Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics

What is known and Objective: Second‐generation antipsychotics (SGAs) play an important role in the pharmacologic management of various psychiatric conditions. Use of these medications has been associated with metabolic complications. Adherence to guideline‐recommended monitoring is suboptimal. We evaluated the effect of a computerized physician order entry (CPOE) pop‐up alert designed to improve rates of laboratory metabolic monitoring of patients treated with SGAs on a University Hospital inpatient psychiatry unit. Methods: A single‐centre, retrospective chart review was performed in which patient demographics and SGA drug and laboratory data were extracted from the CPOE database. We assessed the number of orders for appropriate metabolic monitoring data for patients admitted within a 6‐month period before or after the alert implementation. Results and Discussion: Pre‐alert (n = 171) and post‐alert (n = 157) groups were similar with respect to age, length of stay, sex, race and comorbidities. Following alert implementation, significant increases in monitoring both random (92·4% vs. 100%) and fasting (46·8% vs. 70%) glucose levels as well as random (28·7% vs. 74·5%) and fasting (18·7% vs. 59·9%) lipid panels (all P ≤ 0·001) were observed. The number of patients with both a fasting glucose level and fasting lipid panel available for monitoring increased from 12·9% to 47·8% (P < 0·0001). Significantly more post‐alert laboratory orders were submitted at the same time as the SGA drug order (P < 0·0001), suggesting that the alert itself had a direct influence on the ordering of metabolic monitoring labs. What is new and Conclusions: Implementation and use of an electronic pop‐up alert in an inpatient psychiatric unit significantly improved rates of ordering fasting blood glucose and lipid levels for inpatients treated with SGAs. Overall rates remain suboptimal, suggesting a need for additional strategies to further improve metabolic monitoring.     

Markers of cardiovascular risk in patients with antiphospholipid syndrome: A meta-analysis of literature studies

Abstract

Several studies reported on the association between antiphospholipid syndrome (APS) and venous thrombosis. In contrast, little is known about cardiovascular (CV) risk in APS. We performed a meta-analysis on the impact of APS on major markers of CV risk.

Studies on the relationship between APS and common carotid artery intima-media thickness (CCA-IMT), internal carotid artery IMT (ICA-IMT), carotid bifurcation IMT (BIF-IMT), prevalence of carotid plaques, flow-mediated dilation (FMD), nitrate-mediated dilation (NMD), and ankle-brachial index (ABI) were systematically searched in PubMed, Web of Science, Scopus, and EMBASE databases. Twenty case-control studies (668 cases, 678 controls) were included. Compared to controls, APS patients showed a higher CCA-IMT (mean difference [MD] 0.11 mm; 95% CI 0.07, 0.14), ICA-IMT (MD 0.08 mm; 95% CI 0.05, 0.11), BIF-IMT (MD 0.09 mm; 95% CI 0.06, 0.12) and a higher frequency of carotid plaques (OR 3.87; 95% CI 1.61, 9.31). Moreover, a lower FMD was found in APS subjects than in controls (MD –4.49%; 95% CI –6.20, –2.78), with no differences in NMD (MD –1.80%; 95% CI –4.01, 0.42). Finally, an increased prevalence of pathological ABI was found in APS patients compared to controls (OR 7.26; 95% CI 1.77, 29.71).

Despite heterogeneity among studies, APS appears significantly associated with markers of subclinical atherosclerosis and CV risk. These findings can be useful to plan adequate prevention strategies and therapeutic approaches.     

Association of cardiovascular emerging risk factors with acute coronary syndrome and stroke: A case‐control study

In this study, we estimated the risk of acute coronary syndrome and stroke associated with several emerging cardiovascular risk factors. This was a case‐control study, where an age ‐ and sex‐matched acute coronary syndrome group and stroke group were compared with controls. Demographic and clinical data were collected through patient interviews, and blood samples were taken for analysis. In the bivariate analysis, all cardiovascular risk factors analyzed showed as predictors of acute coronary syndrome and stroke, except total cholesterol and smoking. In the multivariate logistic regression model for acute coronary syndrome, hypertension and body mass index, N‐terminal section brain natriuretic peptide and pregnancy‐associated plasma protein‐A were independent predictors. For stroke, the predictors were hypertension, diabetes mellitus, body mass index, and N‐terminal section brain natriuretic peptide. Controlling for age, sex, and classical cardiovascular risk factors, N‐terminal section brain natriuretic peptide and pregnancy‐associated plasma protein‐A were independent emerging cardiovascular risk factors for acute coronary syndrome, but pregnancy‐associated plasma protein‐A was not for stroke. High levels of cardiovascular risk factors in individuals with no episodes of cardiovascular disease requires the implementation of prevention programs, given that at least half of them are modifiable.     

Exercise intervention and health checks for middle-aged men with elevated cardiovascular risk: A randomized controlled trial

Abstract

Objective. To study the effects of a health check by a nurse alone or combined with an exercise intervention in middle-aged men at increased cardiovascular risk. Design. A randomized controlled trial. Setting and intervention. Primary care in Kirkkonummi municipality with 36 000 inhabitants. A health check by a nurse alone or combined with an exercise intervention to controls with no intervention was compared. Subjects. A total of 168 men aged 35 to 45 years with at least two cardiovascular risk factors and physical activity (PA) frequency < 3 times a week. Main outcome measures. Metabolic syndrome (MetS) as defined by International Diabetes Federation/American Heart Association and self-reported PA frequency. Results. Overall, focusing on health increased physical activity frequency in middle-aged men. After one year, 19% had increased PA to ≥ 3 times a week (95% CI 12–26). All study groups increased PA to ≥ 3 times: 26% of men in the exercise intervention group, 15% of men in the health check group, and 16% of controls. The differences between the groups were not statistically significant. The intervention did not have any meaningful impact on MetS or other cardiovascular outcomes at one-year follow up. Conclusions. Physical activity increased in all study groups of middle-aged men in this health-promotion trial. The interventions had no effect on metabolic syndrome or other cardiovascular outcomes in the participants. The trial increased awareness and collaboration in physical activity promotion among municipal health care and exercise services.     

Systematic review of cardiovascular disease in women: assessing the risk

Cardiovascular disease is the number one cause of death for women. In an effort to reduce cardiovascular burden for women, identifying risk factors and increasing awareness of sex differences are fundamental. This systematic review examines cardiovascular disease risk for women. A search of the literature was undertaken using key health databases. Search terms used were cardiovascular disease AND women OR gender. Additional references were manually identified from this literature; 58 articles were reviewed in total. On average, cardiovascular disease presents 10 years later in women compared to men. By this time, they are more likely to suffer from more comorbidities, placing them at higher risk. The complexity of cardiovascular disease identification in women is accentuated through atypical symptoms, and has the potential to lead to delayed and/or misdiagnosis. It is clear through identifying sex differentiation in cardiovascular risk factors that there has been an increased awareness of symptom presentation for women. In light of the sex differences in risk factors, sex‐specific aspects should be more intensively considered in research/practice to improve clinical outcomes for female cardiovascular disease patients.     

Effects of berberine on lipid profile in subjects with low cardiovascular risk

Objective: To evaluate the efficacy as antihypercholesterolemic agent of berberine in patients with low cardiovascular risk.

Research design and methods: 144 Caucasian subjects were enrolled. After a 6-month run-in period following diet and practicing physical activity, patients were randomized to take placebo or berberine 500 mg twice a day, for 3 months, in a double-blind, placebo-controlled design. Berberine and placebo were then interrupted for 2 months (washout period), and all patients continued with only diet and physical activity. At the end of the washout period, patients restarted berberine or placebo twice a day for further 3 months. Anthropometric and metabolic parameters were assessed during the run-in period, at randomization, before and after the washout period.

Results: A decrease of body weight and BMI was observed after the run-in period. Berberine reduced total cholesterol, triglycerides and LDL cholesterol and increased HDL cholesterol after 3 months from randomization and compared with placebo. After the washout period, lipid profile worsened; afterward, when berberine was reintroduced, lipid profile improved again both compared with the washout period, and with placebo.

Conclusions: Berberine is effective and safe to mildly improve lipid profile in subjects with low risk for cardiovascular disease.     

Design and methodology of POWER,an open‐label observation of the effect of primary care interventions on total cardiovascular risk in patients with hypertension

This article describes the design and methodology of the POWER study (Physicians’ Observational Work on Patient Education According to their Vascular Risk). POWER is an open‐label multinational postmarketing study of the angiotensin II‐receptor blocker eprosartan. The Systemic Coronary Risk Evaluation (SCORE) model has been used to estimate total cardiovascular risk and changes in total cardiovascular risk status during treatment for patients recruited in all countries other than Canada. Framingham Heart Study equations have been used to estimate risk in the Canadian contingent of POWER. Observations from POWER will provide insights into how clinicians try to achieve blood pressure goals within the framework of total cardiovascular risk management and how they integrate their treatment of blood pressure with other interventions. Experience during the POWER study may also help to affirm the utility, practicability and perhaps limitations of the SCORE system for estimating total cardiovascular risk and identify ways to improve the acceptance and implementation of risk estimation methods in cardiovascular primary prevention.     

Effects of a community‐based intervention on cardio‐metabolic risk and self‐care behaviour in older adults with metabolic syndrome

This pilot study was performed to investigate the effects of a community‐based intervention (CBI) on cardio‐metabolic risk and self‐care behaviour in 92 older adults with metabolic syndrome at public health centres in Suwon, Korea. A prospective, pretest and posttest, controlled, quasi‐experimental design was used. The older adults in the intervention group participated in an 8‐week intensive lifestyle counselling, whereas those in the control group received usual care. The mean (standard deviation) age of the participants was 71.4 (4.43) years ranging from 60 to 84, and 75.0% of the participants were female. The intervention group at 8 weeks showed significant reduction in waist circumference by ?1.35 cm (P < 0.001) and improved self‐care behaviour (+ 5.17 score, P < 0.05) and self‐efficacy (+ 4.84 score, P < 0.001) when compared with the control group. The percentages of those who successfully completed the targeted behavioural modification were 71.7% for exercise and 52.2% for dietary control in the intervention group at 8 weeks. This pilot study provided evidence of the beneficial impact of the CBI for Korean older adults with metabolic syndrome.     

Low drug levels and thrombotic complications in high‐risk atrial fibrillation patients treated with direct oral anticoagulants

Essentials

• Direct oral anticoagulants (DOACs) do not require laboratory monitoring currently.
• DOAC specific measurements were performed at trough in patients with atrial fibrillation.
• Patients who developed thromboembolic events showed lower DOAC plasma levels.
• This study supports the concept of measuring DOAC levels at steady state.

Summary

Background

Direct oral anticoagulants (DOACs) are administered at fixed doses without the need for dose adjustment according to laboratory testing. High interindividual variability in drug blood levels has been shown with all DOACs. To evaluate a possible relationship between DOAC C‐trough anticoagulant levels and thromboembolic events, 565 consecutive naive patients with atrial fibrillation (AF) were enrolled in this study performed within the START Laboratory Registry.

Methods

DOAC‐specific measurements (diluted thrombin time or anti‐activated factor II calibrated for dabigatran; anti‐activated FX calibrated for rivaroxaban or apixaban) at C‐trough were performed locally at steady state within 15–25 days after the start of treatment. For each DOAC, the interval of C‐trough levels, from the limit of quantification to the highest value, was subdivided into four equal classes, and results were attributed to these classes; the median values of results were also calculated. Thromboembolic complications occurring during 1 year of follow‐up were recorded.

Results

Thromboembolic events (1.8%) occurred in 10 patients who had baseline C‐trough levels in the lowest class of drug levels. The incidence of thromboembolic events among patients with DOAC C‐trough levels in the lowest level class was 2.4%, and that in the remaining groups was 0%. The patients with thrombotic complications also had a higher mean CHA₂DS₂‐VASc score than that of the total patient population: 5.3 (95% confidence interval [CI] 4.3–6.3 versus 3.0 (95% CI 2.9–3.1).

Conclusion

In this study cohort, thrombotic complications occurred only in DOAC‐treated AF patients who had very low C‐trough levels, with a relatively high CHA₂DS₂‐VASc score. Larger studies are warranted to confirm these preliminary observations.