Ischaemic Heart Disease: A Secondary Prevention Trial Using Clofibrate

A trial is reported of the effects of giving clofibrate to prevent progression of pre-existing ischaemic heart disease. There were two groups randomly distributed between clofibrate (350 patients) and placebo (367 patients) regimens. The trial lasted about six years and was conducted in 19 hospitals in Scotland. The criteria of acceptance into the trial were precise and were monitored by one observer. The standards of diagnosis of events were defined and all protocols and electrocardiograms were read blind by one observer.Three categories of patients were admissible to the trial: (1) patients with one myocardial infarction (W.H.O. E.C.G. criteria) between 8 and 16 weeks before the start of the trial; (2) patients with angina of a duration of 3 to 24 months, provided their E.C.G. showed signs of myocardial ischaemia at rest or after exercise; and (3) patients with one recent myocardial infarction and pre-existing angina as defined above.There were fewer deaths in patients with angina (categories 2 and 3 above) treated with clofibrate than in those on placebo. The mortality in the former group was reduced by 62%, and this is a statistically significant difference. Clofibrate did not have any statistically significant effect in reducing the rate of non-fatal infarction in patients with angina or in those with myocardial infarction and pre-existing angina, though a beneficial trend was evident when both subgroups were combined (a 44% reduction compared with the placebo group). There was a significant reduction in all events (fatal and non-fatal) in patients with angina (“all anginas”) in the clofibrate-treated group; the rate was reduced by 53%.Clofibrate did not alter the overall mortality or morbidity rates in patients admitted to the trial with recent myocardial infarction without preceding angina of more than three months'' duration. In one subgroup there was a statistically significant adverse effect in the clofibrate-treated group. The lack of any overall effect in patients with myocardial infarction might be related to the unexpectedly low mortality rate (2·97%) in the placebo group; it is usually in the region of 4-9% per annum after first myocardial infarction.In patients categorized as “all anginas” there was significant reduction in events whether the initial serum cholesterol level was high (greater than 260 mg/100 ml) or normal. Clofibrate seemed to have a small but not significant beneficial effect in patients with myocardial infarction with initially high serum cholesterol levels, but was of no value in those with initially normal serum cholesterol levels. There was no significant relationship between the response or lack of response of serum cholesterol to clofibrate and the incidence of events either in patients with angina or in those with infarction.The main conclusion of this trial is that clofibrate had a beneficial effect in reducing mortality and, to a lesser extent, morbidity in patients who presented with angina (“all anginas”). This effect was independent of initial serum cholesterol levels or the extent to which serum cholesterol was lowered. The drug had no significant overall effect on prognosis in patients with myocardial infarction alone.     

Low-Dose Aspirin for Prevention of Cardiovascular Disease in Patients with Chronic Kidney Disease

Background

Chronic kidney disease (CKD) is a major risk factor for the development of cardiovascular disease (CVD). Previous trials have investigated the effects of low-dose aspirin on CVD prevention in patients with diabetes; however, patients with CKD were not examined. The role of aspirin in diabetics is controversial, and the available literature is contradictory. Therefore, we studied whether low-dose aspirin would be beneficial for patients with CKD, a group that is at high risk for CVD.

Method

From a total of 25340 patients with CKD, 1884 recipients of low-dose aspirin (100 mg/day) were paired 1∶1 with non-recipients for analysis using propensity score matching. The primary endpoint was the development of atherosclerotic CVD, including coronary arterial disease, stroke, and peripheral arterial disease. Secondary endpoints included death from any cause, bleeding events, doubling of serum creatinine, and renal death.

Results

The incidence of a primary endpoint of any atherosclerotic CVD was significantly higher in the aspirin users than in the non-users (P<0.001). Secondary endpoints, including all-cause mortality and composite bleeding events, were not significantly different between the aspirin users and the non-users. However, the doubling of serum creatinine levels (P = 0.001) and renal death (P = 0.042) were significantly associated with the use of aspirin.

Conclusion

These results suggest that the use of low-dose aspirin in patients with CKD may have harmful consequences related to the development of CVD and renal progression.     

一级预防护理干预对特需病房冠心病高危患者的影响

目的:探讨特需病房冠心病高危患者一级预防的护理干预效果。方法:以2010年7月~2012年7月期间四川大学华西医院金卡医疗中心收住的104例冠心病高危患者为研究对象,随机分为对照组和干预组两组各52例,分别实施常规护理和冠心病一级预防护理干预并随访1年,观察两组效果。结果:干预组干预后血压、血脂、血糖以及体重指数的全部指标值及各项指标达标人数和干预前比较差异均有统计学意义(P0.05或0.001);除TG指标外,其他指标值以及各项指标达标人数和对照组比较差异也均有统计学意义(P0.05或0.001)。对照组患除血压及血压达标人数和入院时比较有明显差异(P0.05或0.001),其余各项指标及达标人数均出入不大(P0.05)。两组随访1年,干预组发生冠心病3例,其他心血管事6例,发生率均明显低于对照组(P0.05)。结论:对特需病房冠心病高危人群通过认知、行为、饮食、用药、心理等方面的护理干预进行冠心病的一级预防,患者血压、血脂、血糖及体重指数均得到了较好的控制。患者若能长期坚持执行预防措施,将大大降低冠心病的发病危险。     

国内外心脏疾病医疗服务质量评估现状

心血管疾病作为全球主要死亡和致残原因,给医疗卫生系统带来了巨大负担。世界各国专家已对该类疾病开展了大量的研究,其中极为重要的一项是通过评价心血管病的医疗服务质量来帮助医院发现问题以及找到提高医疗服务水平的突破口。文章总结并讨论了国内外心脏病医疗服务质量评价的方法、目的、内容以及数据来源,为建立和完善中国的心血管疾病医疗服务质量评估体系提供借鉴。     

酚妥拉明联合银杏达莫治疗慢性肺源性心脏病疗效观察

目的：观察酚妥拉明联合银杏达莫对慢性肺源性心脏病心衰患者的疗效,为临床治疗提供依据。方法：将90例患者随机分为治疗组和对照组各45例。两组采用常规内科治疗如控制感染、氧疗、强心、利尿等,治疗组在上述治疗基础上加用酚妥拉明20mg＋银杏达莫25mL于10％葡萄糖注射液500mL中静脉滴注,1次／d,疗程均为10d。结果：治疗组的疗效、血气分析、血液流变学、功能的改善优于对照组,差异具有统计学意义（P〈0．05）。结论：酚妥拉明联合银杏达莫对慢性肺源性心脏痛心衰患者具有良好的疗效及安全性,值得临床推广应用。     

老年冠心病护理健康教育对策及应用效果分析

目的：分析老年冠心病患者的护理健康教育需求,并给予有效护理干预方法,分析其临床效应。方法：选取本院治疗的80例老年冠心病患者为研究对象,随机分为对照组和观察组各40例,入院后给予健康教育知识评估,对照组采用常规护理模式,观察组针对健康知识评估给予护理干预。随访3个月,比较两组患者护理后健康知识的掌握及实际临床效果。结果：①住院期间,观察组对冠心病知识的掌握情况,服药依从性均明显优于对照组（P〈0．05）。②出院3个月后,观察组体重指数、甘油三酯、血压改善情况明显优于对照组（P〈0．05）。结论：针对性护理教育提高了患者治疗依从性,各项临床指标得到了改善,是治疗冠心病的有效补充。     

酚妥拉明联合银杏达莫治疗慢性肺源性心脏病疗效观察

目的:观察酚妥拉明联合银杏达莫对慢性肺源性心脏病心衰患者的疗效,为临床治疗提供依据。方法:将90例患者随机分为治疗组和对照组各45例。两组采用常规内科治疗如控制感染、氧疗、强心、利尿等,治疗组在上述治疗基础上加用酚妥拉明20mg+银杏达莫25 mL于10%葡萄糖注射液500 mL中静脉滴注,1次/d,疗程均为10 d。结果:治疗组的疗效、血气分析、血液流变学、功能的改善优于对照组,差异具有统计学意义(P<0.05)。结论:酚妥拉明联合银杏达莫对慢性肺源性心脏病心衰患者具有良好的疗效及安全性,值得临床推广应用。     

慢性肾脏病继发性甲状旁腺功能亢进的发病机制研究进展

继发性甲状旁腺功能亢进是慢性肾脏病的常见并发症,严重影响患者的生活质量和生存率。其发病机制主要包括低钙血症、高磷血症、活性维生素D缺乏、维生素D受体及钙敏感受体表达下调等。近年来,成纤维细胞生长因子23在继发性甲状旁腺功能亢进发病机制中的作用,也越来越受到重视。上述机制均可导致慢性肾脏病患者的甲状旁腺细胞增生,由多克隆增生逐渐发展为单克隆增生、腺瘤等,甲状旁腺功能亢进也逐渐加重。现就慢性肾脏病继发性甲状旁腺功能亢进的发病机制的进展做一综述。     

Heart Failure in a Cohort of Patients with Chronic Kidney Disease: The GCKD Study

ConclusionsThe burden of self-reported and Gothenburg HF among patients with CKD is high. The proportion of patients who meet the criteria for Gothenburg HF in a European cohort of patients with moderate CKD is more than twice as high as the prevalence of self-reported HF. However, because of the shared signs, symptoms and medications of HF and CKD, the Gothenburg score cannot be used to reliably define HF in CKD patients. Our results emphasize the need for early screening for HF in patients with CKD.     

Patient and Disease Characteristics Associated with Activation for Self-Management in Patients with Diabetes,Chronic Obstructive Pulmonary Disease,Chronic Heart Failure and Chronic Renal Disease: A Cross-Sectional Survey Study

A substantial proportion of chronic disease patients do not respond to self-management interventions, which suggests that one size interventions do not fit all, demanding more tailored interventions. To compose more individualized strategies, we aim to increase our understanding of characteristics associated with patient activation for self-management and to evaluate whether these are disease-transcending. A cross-sectional survey study was conducted in primary and secondary care in patients with type-2 Diabetes Mellitus (DM-II), Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF) and Chronic Renal Disease (CRD). Using multiple linear regression analysis, we analyzed associations between self-management activation (13-item Patient Activation Measure; PAM-13) and a wide range of socio-demographic, clinical, and psychosocial determinants. Furthermore, we assessed whether the associations between the determinants and the PAM were disease-transcending by testing whether disease was an effect modifier. In addition, we identified determinants associated with low activation for self-management using logistic regression analysis. We included 1154 patients (53% response rate); 422 DM-II patients, 290 COPD patients, 223 HF patients and 219 CRD patients. Mean age was 69.6±10.9. Multiple linear regression analysis revealed 9 explanatory determinants of activation for self-management: age, BMI, educational level, financial distress, physical health status, depression, illness perception, social support and underlying disease, explaining a variance of 16.3%. All associations, except for social support, were disease transcending. This study explored factors associated with varying levels of activation for self-management. These results are a first step in supporting clinicians and researchers to identify subpopulations of chronic disease patients less likely to be engaged in self-management. Increased scientific efforts are needed to explain the greater part of the factors that contribute to the complex nature of patient activation for self-management.     

Cost-Effectiveness of Apixaban Compared with Warfarin for Stroke Prevention in Atrial Fibrillation

Background

Apixaban was shown to be superior to adjusted-dose warfarin in preventing stroke or systemic embolism in patients with atrial fibrillation (AF) and at least one additional risk factor for stroke, and associated with reduced rates of hemorrhage. We sought to determine the cost-effectiveness of using apixaban for stroke prevention.

Methods

Based on the results from the Apixaban Versus Warfarin in Patients with Atrial Fibrillation (ARISTOTLE) trial and other published studies, we constructed a Markov model to evaluate the cost-effectiveness of apixaban versus warfarin from the Medicare perspective. The base-case analysis assumed a cohort of 65-year-old patients with a CHADS₂ score of 2.1 and no contraindication to oral anticoagulation. We utilized a 2-week cycle length and a lifetime time horizon. Outcome measures included costs in 2012 US$, quality-adjusted life-years (QALYs), life years saved and incremental cost-effectiveness ratios.

Results

Under base case conditions, quality adjusted life expectancy was 10.69 and 11.16 years for warfarin and apixaban, respectively. Total costs were $94,941 for warfarin and $86,007 for apixaban, demonstrating apixaban to be a dominant economic strategy. Upon one-way sensitivity analysis, these results were sensitive to variability in the drug cost of apixaban and various intracranial hemorrhage related variables. In Monte Carlo simulation, apixaban was a dominant strategy in 57% of 10,000 simulations and cost-effective in 98% at a willingness-to-pay threshold of $50,000 per QALY.

Conclusions

In patients with AF and at least one additional risk factor for stroke and a baseline risk of ICH risk of about 0.8%, treatment with apixaban may be a cost-effective alternative to warfarin.