane Library
Follow this link for fulltext
Date of publication: 14 January 2011
Publication type: Editorial
In a nutshell: This editorial is written by Carl Heneghan, Director of the Centre for Evidence Based Medicine, and Clinical Reader in the Department of Primary Health Care, University of Oxford. It is based on the evidence from two new Cochrane reviews of preventive strategies: multiple risk factor interventions for primary prevention of CHD, and statins for the primary prevention of CVD.
Length of publication: 1 web page
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Prevention, Volume 3 Issue 2 Tagged: evidence, preventative services, Prevention
Parental history and myocardial infarction
Posted: 10 Feb 2011 06:18 AM PST
Source: Reuters 27.1.11
Follow this link for fulltext
Date of publication: 27 January 2011
Publication type: News item
In a nutshell: Reports on the findings of the INTERHEART study, published recently in the Journal of the American College of Cardiology. 12 000 participants from 52 countries were studied, and across all nationalities, the risk of heart disease was almost doubled in those with a family history of heart attack.
Length of publication: 1 web page
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.
Acknowledgement: Journal of the American College of Cardiology (JACC), 2011, 57, pp 619-627Filed under: Cardiovascular diseases, Volume 3 Issue 2 Tagged: family history, risk factors
The association of breast arterial calcification and coronary heart disease
Posted: 10 Feb 2011 04:01 AM PST
Source: Obstetrics and Gynecology, 2011, 117 (2 part 1) p. 233-241
Follow this link for fulltext
Date of publication: February 2011
Publication type: Research
In a nutshell: The objective of this study was to determine whether mammography could be an early prediction tool for the development of coronary heart disease (CHD). The study found that the presence of breast arterial calcifications on mammograms indicated a significantly increased risk of developing CHD or a stroke, and could therefore be used as a marker.
Length of publication: 9 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Prevention, Volume 3 Issue 2 Tagged: CHD, mammography, risk markers, risk prediction tools
Conventional versus automated measurement of blood pressure in primary care
Posted: 10 Feb 2011 03:23 AM PST
Source: BMJ 2011;342:d286 (Online First)
Follow this link for fulltext
Date of publication: 7th February 2011
Publication type: Research
In a nutshell: The objective of this randomised controlled trial was to compare the quality and accuracy of manual office blood pressure and automated office blood pressure. Primary care practices in five Canadian cities were randomly allocated to the use of either manual or automated office blood pressure.
Length of publication: 9 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Canada, Cardiovascular diseases, Prevention, Volume 3 Issue 2 Tagged: BP monitoring
Early life socioeconomic adversity is associated in adult life with chronic inflammation, carotid artherosclerosis, poorer lung function and decreased cognitive performance: a cross-sectional, population-based study
Posted: 09 Feb 2011 07:14 AM PST
Source: BMC Public Health, 2011, 11:42
Follow this link for fulltext
Date of publication: 17 January 2011
Publication type: Journal article
In a nutshell: The Scottish Psychosocial and Biological Determinants of Ill-health (pSoBid) Study was conducted to examine links between early life adversity, intermediary phenotypes and markers of ill-health in adulthood, including artherosclerosis.
Length of publication: 16 pages
Some important notes: Please contact your local NHS library if you cannot access the full text. Follow this link to find your local NHS library.Filed under: Cardiovascular diseases, Volume 3 Issue 2 Tagged: health inequalities, risk factors
Further dissemination
Posted: 08 Feb 2011 05:44 AM PST
If you think someone would benefit from receiving this posting, please e-mail them the link to this blog and suggest that they sign up to the e-mail newsletter to stay up to date with new content.Filed under: Cardiovascular diseases, Volume 3 Issue 2
Showing posts with label coronary heart disease. Show all posts
Showing posts with label coronary heart disease. Show all posts
Tuesday, 15 February 2011
Wednesday, 9 February 2011
NHS EVIDENCE
Antiplatelet dosage for PCIOverview: Percutaneous coronary intervention (PCI) is an important advance in the treatment of patients with acute coronary syndromes, with or without ST segment elevation. Despite the capacity of PCI to reduce major cardiovascular events, the risk of thrombotic complications remains an important concern. Hence, attention is being focused on the development of fast-acting anti-platelet regimens that achieve high levels of platelet inhibition.
Current advice: Aspirin, in combination with clopidogrel – a thienopyridine adenosine diphosphate receptor antagonist – prevents major thrombotic events in patients undergoing PCI and has been the standard of care for more than a decade.NICE guidance on the early management of unstable angina and non ST segment elevation myocardial infarction recommends offering a single loading dose of 300 mg aspirin and continuing aspirin indefinitely.For patients with no contraindications, who may undergo PCI within 24 hours of admission to hospital, NICE recommends offering a 300 mg loading dose of clopidogrel. The guidance states that there is emerging evidence about the use of a 600 mg loading dose of clopidogrel for patients undergoing PCI within 24 hours of admission. However, NICE was not able to formally review all the evidence and was therefore unable to recommend this at the time of guidance publication (March 2010).
New evidence: The CURRENT-OASIS 7 trial (The Lancet Volume 376, Issue 9748) assessed whether doubling of the loading and maintenance dose of clopidogrel for 7 days was better than the standard dose and if high dose aspirin was better than low dose aspirin in patients undergoing PCI.A 7 day double dose clopidogrel regimen (600 mg on day 1, 150 mg on days 2 to 7, then 75 mg daily) was associated with a reduction in cardiovascular events and stent thrombosis compared to the standard dose (300 mg on day 1 then 75 mg daily). The analysis suggests a clear benefit in the 17,236 patients who underwent a PCI procedure.
Using the CURRENT/OASIS 7 trial definition, major bleeding was more common with double than standard dose clopidogrel. Before PCI, rates of ischaemic events or major bleeding did not differ between the groups.The researchers conclude that a double-dose clopidogrel regimen (600 mg loading dose) can be considered for all patients with acute coronary syndromes treated with an early invasive strategy and intended early PCI.Efficacy and safety did not differ between high dose (300 to 325 mg daily) and low dose (75 to 100mg daily) aspirin. However, since the dose comparison was for only 30 days, use of low-dose aspirin is still thought to be reasonable for long-term therapy.
New evidence: The CURRENT-OASIS 7 trial (The Lancet Volume 376, Issue 9748) assessed whether doubling of the loading and maintenance dose of clopidogrel for 7 days was better than the standard dose and if high dose aspirin was better than low dose aspirin in patients undergoing PCI.A 7 day double dose clopidogrel regimen (600 mg on day 1, 150 mg on days 2 to 7, then 75 mg daily) was associated with a reduction in cardiovascular events and stent thrombosis compared to the standard dose (300 mg on day 1 then 75 mg daily). The analysis suggests a clear benefit in the 17,236 patients who underwent a PCI procedure.
Using the CURRENT/OASIS 7 trial definition, major bleeding was more common with double than standard dose clopidogrel. Before PCI, rates of ischaemic events or major bleeding did not differ between the groups.The researchers conclude that a double-dose clopidogrel regimen (600 mg loading dose) can be considered for all patients with acute coronary syndromes treated with an early invasive strategy and intended early PCI.Efficacy and safety did not differ between high dose (300 to 325 mg daily) and low dose (75 to 100mg daily) aspirin. However, since the dose comparison was for only 30 days, use of low-dose aspirin is still thought to be reasonable for long-term therapy.
Commentary:"CURRENT-OASIS 7 is the latest in a long list of trials that tests the impact of dual anti-platelet therapy on efficacy, and since most trials look at the effect of increased therapy to prevent stent thrombosis (or its surrogate acute myocardial infarction/death), also importantly bleeding. A number of studies and retrospective analyses of large trials have shown the benefit of 600 mg over 300 mg.
"I see two problems with this study. First, two things were changed at once (so we don't really know which change, aspirin or clopidogrel, was beneficial in this study) and secondly, increasing the loading dose of clopidogrel to 150 mg with maintenance of 150 mg, if this is thought to be of value (and the trial suggests it might be), was associated with extra bleeding risk.
"So how should we use this study as applied to UK practice? In patients presenting with acute coronary syndrome who are at a low risk of bleeding (i.e. normal renal function, body weight of more than 60kg and no evidence of GI tract disease), it might be reasonable to give 600 mg clopidogrel loading but then to increase the maintenance clopidogrel dose to 150 mg for one week (only) and to maintain the patient on 75 mg aspirin and 75 mg clopidogrel." - Tony Gershlick, Professor of Interventional Cardiology, University of Leicester.
"I see two problems with this study. First, two things were changed at once (so we don't really know which change, aspirin or clopidogrel, was beneficial in this study) and secondly, increasing the loading dose of clopidogrel to 150 mg with maintenance of 150 mg, if this is thought to be of value (and the trial suggests it might be), was associated with extra bleeding risk.
"So how should we use this study as applied to UK practice? In patients presenting with acute coronary syndrome who are at a low risk of bleeding (i.e. normal renal function, body weight of more than 60kg and no evidence of GI tract disease), it might be reasonable to give 600 mg clopidogrel loading but then to increase the maintenance clopidogrel dose to 150 mg for one week (only) and to maintain the patient on 75 mg aspirin and 75 mg clopidogrel." - Tony Gershlick, Professor of Interventional Cardiology, University of Leicester.
For more evidence relating to cardiovascular health visit NHS Evidence - Cardiovascular.
NICE guidance on the early management of unstable angina and non ST segment elevation myocardial infarction is due to be updated in March 2013.
Eyes on Evidence helps contextualise significant new evidence, highlighting areas that could signal a change in clinical practice. It does not constitute formal NICE guidance. The commentaries included are the opinions of contributors and do not necessarily reflect the views of NICE.
Wednesday, 1 December 2010
JOURNAL SNIPPETS November 3
NEJM 25 Nov 2010 Vol 363
2091 Quality improvement is actually, of course, a good thing in itself, and we need better ways of doing it and better ways of studying it. High quality outcomes research, carefully reflected on, is one essential input, and there are two good examples in this week's New England Journal. A general survey of North Carolina hospitals (see below, p.2124) produces a rather gloomy view of overall improvements in patient safety, but this study of mortality from allogeneic haematopoietic-cell transplantation is very much cheerier. The period 2003-7 showed an overall mortality fall of over 40% compared with a decade earlier, driven by significant decreases in the risk of severe GVHD; disease caused by viral, bacterial, and fungal infections; and damage to the liver, kidneys, and lungs. Further details are strictly for the haematologists: but it seems they have much to congratulate themselves about.
http://www.nejm.org/doi/full/10.1056/NEJMoa1004383
BMJ 27 Nov 2010 Vol 341
1144 Thrombolysis for acute occlusive stroke has been shown to be marginally beneficial in several RCTs, but the number of people over 80 in these trials is minuscule, whereas in real life, 30% of strokes occur in this age group. There is a presumption that the hazards of thrombolysis will be greater and the outcome difference less. This European registry study indicates that neither is true: thrombolysis remains beneficial for stroke beyond the age of 80.
http://www.bmj.com/content/341/bmj.c6046.full
1146 Any enthusiastic regular drinker of wine, will be delighted to note the PRIME study which confirms that by doing so you halve your chance of myocardial infarction. I suppose you also increase your chance of pancreatitis, cancers of the GI tract and stroke. Perhaps liver disease too, though the literature is surprisingly obscure at levels of intake below about 100u/week. The thing not to do is binge drink, which is a common pattern in Northern Ireland, and probably increases your baseline risk of MI. I think the further north you travel, the more dysfunctional alcohol use becomes, as warm oblivion becomes ever more desirable. As if to illustrate this point, a review of frostbite on p.1151 finds that nearly half of it is associated with alcohol use. I bet that means vodka or whisky in most cases, and wine alone hardly ever.
http://www.bmj.com/content/341/bmj.c6077.fullhttp://www.bmj.com/content/341/bmj.c5864.extract
Arch Intern Med 22 Nov 2010 Vol 170
1926 In studies of drugs that put people into hospital, warfarin usually comes near the top. This study looks at how combined platelet inhibition with aspirin plus clopidogrel compares in emergency department visits for haemorrhage-related events. The score is 2-1: 2.5 events per 1000 prescriptions of warfarin as compared with 1.2 events for aspirin/clopidogrel.
http://archinte.ama-assn.org/cgi/content/abstract/170/21/1892
JAMA 17 Nov 2010 Vol 304
2129 Like all doctors who survived their hospital jobs in the 1970s, I have some shocking memories. Oddly enough, though, some of them are happy too, as the shocks saved lives. The woman dragged out of a freezing canal with a core temperature of 28ºC who survived intact after 16 defibrillations; the 43-year old man with chest pain who went into VF just as we were putting the leads on his chest: all of us can still remember these kinds of event, while our futile attempts go forgotten days after. Surely an automated defibrillator must beat a sleep-deprived, dishevelled house doctor at achieving survival following in-hospital cardiac arrest? Actually no: another massive US cardiac outcomes study looks at the results of introducing automated defibrillators on to the wards of 204 hospitals and finds that results actually tend to be worse.
http://jama.ama-assn.org/cgi/content/abstract/304/19/2129
2137 The harmful effects of low-dose ionizing radiation are not well understood, but from about 100mSv upwards we are no longer talking about low doses, but the kind of exposures about which we have data from Hiroshima and Nagasaki. Alarmingly, such doses were received by a third of patients in this study of repeated myocardial perfusion scanning. OK, the majority of these people were over 60 and had heart disease, and would escape long-term harm: but it suggests that we are getting too gung-ho about exposing people to high energy photons from X-ray machines and unstable isotopes, and the cumulative damage which they cause.
http://jama.ama-assn.org/cgi/content/abstract/304/19/2137
Lancet 20 Nov 2010 Vol 376
1741 Many doctors in the 1990s went through a phase of taking low dose aspirin and recommending it to many of their patients with high blood pressure and/or type 2 diabetes. Then came a series of trials which showed that it doesn't work for primary prevention of cardiovascular events, even in groups who are at increased risk. But it does prevent about 25% of bowel cancer, according to this long-term follow up study of participants in 5 large aspirin trials, matched at a median of 18.3 years with mortality registers. The results suggest that you need to take about 75mg of aspirin for at least 5 years to achieve such protection, and the effect may be specific to the proximal colon. Thus in theory universal aspirin consumption, combined with a universal programme of screening sigmoidoscopy, could prevent most bowel cancer. However, an analysis like this can tell us little about adverse events, and we will only know for certain after a prospective trial lasting at least ten years.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61543-7/abstract
2091 Quality improvement is actually, of course, a good thing in itself, and we need better ways of doing it and better ways of studying it. High quality outcomes research, carefully reflected on, is one essential input, and there are two good examples in this week's New England Journal. A general survey of North Carolina hospitals (see below, p.2124) produces a rather gloomy view of overall improvements in patient safety, but this study of mortality from allogeneic haematopoietic-cell transplantation is very much cheerier. The period 2003-7 showed an overall mortality fall of over 40% compared with a decade earlier, driven by significant decreases in the risk of severe GVHD; disease caused by viral, bacterial, and fungal infections; and damage to the liver, kidneys, and lungs. Further details are strictly for the haematologists: but it seems they have much to congratulate themselves about.
http://www.nejm.org/doi/full/10.1056/NEJMoa1004383
BMJ 27 Nov 2010 Vol 341
1144 Thrombolysis for acute occlusive stroke has been shown to be marginally beneficial in several RCTs, but the number of people over 80 in these trials is minuscule, whereas in real life, 30% of strokes occur in this age group. There is a presumption that the hazards of thrombolysis will be greater and the outcome difference less. This European registry study indicates that neither is true: thrombolysis remains beneficial for stroke beyond the age of 80.
http://www.bmj.com/content/341/bmj.c6046.full
1146 Any enthusiastic regular drinker of wine, will be delighted to note the PRIME study which confirms that by doing so you halve your chance of myocardial infarction. I suppose you also increase your chance of pancreatitis, cancers of the GI tract and stroke. Perhaps liver disease too, though the literature is surprisingly obscure at levels of intake below about 100u/week. The thing not to do is binge drink, which is a common pattern in Northern Ireland, and probably increases your baseline risk of MI. I think the further north you travel, the more dysfunctional alcohol use becomes, as warm oblivion becomes ever more desirable. As if to illustrate this point, a review of frostbite on p.1151 finds that nearly half of it is associated with alcohol use. I bet that means vodka or whisky in most cases, and wine alone hardly ever.
http://www.bmj.com/content/341/bmj.c6077.fullhttp://www.bmj.com/content/341/bmj.c5864.extract
Arch Intern Med 22 Nov 2010 Vol 170
1926 In studies of drugs that put people into hospital, warfarin usually comes near the top. This study looks at how combined platelet inhibition with aspirin plus clopidogrel compares in emergency department visits for haemorrhage-related events. The score is 2-1: 2.5 events per 1000 prescriptions of warfarin as compared with 1.2 events for aspirin/clopidogrel.
http://archinte.ama-assn.org/cgi/content/abstract/170/21/1892
JAMA 17 Nov 2010 Vol 304
2129 Like all doctors who survived their hospital jobs in the 1970s, I have some shocking memories. Oddly enough, though, some of them are happy too, as the shocks saved lives. The woman dragged out of a freezing canal with a core temperature of 28ºC who survived intact after 16 defibrillations; the 43-year old man with chest pain who went into VF just as we were putting the leads on his chest: all of us can still remember these kinds of event, while our futile attempts go forgotten days after. Surely an automated defibrillator must beat a sleep-deprived, dishevelled house doctor at achieving survival following in-hospital cardiac arrest? Actually no: another massive US cardiac outcomes study looks at the results of introducing automated defibrillators on to the wards of 204 hospitals and finds that results actually tend to be worse.
http://jama.ama-assn.org/cgi/content/abstract/304/19/2129
2137 The harmful effects of low-dose ionizing radiation are not well understood, but from about 100mSv upwards we are no longer talking about low doses, but the kind of exposures about which we have data from Hiroshima and Nagasaki. Alarmingly, such doses were received by a third of patients in this study of repeated myocardial perfusion scanning. OK, the majority of these people were over 60 and had heart disease, and would escape long-term harm: but it suggests that we are getting too gung-ho about exposing people to high energy photons from X-ray machines and unstable isotopes, and the cumulative damage which they cause.
http://jama.ama-assn.org/cgi/content/abstract/304/19/2137
Lancet 20 Nov 2010 Vol 376
1741 Many doctors in the 1990s went through a phase of taking low dose aspirin and recommending it to many of their patients with high blood pressure and/or type 2 diabetes. Then came a series of trials which showed that it doesn't work for primary prevention of cardiovascular events, even in groups who are at increased risk. But it does prevent about 25% of bowel cancer, according to this long-term follow up study of participants in 5 large aspirin trials, matched at a median of 18.3 years with mortality registers. The results suggest that you need to take about 75mg of aspirin for at least 5 years to achieve such protection, and the effect may be specific to the proximal colon. Thus in theory universal aspirin consumption, combined with a universal programme of screening sigmoidoscopy, could prevent most bowel cancer. However, an analysis like this can tell us little about adverse events, and we will only know for certain after a prospective trial lasting at least ten years.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61543-7/abstract
Monday, 15 November 2010
JOURNAL SNIPPETS November 2
JAMA 11 Nov 2010 Vol 304
2028 It's not often that you see a paper in JAMA written by a real working British GP - so congratulations to Louis Levene from Leicester for an excellent study that seeks to inform US practice by showing what happens to coronary heart disease mortality in relation to the recorded characteristics of individual primary care trusts. This was quite a statistical feat in itself, but would have been even more useful had it been done on an individual practice basis - after all, the data are out there, literally for all to see. Anyway, rejoice: CHD in the UK has fallen by nearly a half in the last decade, and although there are regional variations, these are not due to variations in the quality of general practice, except in the detection of high blood pressure, which could easily be remedied.
http://jama.ama-assn.org/cgi/content/abstract/304/18/2028
2059 A neat Commentary piece discusses the dilemmas of interventional cardiology in the light of the COURAGE and SYNTAX studies which show that medical treatment is as effective as percutaneous coronary intervention for stable coronary artery disease. When the first study appeared in 2007, interventional cardiologists were asked if they would now have the conviction of their COURAGE and stop putting stents into every stenosis they happened to see at angiography - what has been described as the "oculo-stenotic reflex". All immediate stenting is lumped together as "ad hoc PCI" and accounts for more than 80% of PCI in the USA; done for acute syndromes, it is generally appropriate, but in other situations, often not. This is a thoughtful, balanced discussion which however tactfully bypasses one factor which may keep ad hoc PCI going in the USA - money. There may be a double incentive - patients and HMOs may want to save the cost of a second angiography; and cardiologists and their institutions may just want the extra dollars they get for putting in a stent there and then. This piece argues that there where there is clinical doubt there should always be informed patient decision-making, even if this means taking a two-week pause between the diagnostic angiogram and the procedure.
http://jama.ama-assn.org/cgi/content/extract/304/18/2059
Lancet 13 Nov 2010 Vol 376
BMJ 13 Nov 2010 Vol 341
1034 Do you like PROMs? When I was 16, I didn't mind queuing for tickets outside the Albert Hall and standing in the top gallery, but now being older, if you buy tickets on-line you can sit down and actually hear the players. This abbreviation also applies to patient-reported outcome measures, of the kind looked at in the context of heart failure. Suddenly these kinds of PROMs have become fashionable politically and get repeated mention in the White Paper "Liberating the NHS" - although they were never designed for service development but as end-points for clinical trials. Their quality and relevance varies widely, as you learn rapidly. This ground-breaking study devised an instrument with a high degree of inter-observer agreement to allow the assessment of PROMs in cardiovascular trials. Suffice to say that in many of the trials where they appear, they are used badly or irrelevantly, while in 70% of trials where they should appear, they don't.
http://www.bmj.com/content/341/bmj.c5707.full
Arch Intern Med 8 Nov 2010 Vol 170
1834 Delay From Symptom Onset to Hospital Presentation for Patients With Non–ST-Segment Elevation Myocardial Infarction. If you're a veteran scanner of titles in the US cardiovascular outcomes literature, the next thing you'll look for is the name of Harlan Krumholz in the authors list - ah yes, there it is, and so too is the name of Brahmajee Nallamothu, co-author of the thoughtful commentary piece on PCI in this week's JAMA. As a result of their work, and that of Henry Ting and John Spertus, who also appear in the credits, we know a huge amount in great detail about the workings of acute cardiology in the USA, despite the great variety of institutional arrangements. As a result of this exercise, for example, we know the exact time delay and clinical characteristics of 104 622 patients admitted to 568 US hospitals with NSTEMI - and realise that there has been no reduction in the delay time between 2001 and 2006. http://archinte.ama-assn.org/cgi/content/abstract/170/20/1834
1842 Now the interventional trials for ST-Elevation MI tell us that time means myocardium, so great efforts have been made in the US as in the UK to ensure that door-to-balloon time should be as short as possible. But what have we here? A study of 8771 patients admitted to a Michigan hospitals group between 2003 and 2008 which shows that although door-to-balloon time improved dramatically, outcomes remained the same. More data from UK studies quickly please: and since we do not have 568 acute hospitals and they all belong to one organisation, this should be a piece of cake compared with Harlan's work.
http://archinte.ama-assn.org/cgi/content/abstract/170/20/1842
1858 From time to time, serious medical journals like to publish pieces about chocolate, which are sure to get them a mention in the global news media. This research letter also involves women, thus allowing journalists to trot out their very funny jokes about the dear ladies and their chocolate. A group from Perth, Australia followed up a female cohort for 10 years to examine the effect of calcium supplements, and happened to ask about chocolate intake in their questionnaire. Here they report that chocolate consumption seems to have a dose-related protective effect against vascular disease in women. Ooh, come on girls, have another. http://archinte.ama-assn.org/cgi/content/extract/170/20/1857
2028 It's not often that you see a paper in JAMA written by a real working British GP - so congratulations to Louis Levene from Leicester for an excellent study that seeks to inform US practice by showing what happens to coronary heart disease mortality in relation to the recorded characteristics of individual primary care trusts. This was quite a statistical feat in itself, but would have been even more useful had it been done on an individual practice basis - after all, the data are out there, literally for all to see. Anyway, rejoice: CHD in the UK has fallen by nearly a half in the last decade, and although there are regional variations, these are not due to variations in the quality of general practice, except in the detection of high blood pressure, which could easily be remedied.
http://jama.ama-assn.org/cgi/content/abstract/304/18/2028
2059 A neat Commentary piece discusses the dilemmas of interventional cardiology in the light of the COURAGE and SYNTAX studies which show that medical treatment is as effective as percutaneous coronary intervention for stable coronary artery disease. When the first study appeared in 2007, interventional cardiologists were asked if they would now have the conviction of their COURAGE and stop putting stents into every stenosis they happened to see at angiography - what has been described as the "oculo-stenotic reflex". All immediate stenting is lumped together as "ad hoc PCI" and accounts for more than 80% of PCI in the USA; done for acute syndromes, it is generally appropriate, but in other situations, often not. This is a thoughtful, balanced discussion which however tactfully bypasses one factor which may keep ad hoc PCI going in the USA - money. There may be a double incentive - patients and HMOs may want to save the cost of a second angiography; and cardiologists and their institutions may just want the extra dollars they get for putting in a stent there and then. This piece argues that there where there is clinical doubt there should always be informed patient decision-making, even if this means taking a two-week pause between the diagnostic angiogram and the procedure.
http://jama.ama-assn.org/cgi/content/extract/304/18/2059
Lancet 13 Nov 2010 Vol 376
1658 A huge trial called SEARCH was set up in Oxford in 1998 in the hope of demonstrating that 80mg of simvastatin would be better than 20mg at preventing further coronary events in survivors of MI, and that additional benefit would result from lowering homocysteine. In fact it has shown neither. The high dose simvastatin group showed a 26-fold increase in significant myopathy, an expected fall in lipid cholesterol (LDL-C), but no significant difference in vascular events at a mean of 6.7 years. Yet in the summary this is taken to mean that high dose simvastatin is preferable, since that fits into a general meta-analysis of statin trials on p.1670. Although medicine has been taught alongside logic in Oxford for 850 years there is still room for improvement. Consider the following three statements:
- there is a continuous association between the observed level of LDL-C and coronary heart disease (CHD)
- all statin drugs lower LDL-C
- all statin drugs lower CHD in the same proportion that they lower LDL-C.
Does it therefore follow that:
(1)statin drugs lower CHD entirely by means of lowering LDL-C
(2) all drugs that lower LDL-C will lower CHD to the same degree as statins?
It would be good to think that any canny medieval Oxford schoolman would immediately answer no to both deductions, or rather "quod non erat demonstrandum".
In the case of (1), the best we can say is that this is a reasonable hypothesis, but a hard one to test. In the case of (2) we can say that this is a weak hypothesis, since every drug class has a mixture of actions, and so far no LDL-C lowering drugs other than statins have been shown to lower CHD. Nor should we prescribe them until they have. But the writing committees of these two studies, sharing a number of Oxford notables, behave more like theologians than logicians. LDL-cholesterol to them is an infallible surrogate, and anything that lowers it must be good, even though they have only studied statins. It's enough to make you want to burn your gown. As for The Lancet: this is the second time in two weeks that they've let triallists write a summary which misrepresents the result of trial which was negative for its primary end-point (SEARCH this week, VITAL last) - not good enough.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60310-8/abstracthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61350-5/abstract
BMJ 13 Nov 2010 Vol 341
1034 Do you like PROMs? When I was 16, I didn't mind queuing for tickets outside the Albert Hall and standing in the top gallery, but now being older, if you buy tickets on-line you can sit down and actually hear the players. This abbreviation also applies to patient-reported outcome measures, of the kind looked at in the context of heart failure. Suddenly these kinds of PROMs have become fashionable politically and get repeated mention in the White Paper "Liberating the NHS" - although they were never designed for service development but as end-points for clinical trials. Their quality and relevance varies widely, as you learn rapidly. This ground-breaking study devised an instrument with a high degree of inter-observer agreement to allow the assessment of PROMs in cardiovascular trials. Suffice to say that in many of the trials where they appear, they are used badly or irrelevantly, while in 70% of trials where they should appear, they don't.
http://www.bmj.com/content/341/bmj.c5707.full
Arch Intern Med 8 Nov 2010 Vol 170
1834 Delay From Symptom Onset to Hospital Presentation for Patients With Non–ST-Segment Elevation Myocardial Infarction. If you're a veteran scanner of titles in the US cardiovascular outcomes literature, the next thing you'll look for is the name of Harlan Krumholz in the authors list - ah yes, there it is, and so too is the name of Brahmajee Nallamothu, co-author of the thoughtful commentary piece on PCI in this week's JAMA. As a result of their work, and that of Henry Ting and John Spertus, who also appear in the credits, we know a huge amount in great detail about the workings of acute cardiology in the USA, despite the great variety of institutional arrangements. As a result of this exercise, for example, we know the exact time delay and clinical characteristics of 104 622 patients admitted to 568 US hospitals with NSTEMI - and realise that there has been no reduction in the delay time between 2001 and 2006. http://archinte.ama-assn.org/cgi/content/abstract/170/20/1834
1842 Now the interventional trials for ST-Elevation MI tell us that time means myocardium, so great efforts have been made in the US as in the UK to ensure that door-to-balloon time should be as short as possible. But what have we here? A study of 8771 patients admitted to a Michigan hospitals group between 2003 and 2008 which shows that although door-to-balloon time improved dramatically, outcomes remained the same. More data from UK studies quickly please: and since we do not have 568 acute hospitals and they all belong to one organisation, this should be a piece of cake compared with Harlan's work.
http://archinte.ama-assn.org/cgi/content/abstract/170/20/1842
1858 From time to time, serious medical journals like to publish pieces about chocolate, which are sure to get them a mention in the global news media. This research letter also involves women, thus allowing journalists to trot out their very funny jokes about the dear ladies and their chocolate. A group from Perth, Australia followed up a female cohort for 10 years to examine the effect of calcium supplements, and happened to ask about chocolate intake in their questionnaire. Here they report that chocolate consumption seems to have a dose-related protective effect against vascular disease in women. Ooh, come on girls, have another. http://archinte.ama-assn.org/cgi/content/extract/170/20/1857
Wednesday, 27 October 2010
JOURNAL SNIPPETS
JAMA 20 Oct 2010 Vol 304
1693 There was a time when the professor of surgery wouldn't know the names of his immediate juniors, and surgeons who regularly made their nurses cry and threw instruments in theatre. For a few young men, these became heroic role models: the rest were put off surgery for life. "There is insufficient information about the effectiveness of medical team training on surgical outcomes," according to this study of team training in US Veterans' hospitals. They found that such training brought about a 50% fall in mortality rates. Further studies should include Kleenex counts among operating room staff.
http://jama.ama-assn.org/cgi/content/abstract/304/15/1693
NEJM 21 Oct 2010 Vol 363
1597 There is probably at least one patient with aortic stenosis who is considered too poor a surgical risk for open valve replacement and who will therefore become increasingly symptomatic and die within a couple of years. In the future, such patients will face a difficult choice: whether to go for trans-catheter aortic valve replacement, which involves a bovine valve being implanted via a femoral artery catheter and expanded with a balloon. This is as tricky as it sounds and carries a 5% risk of stroke and a 16% risk of major vascular complications; on the other hand, in this randomised study (TAVI) 70% of the patients randomised to catheter valve replacement were alive at one year compared with 50% of those randomised to standard treatment (which could include balloon valvuloplasty). http://www.nejm.org/doi/full/10.1056/NEJMoa1008232
1608 About ten years ago, The Lancet (less pompous in those days) published a picture of a piece of glass at an angle of 45 degrees with trickles of blood running down it. This was a patient's way of measuring his own INR while taking warfarin on a trip to remote China. Nowadays there are expensive home testing kits which do the same thing. Here is a trial that compares weekly home testing with monthly standard lab testing in patients taking warfarin for atrial fibrillation or valve replacement. Fortunately it was funded by the Department of Veterans Cooperative Studies Program, rather than a diagnostics company, and it concludes quite simply that "These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy." If a testing kit manufacturer had paid for it, it probably would have read "Self-testing shows significant benefits in time within target INR range and patient satisfaction, with no increase in stroke, major bleeding episode or death.
http://www.nejm.org/doi/full/10.1056/NEJMoa1002617
Lancet 23 Oct 2010 Vol 376
1393 When you see the title of this paper: A multilocus genetic risk score for coronary heart disease: case-control and prospective cohort analyses, you will need to read right though it, because the abstract is of little help. "Using a genetic risk score based on 13 SNPs associated with coronary heart disease, we can identify the 20% of individuals of European ancestry who are at roughly 70% increased risk of a first coronary heart disease event." But what the Finnish investigators discovered was a difference of 70% between the lowest and highest quintiles in their gene-carriage score, which is not the same thing at all: it probably means a risk increase of about 30% compared with the mean. And factoring in these SNPs adds nothing to existing cardiovascular risk scores. The vast amount of work these investigators put in to this analysis of the FINRISK and COROGENE cohorts seems doomed from the start: as the accompanying editorial states, "it seems unlikely that genomic risk prediction alone will attain the discriminatory resolution to predict individual disease-risk for many common diseases with only modest heritability." In other words, if a disease isn't already strongly predictable from family history, trawling through billions of gene pairs to identify candidate SNPs and doing case-control studies to achieve p values of less than 10-6 is likely to be a waste of time. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61267-6/abstract
1693 There was a time when the professor of surgery wouldn't know the names of his immediate juniors, and surgeons who regularly made their nurses cry and threw instruments in theatre. For a few young men, these became heroic role models: the rest were put off surgery for life. "There is insufficient information about the effectiveness of medical team training on surgical outcomes," according to this study of team training in US Veterans' hospitals. They found that such training brought about a 50% fall in mortality rates. Further studies should include Kleenex counts among operating room staff.
http://jama.ama-assn.org/cgi/content/abstract/304/15/1693
NEJM 21 Oct 2010 Vol 363
1597 There is probably at least one patient with aortic stenosis who is considered too poor a surgical risk for open valve replacement and who will therefore become increasingly symptomatic and die within a couple of years. In the future, such patients will face a difficult choice: whether to go for trans-catheter aortic valve replacement, which involves a bovine valve being implanted via a femoral artery catheter and expanded with a balloon. This is as tricky as it sounds and carries a 5% risk of stroke and a 16% risk of major vascular complications; on the other hand, in this randomised study (TAVI) 70% of the patients randomised to catheter valve replacement were alive at one year compared with 50% of those randomised to standard treatment (which could include balloon valvuloplasty). http://www.nejm.org/doi/full/10.1056/NEJMoa1008232
1608 About ten years ago, The Lancet (less pompous in those days) published a picture of a piece of glass at an angle of 45 degrees with trickles of blood running down it. This was a patient's way of measuring his own INR while taking warfarin on a trip to remote China. Nowadays there are expensive home testing kits which do the same thing. Here is a trial that compares weekly home testing with monthly standard lab testing in patients taking warfarin for atrial fibrillation or valve replacement. Fortunately it was funded by the Department of Veterans Cooperative Studies Program, rather than a diagnostics company, and it concludes quite simply that "These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy." If a testing kit manufacturer had paid for it, it probably would have read "Self-testing shows significant benefits in time within target INR range and patient satisfaction, with no increase in stroke, major bleeding episode or death.
http://www.nejm.org/doi/full/10.1056/NEJMoa1002617
Lancet 23 Oct 2010 Vol 376
1393 When you see the title of this paper: A multilocus genetic risk score for coronary heart disease: case-control and prospective cohort analyses, you will need to read right though it, because the abstract is of little help. "Using a genetic risk score based on 13 SNPs associated with coronary heart disease, we can identify the 20% of individuals of European ancestry who are at roughly 70% increased risk of a first coronary heart disease event." But what the Finnish investigators discovered was a difference of 70% between the lowest and highest quintiles in their gene-carriage score, which is not the same thing at all: it probably means a risk increase of about 30% compared with the mean. And factoring in these SNPs adds nothing to existing cardiovascular risk scores. The vast amount of work these investigators put in to this analysis of the FINRISK and COROGENE cohorts seems doomed from the start: as the accompanying editorial states, "it seems unlikely that genomic risk prediction alone will attain the discriminatory resolution to predict individual disease-risk for many common diseases with only modest heritability." In other words, if a disease isn't already strongly predictable from family history, trawling through billions of gene pairs to identify candidate SNPs and doing case-control studies to achieve p values of less than 10-6 is likely to be a waste of time. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61267-6/abstract
Thursday, 12 August 2010
OXYGEN FOR HEART PATIENTS
Evidence unclear on oxygen use for heart attackOverview: Coronary heart disease is the leading cause of death in the UK, accounting for a third of all deaths in people aged 35 and over. Myocardial infarction occurs when the flow of oxygenated blood in the heart is interrupted for a sustained period of time. Supplementary oxygen, delivered by a face mask or cannula, is often given to a patient with acute myocardial infarction (AMI) with the rationale that it may improve the oxygenation of the ischaemic myocardial tissue and reduce pain, infarct size and consequent morbidity and mortality.Current treatment: Current evidence neither supports nor refutes the routine use of oxygen for patients with acute myocardial infarction. It is biologically plausible that oxygen is helpful but it is also biologically plausible that it is harmful. NICE recommends oxygen should not be routinely administered to patients with acute chest pain of suspected cardiac origin, but that oxygen saturation levels should be monitored and used to guide its administration. SIGN guidance only recommends oxygen use in hypoxaemia
New evidence: A Cochrane systematic review (Cabello et al 2010 Jun 16;6:CD007160) found three randomised controlled trials comparing the outcomes in patients given oxygen to those given normal air to breathe. It examined whether there was a difference in death, pain and complications.The results reaffirm the current uncertainty of the role of oxygen in patients with myocardial infarction, and the authors call for a large, definitive randomised controlled trial on which clinical practice guidelines can be more confidently based.
Commentary: "The rapid assessment and treatment of a patient with a heart attack is drummed into most medical students very early on in their training. ABC: airway, breathing, circulation. Part of that resuscitation is the delivery of oxygen to patients with a heart attack, mainly due to the fact that the flow of oxygenated blood in the heart is stopped for a period of time."We have moved from one set of guidelines based on expert opinion to another set of guidelines with a different set of recommendations, but the research evidence has not changed. As this recent Cochrane review highlights, there is still no conclusive evidence from randomised controlled trials to support the routine use of inhaled oxygen in patients with acute heart attack."As the reviewers rightly state, we urgently need a large scale trial to unpick the uncertainty. Potentially, if further research addresses the uncertainty in one direction or another, implications for public health and cost efficiency could be huge." - Carl Heneghan, Director of thNHS Evidence - cardiovasculare Centre for Evidence Based Medicine, GP and clinical lecturer at the University of Oxford.
For more information on evidence relating to cardiovascular health visit .
Commentary: "The rapid assessment and treatment of a patient with a heart attack is drummed into most medical students very early on in their training. ABC: airway, breathing, circulation. Part of that resuscitation is the delivery of oxygen to patients with a heart attack, mainly due to the fact that the flow of oxygenated blood in the heart is stopped for a period of time."We have moved from one set of guidelines based on expert opinion to another set of guidelines with a different set of recommendations, but the research evidence has not changed. As this recent Cochrane review highlights, there is still no conclusive evidence from randomised controlled trials to support the routine use of inhaled oxygen in patients with acute heart attack."As the reviewers rightly state, we urgently need a large scale trial to unpick the uncertainty. Potentially, if further research addresses the uncertainty in one direction or another, implications for public health and cost efficiency could be huge." - Carl Heneghan, Director of thNHS Evidence - cardiovasculare Centre for Evidence Based Medicine, GP and clinical lecturer at the University of Oxford.
For more information on evidence relating to cardiovascular health visit .
Friday, 6 August 2010
CARDIOVASCULAR DISEASE
Cardiovascular disease
Effect of smoking cessation advice on cardiovascular disease Centre for Reviews and Dissemination
Quantitative effects on cardiovascular risk factors and coronary heart disease risk of replacing partially hydrogenated vegetable oils with other fats and oils Centre for Reviews and Dissemination
Effect of smoking cessation advice on cardiovascular disease Centre for Reviews and Dissemination
Quantitative effects on cardiovascular risk factors and coronary heart disease risk of replacing partially hydrogenated vegetable oils with other fats and oils Centre for Reviews and Dissemination
Wednesday, 21 July 2010
NHS EVIDENCE
This month (July) Eyes on Evidence highlights new evidence in emergency stroke treatment, lifestyle measures to reduce cardiovascular risk and effective ways to put evidence into practice.NHS Evidence provides access to more than 150 reliable evidence sources. This month we focus on UK Database of Uncertainties about the Effects of Treatments (UK DUETs), explaining how to use it and what kind of information you can expect to find.The current economic climate has focused our minds on the need for increased financial efficiency. The QIPP collection highlights practical examples of how NHS organisations are both cutting costs and improving quality. It showcases what the NHS is already doing well, allowing colleagues to share best practice and deliver successful improvements without having to reinvent the wheel. Each month in Eyes on Evidence we will showcase an outstanding example of local best practice. To start us off we look at the success of Oxford Radcliffe Hospitals' electronic blood transfusion system. To find out how to share your success stories visit NHS Evidence. As always, user feedback is central to the future development of NHS Evidence, so if you have any comments let us know.
Examining the window for emergency stroke treatment
Examining the window for emergency stroke treatment
Overview: Stroke is a major health problem in the UK and is estimated to cost the economy around £7 billion per year. Most people survive a first stroke, but often have significant morbidity. More than 900,000 people in England are living with the effects of stroke, with half of these being dependent on other people for help with everyday activities.
Current treatment: Early management of stroke aims to avoid or minimise damage to the ischaemic brain. Intravenous recombinant tissue plasminogen activator (rt-PA) after ischaemic stroke can improve outcome. NICE recommends alteplase (rt-PA) should be considered for thromobolysis within 3 hours of symptom onset (in line with its marketing authorisation). However, it has been suggested that there is potential benefit of starting alteplase beyond 3 hours from onset.
New evidence: This pooled analysis by Lees et al (Lancet 2010; 375: 1695–703) re-examined the effect of time to treatment with alteplase on therapeutic benefit and clinical risk by adding recent trial data from ECASS III and EPITHET to pooled data from six other trials of alteplase for acute stroke. Treatment was started within 6 hours of stroke onset in 3,670 patients randomly allocated to alteplase or to placebo. Results indicated that treatment should be initiated as soon as possible to maximise benefit. Favourable 3-month outcome was significantly more likely with a shorter interval between symptom onset and treatment. There was no benefit of starting alteplase treatment after 4.5 hours and mortality significantly increased with a longer interval between symptom onset and treatment. 
Commentary: "Lees et al confirm the view that treatment benefit outweighs risk beyond the current 3 hour window from stroke onset, to 4.5 hours. After 4.5 hours, mortality rises with treatment, a fact not wholly explained by intracranial haemorrhage. The evidence favours extending the treatment licence to 4.5 hours, as this will increase the probability of a good outcome and potentially increase the number of patients who might benefit. But the authors rightly emphasise the point that such an extension in the 'time window' for thrombolysis should not lead to a more relaxed approach to hyper-acute stroke management. Their analysis shows that the greatest benefit comes from earlier treatment – 'time is brain'." - Dr Lionel Ginsberg, Clinical Lead, NHS Evidence – neurological; and Prof Tom Quinn, Clinical Lead NHS Evidence - cardiovascular, stroke and vascular.For more information on evidence relating to stroke visit NHS Evidence – stroke.
Can brushing teeth cut your cardiovascular risk?
Overview: In the UK, nearly three million women and three million men are living with the disabling effects of cardiovascular disease, which includes heart disease and stroke. More than 40,000 people die from premature cardiovascular disease each year. Overall, cardiovascular disease costs the UK approximately £30 billion annually.
Current treatment: Cardiovascular disease is a largely preventable condition that can be effectively tackled by making simple changes to diet, stopping smoking and increasing physical activity. NICE has recently published public health guidance on 'Prevention of cardiovascular disease', which aims to tackle this issue using a population-based approach.
New evidence: A study by de Oliveira et al. (BMJ 2010;340:c2451 doi:10.1136/bmj.c2451) examined if self-reported toothbrushing behaviour was associated with cardiovascular disease and markers of inflammation (C-reactive protein) and coagulation (fibrinogen).A population-based survey drew a nationally representative sample of nearly 12,000 people in Scotland, with an average age of 50. Oral hygiene was assessed using self-reported frequency of toothbrushing and surveys were linked prospectively to clinical hospital records. There were 555 cardiovascular disease events over an average 8 years follow-up, with coronary heart disease thought to be responsible for about three out of four of these. Poor oral hygiene seemed to be associated with higher levels of risk of cardiovascular disease and low grade inflammation. Participants who never or rarely brushed their teeth had a significantly greater risk of a cardiovascular disease event and higher concentrations of C-reactive protein and fibrinogen.
Commentary: "It is important for dental health that people brush their teeth regularly. A recent study in the BMJ suggests that those people who brush their teeth regularly are also less likely to suffer from cardiovascular disease in the future. However, there is no evidence of a causal link between teeth brushing and the development of cardiovascular disease. As the authors themselves discuss, residual confounding by social class and/or healthy lifestyle is likely to have had a major impact on the results." - Dr Jackie Price, Clinical Senior Lecturer in Epidemiology and Public Health, University of Edinburgh.
Commentary: "It is important for dental health that people brush their teeth regularly. A recent study in the BMJ suggests that those people who brush their teeth regularly are also less likely to suffer from cardiovascular disease in the future. However, there is no evidence of a causal link between teeth brushing and the development of cardiovascular disease. As the authors themselves discuss, residual confounding by social class and/or healthy lifestyle is likely to have had a major impact on the results." - Dr Jackie Price, Clinical Senior Lecturer in Epidemiology and Public Health, University of Edinburgh.
For more information on evidence relating to cardiovascular health visit NHS Evidence - cardiovascular.
Wednesday, 21 April 2010
ETHNICITY and CARDIOVASCULAR ISSUES
Cardiovascular Diseases:
Ethnic differences in cardiovascular risk
Produced by general practitioners for the British Heart Foundation, this fact file explores the ethnic differences in cardiovascular risk in the UK.
Ethnicity and coronary heart disease: making sense of risk and improving care
This is number 16 in the Race Equality Foundation’s “Better Health Briefing” series.
Ethnic differences in cardiovascular risk
Produced by general practitioners for the British Heart Foundation, this fact file explores the ethnic differences in cardiovascular risk in the UK.
Ethnicity and coronary heart disease: making sense of risk and improving care
This is number 16 in the Race Equality Foundation’s “Better Health Briefing” series.
Thursday, 8 April 2010
PUBLIC HEALTH E-ARTICLES CARDIOVASCULAR DISEASE
Cardiovascular disease
Cardiovascular health disparities: a systematic review of health care interventions
Centre for Reviews and Dissemination
Health service interventions targeting relatives of heart patients: a review of the literature
Centre for Reviews and Dissemination
Making chronic conditions count: Hypertension, stroke, coronary heart disease, diabetes. A systematic approach to estimating and forecasting population prevalence on the island of Ireland.
Institute of Public Health in Ireland (IPH)
QIPP intelligence report : cardiovascular disease prevention strategies - improving quality & productivity in the NHS through partnerships
NHS North West
Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review
Centre for Reviews and Dissemination
Cardiovascular health disparities: a systematic review of health care interventions
Centre for Reviews and Dissemination
Health service interventions targeting relatives of heart patients: a review of the literature
Centre for Reviews and Dissemination
Making chronic conditions count: Hypertension, stroke, coronary heart disease, diabetes. A systematic approach to estimating and forecasting population prevalence on the island of Ireland.
Institute of Public Health in Ireland (IPH)
QIPP intelligence report : cardiovascular disease prevention strategies - improving quality & productivity in the NHS through partnerships
NHS North West
Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review
Centre for Reviews and Dissemination
Tuesday, 2 March 2010
SNIPPETS FROM JOURNALS
The following are all from www.cebm.net
Lancet 27 Feb 2010 Vol 375
727 Not long ago, someone had a myocardial infarction on a transatlantic flight. So what does a professor of surgery do under these circumstances? Possibly take an aspirin and pray a good deal. He should have squeezed his arm repeatedly for periods of five minutes or so at a pressure above systolic. Believe it or not, this simple manoeuvre can reduce the area of myocardial damage, as proved in this Danish trial where patients with presumptive MI were randomised to have the squeezing done (or not done) by a sphygmomanometer in the ambulance conveying them to hospital. This is known as ischaemic preconditioning, though in such circumstances it should perhaps be known as simultaneous ischaemic conditioning. There were no hard end-points in this trial but a convincing reduction in damage on myocardial perfusion imaging at 30 days. More trials are needed, but meantime there seems no possible reason not to give it a try.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62001-8/abstract
752 This is a rather rambling 10-page review of dilated cardiomyopathy. The Panel of Mechanisms covers just about everything except interference by aliens, and there's a panel of gene loci too, but no panel of relative frequencies and prognoses for each aetiology. There is no mention of spontaneous recovery, which can't be rare if it has been seen twice.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62023-7/abstract
763 Say you had stable coronary artery disease: would you want an angiogram? And if the cardiologist saw a stenosis, would you want a stent put in? A year or two ago, these questions would have seemed like no-brainers, but then along came COURAGE and BARI-2D showing that medical treatment is as good as percutaneous intervention. Do you truly and deeply believe this, though? See how you feel when you read this review by two Swiss and an American cardiologist. It presents enough evidence to allow a tailored approach, and says that it "proposes a treatment algorithm that is applicable to daily clinical practice." The word "algorithm" is to be avoided, but people who use it generally refer to a flow chart, but there isn't one. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60168-7/abstract
BMJ 27 Feb 2010 Vol 340
459 A useful systematic review compares the results of carotid endarterectomy vs. carotid stenting in 11 randomised trials. On the face of it, endarterectomy wins, because the risk of periprocedural stroke is less; in the longer term there is little difference. Techniques and experience increase all the time - it may happen that the guy who puts in stents near you does that better than the guy who scrapes arteries. So more studies are justified and the matter is not quite settled yet.
http://www.bmj.com/cgi/content/full/340/feb12_1/c467
JAMA 17 Feb 2010 Vol 303
631 The Women's Genome Health Study is a prospective cohort of 19,313 women followed up for a median of 12.3 years, during which they experienced 777 cardiovascular events. In these women, 101 single nucleotide polymorphisms were added with one or two other genomic factors to create a genetic risk score. Surely this would usher in a new era of refined cardiovascular risk prediction? Well, actually it showed no significant association with the incidence of total cardiovascular disease: a simple family history alone was more predictive. On the other hand, there is so much anonymized data about the participants that you could probably find out the full disease status of any individual if you could identify their genome from some other source. This is discussed in a fascinating commentary on p.659. Genomic studies seem almost disconcertingly useless at the population level, but if you know 35,000 gene variants in a single individual, you can measure their left ventricular mass more accurately than if you had an echocardiogram.
http://jama.ama-assn.org/cgi/content/abstract/303/7/631
NEJM 18 Feb 2010 Vol 362
590 Some people like to see evidence from randomised controlled trials with hard end-points before a computer prediction that a certain intervention will reduce new cases of CHD in America by up to 120,000 annually, stroke by up to 66,000, and death by up to 92,000. The editorial on p. 650 suggests a saving in health costs of $10-24 billion. Aha, we save health costs by keeping older people alive longer, do we? Apart from that basic point, there is also the problem that the evidence for salt reduction is - as far as I can tell - nowhere near as strong as the computer model in this economic simulation suggests. The evidence we have is about a surrogate marker - blood pressure - which can be reduced slightly by the sort of salt reductions proposed here and already in force in the UK for prepared foods. On the balance of probabilities, I'm happy to support salt reduction, as I am carbon emission reduction; but that doesn't mean swallowing every extrapolation that zealots come up with. A paper like this doesn't really belong in the world's leading medical journal.
http://content.nejm.org/cgi/content/abstract/362/7/590
Ann Intern Med 16 Feb 2010 Vol 152
211 The Women's Health Initiative trial was an RCT of hormone replacement therapy which brought about a volte-face in clinical practice but which is described as "far from impeccable" in a letter in this week's BMJ (p.382). Peccability is openly confessed in this Lenten analysis of the effect of continuous combined HRT on coronary heart disease. They more or less admit to residual confounding and small subgroup sizes. The bottom line message is that continuous HRT may confer added risk of CHD in the first years, then decreased risk after 6 years. Which is not quite what we were all initially led to believe.
http://www.annals.org/content/152/4/211.abstract
218 Initiated permanent anticoagulation for severe recurrent superficial thrombophlebitis with the reluctant concurrence of the local haematologist. Such events are benign and self-limiting and do not herald serious thromboembolism, but this French study casts doubts on that. In fact 25% of subjects with superficial phlebitis of 5cm or more had or went on to develop deep vein thrombosis in this series of 844 consecutive cases in a specialist referral centre. We need some primary care studies, quite urgently.
http://www.annals.org/content/152/4/218.abstract
Lancet 27 Feb 2010 Vol 375
727 Not long ago, someone had a myocardial infarction on a transatlantic flight. So what does a professor of surgery do under these circumstances? Possibly take an aspirin and pray a good deal. He should have squeezed his arm repeatedly for periods of five minutes or so at a pressure above systolic. Believe it or not, this simple manoeuvre can reduce the area of myocardial damage, as proved in this Danish trial where patients with presumptive MI were randomised to have the squeezing done (or not done) by a sphygmomanometer in the ambulance conveying them to hospital. This is known as ischaemic preconditioning, though in such circumstances it should perhaps be known as simultaneous ischaemic conditioning. There were no hard end-points in this trial but a convincing reduction in damage on myocardial perfusion imaging at 30 days. More trials are needed, but meantime there seems no possible reason not to give it a try.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62001-8/abstract
752 This is a rather rambling 10-page review of dilated cardiomyopathy. The Panel of Mechanisms covers just about everything except interference by aliens, and there's a panel of gene loci too, but no panel of relative frequencies and prognoses for each aetiology. There is no mention of spontaneous recovery, which can't be rare if it has been seen twice.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62023-7/abstract
763 Say you had stable coronary artery disease: would you want an angiogram? And if the cardiologist saw a stenosis, would you want a stent put in? A year or two ago, these questions would have seemed like no-brainers, but then along came COURAGE and BARI-2D showing that medical treatment is as good as percutaneous intervention. Do you truly and deeply believe this, though? See how you feel when you read this review by two Swiss and an American cardiologist. It presents enough evidence to allow a tailored approach, and says that it "proposes a treatment algorithm that is applicable to daily clinical practice." The word "algorithm" is to be avoided, but people who use it generally refer to a flow chart, but there isn't one. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60168-7/abstract
BMJ 27 Feb 2010 Vol 340
459 A useful systematic review compares the results of carotid endarterectomy vs. carotid stenting in 11 randomised trials. On the face of it, endarterectomy wins, because the risk of periprocedural stroke is less; in the longer term there is little difference. Techniques and experience increase all the time - it may happen that the guy who puts in stents near you does that better than the guy who scrapes arteries. So more studies are justified and the matter is not quite settled yet.
http://www.bmj.com/cgi/content/full/340/feb12_1/c467
JAMA 17 Feb 2010 Vol 303
631 The Women's Genome Health Study is a prospective cohort of 19,313 women followed up for a median of 12.3 years, during which they experienced 777 cardiovascular events. In these women, 101 single nucleotide polymorphisms were added with one or two other genomic factors to create a genetic risk score. Surely this would usher in a new era of refined cardiovascular risk prediction? Well, actually it showed no significant association with the incidence of total cardiovascular disease: a simple family history alone was more predictive. On the other hand, there is so much anonymized data about the participants that you could probably find out the full disease status of any individual if you could identify their genome from some other source. This is discussed in a fascinating commentary on p.659. Genomic studies seem almost disconcertingly useless at the population level, but if you know 35,000 gene variants in a single individual, you can measure their left ventricular mass more accurately than if you had an echocardiogram.
http://jama.ama-assn.org/cgi/content/abstract/303/7/631
NEJM 18 Feb 2010 Vol 362
590 Some people like to see evidence from randomised controlled trials with hard end-points before a computer prediction that a certain intervention will reduce new cases of CHD in America by up to 120,000 annually, stroke by up to 66,000, and death by up to 92,000. The editorial on p. 650 suggests a saving in health costs of $10-24 billion. Aha, we save health costs by keeping older people alive longer, do we? Apart from that basic point, there is also the problem that the evidence for salt reduction is - as far as I can tell - nowhere near as strong as the computer model in this economic simulation suggests. The evidence we have is about a surrogate marker - blood pressure - which can be reduced slightly by the sort of salt reductions proposed here and already in force in the UK for prepared foods. On the balance of probabilities, I'm happy to support salt reduction, as I am carbon emission reduction; but that doesn't mean swallowing every extrapolation that zealots come up with. A paper like this doesn't really belong in the world's leading medical journal.
http://content.nejm.org/cgi/content/abstract/362/7/590
Ann Intern Med 16 Feb 2010 Vol 152
211 The Women's Health Initiative trial was an RCT of hormone replacement therapy which brought about a volte-face in clinical practice but which is described as "far from impeccable" in a letter in this week's BMJ (p.382). Peccability is openly confessed in this Lenten analysis of the effect of continuous combined HRT on coronary heart disease. They more or less admit to residual confounding and small subgroup sizes. The bottom line message is that continuous HRT may confer added risk of CHD in the first years, then decreased risk after 6 years. Which is not quite what we were all initially led to believe.
http://www.annals.org/content/152/4/211.abstract
218 Initiated permanent anticoagulation for severe recurrent superficial thrombophlebitis with the reluctant concurrence of the local haematologist. Such events are benign and self-limiting and do not herald serious thromboembolism, but this French study casts doubts on that. In fact 25% of subjects with superficial phlebitis of 5cm or more had or went on to develop deep vein thrombosis in this series of 844 consecutive cases in a specialist referral centre. We need some primary care studies, quite urgently.
http://www.annals.org/content/152/4/218.abstract
Tuesday, 9 February 2010
CARDIOVASCULAR DISEASE PUBLIC HEALTH ARTICLES
Cardiovascular disease
Economic evaluation of the direct healthcare cost savings resulting from the use of walking interventions to prevent coronary heart disease in Australia
International journal of health care finance and economics
Evidence based cardiovascular disease screening and treatment
Department of Health
Yorkshire and Humber Cardiovascular Disease (CVD) Commissioning Health Intelligence Toolkit Yorkshire and Humber Public Health Observatory (YHPHO)
Economic evaluation of the direct healthcare cost savings resulting from the use of walking interventions to prevent coronary heart disease in Australia
International journal of health care finance and economics
Evidence based cardiovascular disease screening and treatment
Department of Health
Yorkshire and Humber Cardiovascular Disease (CVD) Commissioning Health Intelligence Toolkit Yorkshire and Humber Public Health Observatory (YHPHO)
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