A new tool for benchmarking cardiovascular fluoroscopes.

This article reports the status of a new cardiovascular fluoroscopy benchmarking phantom. A joint working group of the Society for Cardiac Angiography and Interventions (SCA&I) and the National Electrical Manufacturers Association (NEMA) developed the phantom. The device was adopted as NEMA standard XR 21-2000, "Characteristics of and Test Procedures for a Phantom to Benchmark Cardiac Fluoroscopic and Photographic Performance," in August 2000. The test ensemble includes imaging field geometry, spatial resolution, low-contrast iodine detectability, working thickness range, visibility of moving targets, and phantom entrance dose. The phantom tests systems under conditions simulating normal clinical use for fluoroscopically guided invasive and interventional procedures. Test procedures rely on trained human observers.     

Trends in cardiovascular risk factor prevalence (1995-2000-2005) in northeastern Spain.

BACKGROUND: High prevalence of cardiovascular risk factors has been observed in Spain along with low incidence of acute myocardial infarction. Our objective was to determine the trends of cardiovascular risk factor prevalence between 1995 and 2005 in the 35-74-year-old population of Gerona, Spain. DESIGN: Comparison of cross-sectional studies were conducted in random population samples in 1995, 2000, and 2005 at Gerona, Spain. METHODS: An electrocardiogram was obtained, along with standardized measurements of body mass index, lipid profile, systolic and diastolic blood pressure, glycaemia, energy expenditure in physical activity, smoking, use of lipid-lowering and antihypertensive medications, and cardiovascular risk. Prevalence of diabetes, hypertension, and obesity was calculated and standardized for age. RESULTS: A total of 7571 individuals (52.0% women) were included (response rate 72%). Low-density lipoprotein cholesterol >3.4 mmol/l (130 mg/dl) (49.7%) and hypertension (39.1%) were the most prevalent cardiovascular risk factors. In 1995, 2000 and 2005, low-density lipoprotein cholesterol decreased in both men and women: 4.05-3.91-3.55 mmol/l (156-151-137 mg/dl) and 3.84-3.81-3.40 mmol/l (148-147-131 mg/dl), respectively. Increases were observed in lipid-lowering drug use (5.7-6.3-9.6% in men and 4.0-5.8-8.0% in women), controlled hypertension (14.8-35.4-37.7% in men and 21.3-36.9-45.0% in women); (all P-trends <0.01), and obesity (greatest for men: 17.5-26.0-22.7%, P-trends=0.020). Prevalence of myocardial infarction or possibly abnormal Q waves in electrocardiogram also increased significantly (3.9-4.7-6.4%, P-trends=0.018). CONCLUSIONS: The cardiovascular risk factor prevalence change in Gerona was marked in this decade by a shift of total cholesterol and low-density lipoprotein cholesterol distributions to the left, independent of the increase in lipid-lowering drug use, and better hypertension control with increased use of antihypertensive drugs.     

Drug-resistant tuberculosis in Castilla-León, Spain, 1996-2000.

SETTING: During 1996-2000, a regional anti-tuberculosis drug resistance survey was conducted in Castilla-León, Spain. OBJECTIVE: To determine the incidence of drug-resistant tuberculosis (TB) in newly treated human immunodeficiency virus (HIV) negative and HIV-positive TB patients. DESIGN: Nine hundred and eighty-five Mycobacterium tuberculosis strains isolated from HIV-negative (926) and HIV-positive (59) patients were studied (one strain per patient). Univariate and multivariate analyses were used to determine the prevalence of drug resistance in high-risk groups. RESULTS: Thirty-eight isolates (3.8%) showed resistance to one of the following drugs: streptomycin (S), isoniazid (H), rifampicin (R) or ethambutol (E). Of these, 36 (3.9%) were from HIV-negative and 2 (3.4%) from HIV-positive patients. The rate of drug resistance among HIV-negative patients was 1.2%, 2.0%, 0.3% and 0.8%, respectively, for S, H, R and E, and for HIV-positive patients it was 3.4%, 0%, 0% and 1.7%. Among the HIV-negative patients, monoresistance was observed in 32 (3.4%) strains and resistance to both H and R (multi-drug resistance) was detected in one. CONCLUSION: The incidence of primary drug resistance in the surveyed area was low and increased resistance was not observed in the HIV-positive group (P = 0.99). Routine surveillance of drug resistance is recommended by the TB control programme in representative patient populations to optimise treatment regimens.     

Control and prevention of cardiovascular disease around the world

The situation regarding cardiovascular disease in different parts of the world is presented, and the prevalence and trends in main risk factors based on Omran's epidemiological transition model are reported. A World Heart Federation survey documenting the limited human and technical resources in some developing countries and inadequate use of these resources in others is discussed. This survey also shows that few countries have guidelines for the management of cardiovascular disease and its risk factors, and reveals a lack of relationship between the percentage of countries with guidelines and the importance of a given disease or risk factor. Because economic resources for health in highly populated developing countries are limited, preventive measures for cardiovascular disease and its risk factors must be combined with those for all other chronic diseases. We recommend the following actions: a). improve the use of facilities for the dissemination of information; b). create suitable conditions for the development of research in developing countries; c). incorporate into primary care the innovations proposed by the WHO in 2002 to control chronic diseases, and d). assist in the development of the program proposed by the World Heart Federation.     

Salmonella enteric infections in Gipuzkoa,Spain, 1983-2000

The incidence of Salmonella enteric infections in Gipuzkoa, Spain, was estimated by studying a stable population between 1983 and 2000. Only stool culture confirmed cases were included. The annual mean rate of infection in children under 2 years old was 1121 per 100,000 (CI 95%; 1060-1181). This age group had the highest relative risk (RR), 16.2-fold higher than the RR of those aged over 14 years. Salmonella Enteritidis was the most prevalent serovar (80.4% of all patients), followed by Salmonella Typhimurium (11.7%).     

Progress toward prevention of cardiovascular disease. A 30-year retrospective.

Since its creation as the National Heart Institute in 1948, the National Heart, Lung, and Blood Institute (NHLBI) has led a national biomedical research program in heart, lung, blood, and blood vessel diseases, and has become increasingly involved in complex clinical trials to validate its research findings. In addition, NHLBI sponsors demonstrations and educational activities to apply proved research findings in the health care community. NHLBI's approach to these responsibilities involves acquiring new and basic information, testing and evaluating the information, and applying it to improve prevention, detection, and treatment of disease. New equipment such as the heart-lung machine and the pacemaker, better diagnostic procedures, new operative and treatment devices, new drugs, and increased use of preventive medicine have dramatically reduced mortality from heart attack, hypertension and stroke.     

Interventions for cardiovascular disease prevention

Cardiovascular disease prevention is a continuum that encompasses the life-course. This article discusses preventive strategies focusing on policy and clinical initiatives including primordial prevention (lifestyle changes involving smoking, diet and exercise), primary prevention (risk factor control), and secondary prevention (acute and chronic disease management). Combined use of all the three strategies can have an immediate and large impact on reducing CVD morbidity and mortality.     

Organizing services for cardiovascular prevention

Opinion statement With an aging population, cardiovascular disease (CVD) prevalence will continue to increase for at least the next 30 years. Current clinical trial evidence expands the indications for aggressive treatment of risk factors. Concurrently, the use of new screening and diagnostic technologies will expand the number of identified high-risk individuals requiring clinical care. These likely scenarios will force efficient resource allocation. The impression of the authors is that new models of shared responsibilities of care are needed to enable CVD prevention. All stages of care for those with CVD should entail cooperation among nurses, pharmacists, primary care providers, and cardiovascular specialists in delivering comprehensive, evidence-based care. The persistent treatment gap between current knowledge and clinical practice suggests old models of acute patient care by specialists require revision into fundamentally different systems of long-term care by a team of providers such as that proposed by the Chronic Care Model.     

Principles of prevention of cardiovascular disease.

Dear Sir The International Atherosclerosis Society (IAS) recently releasedharmonized guidelines for prevention of atherosclerotic diseasethrough clinical management.¹ These guidelines integrate andharmonize existing guidelines for this purpose. Thanks to alarge number of clinical trials, it is now possible to providestrong evidence-based guidelines for risk factor modificationto prevent both recurrent atherosclerotic events (secondaryprevention)     

Diuretics for cardiovascular prevention in the elderly

High blood pressure (BP) is a major risk factor for cardiovascular and cerebrovascular diseases in elderly subjects. Antihypertensive drugs have shown clinical benefit both in primary and secondary prevention of cardiovascular events. If BP lowering represents the major determinant of the effects conferred by the antihypertensive treatment for prevention, recent studies have suggested some differences between classes of antihypertensive drugs according to age. Based on the available clinical data, the recent medical guidelines have recommended thiazide-type diuretics as the preferred drug for the treatment of elderly hypertensive patients, followed by long-acting calcium antagonists. Indeed, diuretics constitute one of the most valuable classes of antihypertensive drugs, and in the elderly, diuretic-based treatment studies have been clearly shown to prevent major cardiovascular events, including stroke, heart failure and coronary heart disease.     

A new score for improving cardiovascular risk prediction and prevention

Background and aimsThe ultrasonographic detection of subclinical atherosclerosis (scATS) at carotid and femoral vascular sites using the atherosclerosis burden score (ABS) improves the risk stratification for atherosclerotic cardiovascular disease beyond traditional cardiovascular (CV) risk factors. However, its predictive value should be further enhanced. We hypothesize that combining the ABS and the Framingham risk score (FHRS) to create a new score called the FHRABS will improve CV risk prediction and prevention. We aim to investigate if incorporating the ABS into the FHRS improved CV risk prediction in a primary prevention setting.Methods and results1024 patients were included in this prospective observational cohort study. Carotid and femoral plaques were ultra-sonographic detected. Major incident cardiovascular events (MACEs) were collected. The receiver operating characteristic curve (ROC-AUC) and Youden's index (Ysi) were used to compare the incremental contributions of each marker to predict MACEs.After a median follow-up of 6.0 ± 3.3 years, 60 primary MACEs (5.8%) occurred. The ROC-AUC for MACEs prediction was significantly higher for the FHRABS (0.74, p < 0.024) and for the ABS (0.71, p < 0.013) compared to the FHRS alone (0.71, p < 0.46). Ysi or the FHRABS (42%, p < 0.001) and ABS (37%, p < 0.001) than for the FHRS (31%). Cox proportional-hazard models showed that the CV predictive performance of FHRS was significantly enhanced by the ABS (10.8 vs. 5.5, p < 0.001) and FHRABS (HR 23.30 vs. 5.50, p < 0.001).ConclusionsFHRABS is a useful score for improving CV risk stratification and detecting patients at high risk of future MACEs. FHRABS offers a simple-to-use, and radiation-free score with which to detect scATS in order to promote personalized CV prevention.     

A hospital-based network for hyperlipidaemia management and cardiovascular disease prevention

BACKGROUND AND AIM: A number of studies have shown that there is a wide gap between scientific evidence and clinical practice. In particular, less than 50% of the patients surviving a myocardial infarction take lipid lowering agents. We have developed an organisational model designed to bridge this gap and implement clinical guidelines in a clinical setting. METHODS AND RESULTS: We have set up 23 clinics for the management of hyperlipidaemia and the prevention of cardiovascular disease. The procedure for establishing these clinics included the training of health staff, the preparation of a medical record, the development of a standard operating protocol, the presentation of the aims and operating procedure of the network to general practitioners and the community, the institution of a freephone number, and the standardisation of quality control. The regional clinical network was established in 1998, and examined 1534 patients during the first four months. As expected, the most frequent hyperlipoproteinaemia was polygenic hypercholesterolaemia (30% of males and 32% of females). Fifty-three percent of the 270 patients asking for long-term follow-up reached an acceptable target according to the international guidelines (total cholesterol < 220 mg/dL) in the first two months. CONCLUSIONS: This organisational model takes advantage of hospital units, which devote a fraction of their time to the prevention of cardiovascular disease. The network is useful for standardising diagnostic and therapeutic procedures in accordance with the guidelines, and has an educational impact on both patients and health staff. The availability of a large database of patients with hyperlipoproteinaemia is the basis for quality control, drug safety surveillance, and clinical studies of specific issues or selected patient subgroups. The hospital-based network is an operational reference for all practitioners in the region and helps to integrate efforts aimed at bridging the gap between scientific evidence and clinical practice.     

Relation between hypertension and cardiovascular events--implications for coronary prevention.

OBJECTIVE: To study the relation between hypertension and cardiovascular events--stroke, myocardial infarction (MI), heart failure (HF), and chronic renal failure (CRF)--and to define implications for cardiovascular disease prevention. DESIGN: Cross-sectional study, in two stages, but with retrospective information about major cardiovascular events. SETTING: Primary care health centers (Lisbon Regional Health Administration). MATERIAL AND METHODS: Participants: 3228 patients, 1100 male (439 aged up to 60 years and 661 aged 60 years) and 2128 females (860 aged up to 60 years and 1268 aged 60 years). The study covered stroke, myocardial infarction, heart failure, chronic renal failure with co-variables of age, gender, body mass index (BMI), blood pressure, heart rate, antihypertensives, diabetes, total cholesterol, dyslipidemic therapy, and smoking. The group without hypertension (normotensives) and hypertensives--treated with antihypertensives and/or with systolic/diastolic blood pressure > or = 140/90 mmHg (n = 2169)--were compared, using logistic regression, to identify nonfatal cardiovascular complications associated with hypertension. Forward conditional logistic regression was used to test the multivariate models. The level of significance was taken to be 5%. The statistical packages Stata and SPSS were used. RESULTS: The analysis included 2839 cases (389 missing). The absolute frequencies of categorical variables were: smoking (n = 343); stroke (n = 150); myocardial infarction (n = 90); heart failure (n = 174); renal failure (n = 34); hypercholesterolemia (n = 864); diabetes (n = 375); male gender (n = 976) and female gender (n = 1863). The regression equation included the following factors: age (p < 0.001; OR = 1.068 and 95% CI 1061-1.075); body weight (p = 0.001; OR = 1.020 and 95% CI 1.008-1.032); stroke (p = 0.007; OR = 2.523 and 95% CI 1.286-4.951); HF (p = 0.013; OR = 2.449 and 95% CI 1.205-4.979); diabetes (p < 0.001; OR = 1.894 and 95% CI 1.328-2.701); hypercholesterolemia (p < 0.001; OR = 1.693 and 95% CI 1.350-2.123); and BMI (p < 0.001; OR = 1.006 and 95% CI 1.003-1.010). CONCLUSIONS: Nonfatal stroke was associated with hypertension, as was heart failure, but neither nonfatal myocardial infarction nor chronic renal failure were. Control of hypertension is therefore expected to be more efficacious in reducing cerebrovascular events than those caused by coronary heart disease.     

CARRISMA: a new tool to improve risk stratification and guidance of patients in cardiovascular risk management in primary prevention.

AIMS: Risk stratification is important for decisions about the intensity of treatment in primary prevention. Risk factors and lifestyle factors are responsible for over 80% of cardiovascular morbidity and mortality. However, body mass index (BMI), physical activity and smoking (cigarettes/day) are not or not quantitatively represented in the risk stratification system. METHODS AND RESULTS: CARdiovascular RISk MAnagement (CARRISMA) is a software program considering the prognostic impact of BMI, physical activity and cigarettes per day adjusted for age and sex based on multivariate regression analyses from the literature on top of one of the three major scores to improve risk stratification. The 10-year European Society of Cardiology Systematic COronary Risk Evaluation (SCORE) cardiovascular mortality risk for an intermediate risk region, e.g. increases from 3 to 6% by considering smoking of 30 cigarettes per day instead of just 'smoking' and by taking into account a BMI of 34. Whereas the 10-year ESC cardiovascular mortality risk of a 55-year-old active individual decreases from 5 to 3%, by considering a physical activity equivalent of 2100 kcal/week, the Framingham or PROspective CArdiovascular Münster (PROCAM) risks change accordingly. CONCLUSION: CARRISMA facilitates the application of knowledge of the current literature in the individual patient in a user-friendly manner allowing a more detailed and yet time-efficient risk stratification and risk management in primary prevention, particularly in the intermediate risk range.