HIV感染者合并慢性非传染性疾病多药依从性管理的研究进展

由于艾滋病抗病毒药物的广泛使用,HIV感染者寿命得以延长,老年HIV感染者的人数不断增多,最终导致HIV合并慢性非传染性疾病（chronic non-communicable diseases,NCDs）的人群逐年递增。NCDs包括心血管疾病、糖尿病、癌症和慢性呼吸道疾病等,需要长期服用多种药物,加之复杂的HIV抗病毒药物方案,会导致HIV感染者服药依从性降低,出现错服、漏服等现象。HIV感染者多药依从性问题逐渐引起重视。该文系统回顾了HIV感染者合并NCDs多药依从性管理的相关研究,对HIV感染者合并NCDs多药依从性的定义和影响因素进行阐述,并提出提高合并NCDs的HIV感染者多药依从性的干预措施,以期为HIV感染者多药依从性管理的研究和护理实践提供参考。     

‘Multiple action fixed combination. Present or future?’

Cardiovascular disease (CVD) is the most common cause of death in Western countries and will continue to be so in upcoming years. A close correlation has been demonstrated among CVD, stroke, ischemic heart disease, renal failure and a number of modifiable risk factors. As cardiovascular (CV) risk factors commonly co-exist, high-risk patients with hypertension, obesity and diabetes may well benefit from a multiple action combination of CV agents with synergistic efficacy. Control of blood pressure (BP) and the other CV risk factors is still far from the optimal rates and achievement of internationally accepted goals must be imperative. The benefits of achieving these goals, including significant reductions in CV morbidity and mortality, are well documented. Thus, a rigorous effort to improve BP goal attainment is required. Most of the patients will need two or more antihypertensives to achieve BP goal. Administering of two drugs in a single-dose formulation substantially improves patient compliance compared with separate agent administration. Fixed-dose combination therapy can offer potential advantages over individual agents, including increased efficacy, reduced incidence of adverse effects, lower healthcare costs and improved patient compliance through the use of a single medication administered once daily. Currently available fixed-dose agents include several combinations with complementary pharmacodynamic activity. Last, the polypill includes several CV acting agents that affects various CV risk factors and offers encouraging results, although more data are needed to strengthen the polypill concept, its efficacy and safety.     

Preventing cardiovascular disease in women

Cardiovascular disease (CVD) has been the primary cause of death in women for almost a century, and more women than men have died of CVD every year since 1984. Although CVD incidence can be reduced by adherence to a heart-healthy lifestyle and detection and treatment of major risk factors, preventive recommendations have not been consistently or optimally applied to women. The American Heart Association guidelines for CVD prevention in women provide physicians with a clear plan for assessment and treatment of CVD risk and personalization of treatment recommendations. The emphasis of preventive efforts has shifted away from treatment of individual CVD risk factors in isolation toward assessment of a woman's overall or "global" CVD risk. In addition to accounting for the presence or absence of preexisting coronary heart disease or its equivalents (e.g., diabetes, chronic kidney disease), cardiovascular risk can be further calculated with the Framingham risk score, which is based on age, sex, smoking history, and lipid and blood pressure levels. Intervention intensity and treatment goals are tailored to overall risk, with those at highest risk receiving the most intense risk-lowering interventions. Women at high risk for CVD and without contraindications should receive aspirin, beta blockers, and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in addition to pharmacologic therapy for hyperlipidemia, hypertension, and diabetes. Women who already are at optimal or low risk for CVD should be encouraged to maintain or further improve their healthy lifestyle practices. Optimal application of these preventive practices significantly reduces the burden of death and disability caused by heart attack and stroke in women.     

Antiarrhythmic drugs for ischemic heart disease.

Therapy with antiarrhythmic drugs may offer the best immediate hope for reducing the large number of deaths due to arrhythmias among patients with ischemic heart disease (IHD). For the prevention of sudden death from ventricular fibrillation, chronic use of these drugs is reasonable in high-risk ambulatory IHD patients, in any patient in whom acute myocardial infarction (MI) is suspected, and in some patients hospitalized for acute MI. However, the effectiveness and possible risks of administering antiarrhythmic drugs in these settings remain essentially unknown. The selection of IHD patients who will benefit most from prophylactic antiarrhythmic drug therapy, the best times for starting and stopping this therapy, and the choice of drug cannot yet be guided by controlled clinical experience. Carefully controlled prospective studies of the beneficial and untoward effects of different drugs in IHD patients are urgently required to provide better guidelines for the clinical use of these potentially life-saving drugs.     

Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review

Aim. This paper is a report of a literature review to identify research involving interventions to improve medication adherence in people with multiple co-existing chronic conditions. Title. Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review. Background. The importance of managing co-existing, chronic conditions in people of all ages is critical to prevent adverse health outcomes. Data sources. Databases, including Cumulative Index of Nursing and Allied Health Literature, Medline, PubMed and Web of Science were searched for the period January 1997–2007 using the combined keywords adherence, compliance, drug therapy, medication, clinical trial, randomized controlled trial, intervention, chronic condition, chronic disease, multiple morbidity and comorbidity. References of retrieved papers were also considered. Methods. The inclusion criteria were: English language, oral medication adherence, self-administered medications, multiple prescribed medications for three or more chronic conditions and randomized controlled trials lasting at least 3 months. Results. Studies examining medication adherence in people with multiple chronic conditions targeted people over 70 years of age, and were primarily focused on the management of polypharmacy and reducing healthcare costs. Adherence was measured using different tools and estimates of adherence, and interventions were predominantly delivered by pharmacists. The evidence for effective interventions to enhance medication adherence in multiple chronic conditions was weak, and psychosocial interventions were absent. Conclusion. Interventions that improve medication adherence for people with multiple chronic conditions are essential, given the increased prevalence of these conditions in people of all ages. Outcomes of improved adherence, such as disease control and quality of life, require investigation. Psychosocial interventions engaging people in medication self-management offer potential for improved patient outcomes in complex diseases.     

The Health Care Resource Utilization and Costs Among Patients With Type 2 Diabetes and Either Cardiovascular Disease or Cardiovascular Risk Factors An Analysis of a US Health Insurance Database

PurposeHealth care costs and cardiovascular (CV) outcomes were evaluated among US patients with type 2 diabetes (T2D) and cardiovascular disease (CVD) or CV risk factors.MethodsPatients with ≥24 months of continuous enrollment were selected from the MarketScan Commercial and Medicare databases from January 1, 2014, to September 30, 2018. For the first qualifying 24-month period, months 1 to 12 defined the baseline period and months 13 to 24 defined the follow-up period. All patients had ≥2 T2D diagnoses during baseline. Two cohorts were created: (1) patients with ≥1 CVD diagnosis during baseline (“CVD cohort”); and (2) patients with ≥1 CV risk factor (“CV risk cohort”) and no diagnosed CVD during baseline. The percentage of patients with subsequent CVD diagnoses and annual all-cause, T2D-related, and CV-related costs in baseline and follow-up periods were reported.FindingsIn total, 1,106,716 patients met inclusion criteria: CVD cohort, 224,018 patients; CV risk cohort, 812,144 patients; and no diagnosed CVD or CV risk factors, 70,554. During baseline, 40.2% of the CVD cohort had 2 or more CVD diagnoses. During follow-up, 10.5% of the CV risk cohort had evidence of CVD (ie, emergent CVD). During baseline, the CVD cohort had mean (SD) all-cause costs of $38,985 ($69,936); T2D-related costs, $16,208 ($34,104); and CV-related annual costs, $18,842 ($44,457). The CV risk cohort had mean all-cause costs of $13,207 ($27,057); T2D-related costs, $5226 ($12,268); and CV-related costs, $2754 ($10,586). During follow-up, the CV risk cohort with emergent CVD had higher mean all-cause, T2D-related, and CV-related annual costs than costs among patients without CVD (all-cause, $39,365 [$67,731] vs $13,401 [$27,530]; T2D related, $18,520 [$37,256] vs $5732 [$12,540]; and CV related, $18,893 [$43,584] vs $2650 [$10,501], respectively).ImplicationsCosts for patients with T2D and either CVD or CV risk are substantial. In this analysis, ∼10% of patients with CV risk were diagnosed with emergent CVD. All-cause costs among patients with emergent CVD were nearly 3 times higher than those among patients with CV risk only. Because costs associated with CVD in the T2D population are high, preventing CVD events in patients with T2D has the potential to decrease overall health care costs and avoid additional disease burden for these patients.     

Epidemiology of ischemic heart disease and characteristics of atherosclerosis in male residents in Yakutsk

AIM: To study trends in prevalence, risk factors (RF) and mortality of ischemic heart disease (IHD), contribution of RF to risk of death due to IHD and other cardiovascular diseases (CVD) among male population of Yakutsk; to determine characteristics of atherosclerosis among native male population and migrants. MATERIAL AND METHODS: A clinicopathological epidemiological trial covered male population of Yakutsk. It was performed by standard techniques within the scope of the cooperative program. RESULTS: The analysis of the trends for the last 10 years demonstrates a marked rise in the incidence rates of arterial hypertension (AH), overweight and hypercholesterolemia. CVD mortality reached 38.4% of overall mortality. Such factors as AH, smoking, IHD, ischemic ECG changes and overweight contribute much to the integral risk of CVD death. A comparative morphometric analysis of atherosclerosis development in 1965-1968 and 1985-1988 showed accelerated development of atherosclerosis both among native population and migrants in 1985-1988. There are population differences in development of atherosclerosis in males from native population and migrants. The effects of trace elements on formation of atherosclerosis components in the Far North were evaluated. CONCLUSION: Present-day epidemiological situation in relation to IHD and other CVD necessitates further monitoring of the situation, activation of primary and secondary IHD prevention among population of the Far North.     

Polypharmacy with common diseases in hospitalized elderly patients

BackgroundElderly persons are exposed to polypharmacy because of multiple chronic conditions. Many risk factors for polypharmacy have been identified including age, race/ethnicity, sex, educational achievement level, health status, and number of chronic diseases. However, drugs prescribed for individual diseases have not been analyzed.ObjectiveThe objective of this study was to analyze each common disease in the elderly with respect to prescribed drugs and polypharmacy.MethodsA 1-year (January through December 2009) cross-sectional study was performed in which all drugs given to hospitalized elderly patients (age, >65 years) were investigated. Common diseases of the elderly were separated into disease groups including hypertension, hyperlipidemia, gastric ulcer, previous stroke, reflux esophagitis, diabetes mellitus, malignancy, osteoporosis, angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, dementia, and depression.ResultsAmong 1768 elderly patients, the mean (range) age of study patients was 78 (65 to 100) years. The mean (SD) number of diseases was 7.7 (3.4), and the number of drugs overall was 4.9 (3.6). The number of drugs and prevalence of polypharmacy were hypertension, 5.2 (3.9 [51%]); hyperlipidemia, 5.6 (3.8 [58%]); gastric ulcer, 5.4 (3.8 [53%]); previous stroke, 5.8 (3.2 [61%]); reflux esophagitis, 5.6 (3.8 [40%]), diabetes mellitus, 5.6 (3.1 [54%]); malignancy, 4.1 (3.1 [37%]); osteoporosis, 5.4 (3.4 [45%]); angina pectoris, 5.7 (3.6 [42%]); congestive heart failure, 6.1 (4.0 [60%]); chronic obstructive pulmonary disease, 5.0 (3.5 [53%]); dementia, 5.1 (3.2 [52%]); and depression, 7.0 (4.2 [73%]).ConclusionsWhen assessing the risk of polypharmacy, physicians should carefully consider the type of any chronic disease. Elderly patients with multiple diseases may be subjected to further polypharmacy.     

Practical Considerations for the Use of Subcutaneous Treatment in the Management of Dyslipidaemia

Suboptimal drug adherence represents a major challenge to effective primary and secondary prevention of cardiovascular disease. While adherence is influenced by multiple considerations, polypharmacy and dosing frequency appear to be rate-limiting factors in patient satisfaction and subsequent adherence. The cardiovascular and metabolic therapeutic areas have recently benefited from a number of advances in drug therapy, in particular protease proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and incretin-based therapies, respectively. These drugs are administered subcutaneously and offer efficacious treatment options with reduced dosing frequency. Whilst patients with diabetes and diabetologists are well initiated to injectable therapies, the cardiovascular therapeutic arena has traditionally been dominated by oral agents. It is therefore important to examine the practical aspects of treating patients with these new lipid-lowering agents, to ensure they are optimally deployed in everyday clinical practice.     

Reducing cardiovascular risk by blockade of the renin-angiotensin-aldosterone system

Many factors contribute to the overall risk of cardiovascular disease (CVD) in a given patient. Activation of the renin-angiotensin-aldosterone system (RAAS) is pivotal in the pathophysiology of CVD and renal disease and appears to place individuals at high risk for cardiovascular (CV) and renal events. Results from many large-scale, long-term clinical trials have demonstrated that RAAS blockade with an angiotensin-converting-enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) can significantly decrease CV and renal morbidity and mortality in a wide range of patients. Some of the clinical benefits derived from use of these agents appears to be independent of their ability to lower blood pressure. The combined use of an ACEI and an ARB for antihypertensive therapy has begun to receive considerable attention. Such an approach may seem counterintuitive, but ACEIs and ARBs have distinct and potentially complementary pharmacologic effects. Results from clinical trials thus far suggest that combination therapy with an ACEI plus an ARB may be a rational choice in patients with chronic activation of the RAAS, including those with heart failure or impaired left ventricular systolic function, diabetes, proteinuria, impaired renal function, recent myocardial infarction, or multiple CV risk factors. Results from ongoing, large-scale, clinical endpoint trials will provide important additional information about the benefits of dual RAAS inhibition in patients at high risk for CV morbidity and mortality.     

Cardiovascular risk in chronic kidney disease: what is new in the pathogenesis and treatment?

The prevalence of chronic kidney disease (CKD) has increased markedly over past decades due to the aging of the worldwide population. Despite the progress in the prevention and treatment, the cardiovascular (CV) morbidity and mortality remain high among patients with CKD. Although CKD is a progressive and irreversible condition, it is possible to slow decreasing kidney function, as well as the development and progression of associated with kidney disease comorbidities. Diabetes mellitus has become major cause of CKD worldwide. It is estimated that the prevalence of diabetes will increase from 425 million worldwide in 2017 to 629 million by 2045, substantially the percentage of diabetic nephropathy among CKD patients is set to rise markedly. The results of multicenter trials concerning novel antidiabetic drugs suggest that efficacy in reducing CV risk is independent of the improvement in glycemic control. This review discusses underlying causes of high CV risk and strategies reducing individual burden among CKD patients.     

Gene therapy for cardiovascular angiogenesis

Atherosclerosis and endothelial dysfunction are responsible for the pathophysiologic basis of the spectrum of cardiovascular disorders including ischaemic heart disease (IHD), the leading cause of morbidity and mortality in the US. There have been major advances, including the use of pharmacotherapy, coronary and peripheral percutaneous transluminal interventions (PTI), coronary and peripheral bypass surgery and primary/secondary prevention measures. There are, however, multiple unmet needs: IHD refractory to medical therapy and unsuitable for revascularisation; critical limb ischaemia unsuitable for PTI or surgery; restenosis; ischaemic/diabetic neuropathy and heart failure. Cardiovascular gene therapy (GT) with vascular endothelial growth factor (VEGF) has yielded improved perfusion and reduced ischaemia in preclinical models of IHD. Several preclinical studies and Phase I and II clinical trials have shown the safety and therapeutic potential of GT in the treatment of IHD, peripheral arterial disease (PAD), restenosis, and ischaemic and diabetic neuropathy, pointing to the need for Phase III clinical trials.     

Gene therapy for cardiovascular angiogenesis

Atherosclerosis and endothelial dysfunction are responsible for the pathophysiologic basis of the spectrum of cardiovascular disorders including ischaemic heart disease (IHD), the leading cause of morbidity and mortality in the US. There have been major advances, including the use of pharmacotherapy, coronary and peripheral percutaneous transluminal interventions (PTI), coronary and peripheral bypass surgery and primary/secondary prevention measures. There are, however, multiple unmet needs: IHD refractory to medical therapy and unsuitable for revascularisation; critical limb ischaemia unsuitable for PTI or surgery; restenosis; ischaemic/diabetic neuropathy and heart failure. Cardiovascular gene therapy (GT) with vascular endothelial growth factor (VEGF) has yielded improved perfusion and reduced ischaemia in preclinical models of IHD. Several preclinical studies and Phase I and II clinical trials have shown the safety and therapeutic potential of GT in the treatment of IHD, peripheral arterial disease (PAD), restenosis, and ischaemic and diabetic neuropathy, pointing to the need for Phase III clinical trials.     

Low HDL Cholesterol Is Associated With the Risk of Stroke in Elderly Diabetic Individuals: Changes in the risk for atherosclerotic diseases at various ages

OBJECTIVE

To clarify the relationship between lipid levels and ischemic heart disease (IHD) and cerebrovascular disease (CVD) in diabetic individuals.

RESEARCH DESIGN AND METHODS

The Japan Cholesterol and Diabetes Mellitus Study is a prospective cohort study of 4,014 type 2 diabetic patients (1,936 women; mean ± SD age 67.4 ± 9.5 years). Lipid and glucose levels and other factors were investigated in relation to occurrence of IHD or CVD.

RESULTS

IHD and CVD occurred in 1.59 and 1.43% of participants, respectively, over a 2-year period. The relation of lower HDL or higher LDL cholesterol to occurrence of IHD in subjects <65 years old was significant. Lower HDL cholesterol was also significantly related to CVD in subjects ≥65 years old and especially in those >75 years old (n = 1,016; odds ratio 0.511 [95% CI 0.239–0.918]; P < 0.05). Stepwise multiple regression analysis with onset of CVD as a dependent variable showed the same result.

CONCLUSIONS

Lower HDL cholesterol is an important risk factor for not only IHD but also CVD, especially in diabetic elderly individuals.Type 2 diabetes, dyslipidemia, and aging are independent risk factors for cardiovascular diseases. Japanese individuals have lower rates of ischemic heart disease (IHD) and higher rates of cerebrovascular disease (CVD); however, diabetic individuals have an increased risk of IHD (1,2). Risk factors for IHD or CVD in elderly diabetic individuals are not fully known (3), and the Japan Cholesterol and Diabetes Mellitus Study was formulated to evaluate them (Umin Clinical Trials Registry, clinical trial reg. no. UMIN00000516; http://www.umin.ac.jp/ctr/index.htm).     

Chronic obstructive lung diseases in patients with ischemic heart disease: a 15-year study]

AIM: To characterize acquired chronic obstructive pulmonary diseases (COPD) in patients with ischemic heart disease (IHD). MATERIAL AND METHODS: Monitoring of external respiration function (ERF) was performed for 15 years in 1552 IHD patients on combined drug treatment. RESULTS: The 15-year follow-up has revealed that IHD patients treated with beta-blockers develop pathological changes in respiration pattern manifesting primarily with dyspnea, obstructive and mixed ventilatory disorders, syndrome of early expiratory obstruction in affected small airways due to subnormal lung elasticity, defective diffuse function, signs of terminal respiratory failure. CONCLUSION: IHD patients taking drugs need monitoring of ERF. Optimal treatment consists in early diagnosis of IHD and COPD, adequate combined therapy with beta-blockers and bronchodilating drugs.     

Patient education strategies for hospitalized cardiovascular patients: a systematic review

Although mortality from cardiovascular (CV) disease has fallen in the past decade, the burden of CV disease and related conditions remains high, with rates of hospitalization and disability and cost on the rise. Prevention and treatment of CV conditions often involve a complex regimen of lifestyle modification, medications, and/or symptom monitoring and management. Cardiovascular health professionals spend a great deal of time promoting awareness of and adherence to national guidelines for the prevention and management of CV conditions. In addition, patient education for hospitalized patients is becoming increasingly regulated by national organizations and payors. However, it is unclear which educational intervention elements or strategies are most effective for educating hospitalized CV patients and their families. The purpose of this systematic review of experimental and quasi-experimental studies was to identify and examine the characteristics and outcomes of CV health education interventions for hospitalized CV patients.     

Which patients should receive aspirin for primary prevention of cardiovascular disease? An economic evaluation

Low-dose aspirin is a standard care for secondary prevention of cardiovascular disease (CVD). Its use in primary prevention is less widely accepted, however, despite recent meta-analyses and US and European guidelines supporting its use in individuals at increased CVD risk. The aim of this study was to define which patients should receive aspirin for primary prevention of CVD using data from four European countries. Based on the clinical data from two meta-analyses, a state-transition model was developed to compare the costs and effects of no treatment and low-dose aspirin as primary prevention for CVD over 10 years. The model was applied to patients at different 10-year risks (2-5%) of fatal CVD according to the SCORE equation. Direct costs from the perspective of the healthcare payer were used (base year 2003). Country-specific discounting was applied. Treating patients with a 10-year risk of fatal CVD of 2% or higher with low-dose aspirin resulted in lower total costs and more quality-adjusted life-years gained in the UK, Germany and Spain. In Italy, savings started at a 10-year fatal CVD risk of 3%. This difference was due to the higher cost of gastrointestinal bleeding in Italy. Monte Carlo analysis showed that aspirin was dominant in more than 90% of patients at a 10-year risk of 4% and 5% in the four countries. In conclusion, low-dose aspirin treatment becomes cost-saving at a very low 10-year risk of fatal CVD. The cost of gastrointestinal bleeding defines the level at which low-dose aspirin becomes cost-saving.     

Polypharmacy in geriatric patients

Although research-based information concerning geriatric polypharmacy is lacking, available data suggest possible causes, health risks, and areas for intervention. Nursing home residents are more likely to be recipients of unnecessary and excessive drugs than community-dwelling elderly. Polypharmacy can lead to increased adverse drug reactions, drug interactions, and medication errors. In the future, there will be single drug therapy for conditions now requiring multiple drugs, but improved diagnosis of disease could lead to persons receiving additional, appropriate drugs for these health problems. Informed patients collaborating with knowledgeable prescribers and those dispensing and administering their medications may be able to reduce the number of drugs they are taking. More research is needed to identify methods that promote safe self-medication behavior and better drug use in nursing homes. Health risks associated with polypharmacy and the escalating costs of medications require that nurse participation in ensuring that the elderly receive only necessary and effective drug treatment.     

Promoting Health and Wellness in the Workplace: A Unique Opportunity to Establish Primary and Extended Secondary Cardiovascular Risk Reduction Programs

Given the burden of cardiovascular disease (CVD), increasing the prevalence of healthy lifestyle choices is a global imperative. Currently, cardiac rehabilitation programs are a primary way that modifiable risk factors are addressed in the secondary prevention setting after a cardiovascular (CV) event/diagnosis. Even so, there is wide consensus that primary prevention of CVD is an effective and worthwhile pursuit. Moreover, continual engagement with individuals who have already been diagnosed as having CVD would be beneficial. Implementing health and wellness programs in the workplace allows for the opportunity to continually engage a group of individuals with the intent of effecting a positive and sustainable change in lifestyle choices. Current evidence indicates that health and wellness programs in the workplace provide numerous benefits with respect to altering CV risk factor profiles in apparently healthy individuals and in those at high risk for or already diagnosed as having CVD. This review presents the current body of evidence demonstrating the efficacy of worksite health and wellness programs and discusses key considerations for the development and implementation of such programs, whose primary intent is to reduce the incidence and prevalence of CVD and to prevent subsequent CV events. Supporting evidence for this review was obtained from PubMed, with no date limitations, using the following search terms: worksite health and wellness, employee health and wellness, employee health risk assessments, and return on investment. The choice of references to include in this review was based on study quality and relevance.