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Background and purpose

With accumulation of diseases, limitations and approaching end of life, the question rises for whom cardiovascular preventive medication (CPM) is still appropriate. We aimed to assess how various clinical characteristics influence the appropriateness of cholesterol lowering treatment, blood pressure lowering treatment and platelet aggregation inhibitors in older adults.

Methods

With the RAND/ UCLA appropriateness Method (RAM) the appropriateness of CPM for adults ≥75 year was assessed, depending on cardiovascular history, complexity of health problems, age, side-effects and life expectancy. The RAM consists of a preparation phase and two rounds of individual ratings by panelists, with one face-to-face panel between these rounds. A treatment was considered appropriate when the expected benefits exceed the negative consequences by a sufficiently wide margin. The multidisciplinary panel consisted of eleven (medical) experts with diverse backgrounds and three older people.

Results

The panelists emphasized the importance of the individual context when deciding to start or stop CPM. However, different patterns of appropriateness judgments across the clinical scenarios and types of medication were found. In general, absence of cardiovascular disease, presence of complex health problems, a life-expectancy < 1 year, and hindering side-effects were important factors in decreasing the appropriateness of medication. Stopping CPM was judged differently than not starting.

Conclusions

In the final decision to start or stop CPM, the individual context was considered decisive. However, general trends of how clinical characteristics influence the appropriateness according to the panelists were identified. Also, stopping and not starting CPM appeared to be two distinct concepts.

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Background and purpose

In Portugal in 2010, the FAMA study verified an overall prevalence of atrial fibrillation (AF) of 2.5% in a population sample older than 40 years and only 56.8% of patients with AF were prescribed adequate oral anticoagulation. The aim is to determine the prevalence of AF and to assess how these patients are being cared for: what anticoagulants are being prescribed and are they being prescribed as recommended?

Methods

Retrospective longitudinal study. This study was conducted in the Regional Health Administration of Northern Portugal and used a database that included 63,526 patients with code K78 of the International Classification of Primary Care between January 2016 and December 2018.

Results

The prevalence of AF among adults over 40 years in the northern region of Portugal was 2.3% in 2016, 2.8% in 2017, and 3% in 2018. From a total of 63,526 patients, 95.8% had an indication to receive anticoagulation therapy. Of these, 44,326 (72.9%) are being treated with anticoagulants: 17,936 (40.5%) were prescribed vitamin K antagonists and 26,390 (59.5%) were prescribed non-vitamin K antagonist anticoagulants. On the other hand, 2688 patients of the total (4.2%) had no indication to receive anticoagulation therapy. Of these 2688 patients, 1100 (40.9%) were receiving anticoagulants.

Conclusions

The prevalence of AF is 3%. Here, we report evidence of both undertreatment and overtreatment. Albeit having an indication, a considerable proportion of patients (27.1%) are not anticoagulated, and among AF patients without an indication to receive anticoagulation therapy, a considerable proportion (40.9%) are receiving anticoagulants.

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Background and purpose

Telephone triage is fully integrated in urgent primary care in the Netherlands. The underlying triage protocols do not consider possible differences between men and women. We aim to evaluate sex-specific differences for acute-onset chest pain, a key symptom in which adequate triage is pivotal.

Methods

A retrospective cohort study of consecutive patients who contacted a regional, urgent primary care facility in Alkmaar, the Netherlands in 2017. We performed descriptive analyses on sex differences in patient and symptom characteristics, triage assessment and subsequent outcomes.

Results

A total of 1,804 patients were included, the median age was 54 years and 57.5% were female. Women more frequently reported centrally located chest pain (32.2% vs 27.7%), nausea (23.4% vs 15.7%) and radiating pain to the back or jaw(s) (9.5% vs 5.9% and 5.8% vs 2.5% respectively).

Cardiovascular comorbidities were less common among women (47.5% vs 54.3%). Triage urgencies were comparable between men and women, with comparable ambulance activation rates. However, women were more often visited at home (10.9% vs 7.4%). At follow-up, women less often had an underlying cardiovascular condition (21.1% vs 29.7%), including acute coronary syndrome (5.3% vs 8.5%), when compared to men.

Conclusion

There are considerable differences between women and men who contact urgent primary care with chest pain. Notably, women have different symptom presentation, fewer cardiovascular risk factors, and lower risk of an underlying cardiovascular condition compared to men. Despite being at lower risk, ambulance activation is comparable between women and men.

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1. Background and purpose

Ruptured Abdominal Aortic Aneurysm (AAA) early diagnosis reduces mortality. According to literature 50% of Aortic Ectasias (AE) evolves into AAA, thus an adequate control contributes to stop its progression.

The aim was to assess prevalences of AAA and AE in men above 50 years old in the Spanish province of Lleida and to describe risk factors.

2. Methods

Descriptive and longitudinal study using data from ILERVAS study[1].

Sample was described by calculating prevalences of AAA and EA plus conditioning to risk factors: Smoking, hypertension, dyslipidemia and obesity.

3. Results

Sample consisted in 1125 participants between the ages of 58 and 66. 18 of them have AAA and 62 AE. 31.1% of they were obese, 74.6% smokers, 52.2% hypertensive and 51.2% dyslipidemics.

AAA sample prevalence is 1.6% (CI95%: 0.867-2.33). For smokers and obese was found an estimation higher and significant: 2.1% (CI95%: 1.053-2.947) and 2.6% (CI95%: 0.933-4.267).

AE sample prevalence is 5.5% (CI95%: 4.168-6.832). Smokers and hypertensive throw higher and significant values: 5.8% (CI95%: 4.006-7.934) and 5.9% (CI95%: 4.079-7.921).

4. Conclusions

Prevalences of AAA and AE showed to be similar to those found in literature for Spain. Smoking seems to be a common risk factor for both.

Given the rate of evolution from AE to AAA mentioned, 31 participants with AE could develop AAA in 5 years if risk factors remain uncontrolled.

[1] Betriu, À. et al. Estudio de intervención aleatorizado para evaluar la prevalencia de enfermedad ateromatosa y renal ocultas y su impacto en la morbimortalidad: Proyecto ILERVAS. Nefrología 36, 389–396 (2016).

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Background: The extent to which remission of type 2 diabetes is associated with reduced cardiovascular disease (CVD) outcomes in key subgroups is unknown. We aimed to quantify the association between type 2 diabetes remission and 5-year incidence of CVD outcomes, overall and in pre-defined subgroups.

Methods: A retrospective cohort analysis of 65,347 adults with type 2 diabetes from the Care and Health Information Analytics (CHIA) database. Multivariable Cox models assessed the association between remission within the first two years of follow-up and incidence of CVD outcomes including events, microvascular and macrovascular complications at 7-year follow-up. Effect modification by age, sex, diabetes duration, pre-existing CVD, baseline body mass index (BMI) and HbA_1c level were assessed.

Results: 29,705 (46.0%) people achieved remission during the first two years of follow-up. Overall, remission was associated with lower risk of CVD outcomes. Remission was associated with reduced risk of CVD events and microvascular complications for younger age groups (aHR ranging from 0.51(0.38-0.69) to 0.85(0.76-0.96)) but not in those aged 85+ years (aHR: 0.74 (0.52-1.05) and aHR: 0.77 (0.60-1.00), respectively). People with no comorbidities had lowest risk of CVD events (aHR: 0.67(0.57-0.77), microvascular complications (aHR: 0.64(0.58-0.70)), macrovascular complications (aHR: 0.74(0.64-0.84)) compared to those with 1-2 or more than 3 comorbidities (aHR: 0.79 (0.67-0.93), aHR: 0.81(0.72-0.90), aHR: 0.83(0.73-0.95), respectively). There were no significant interactions in the remaining subgroups.

Conclusions: Achieving remission of type 2 diabetes is associated with a lower risk of CVD outcomes, particularly for younger groups and those with few comorbidities. Targeted interventions that focus on promoting remission in these groups may reduce the impact of CVD and associated health costs.

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Background: There is a knowledge gap regarding etiology and potential genetic cause in sudden cardiac death (SCD) among individuals who appear healthy before the event in the general practice.

Purpose: To describe causes of SCD and the potential for a genetic association in apparently healthy patients in the general practice population in Leiden, the Netherlands.

Methods: Patients were recruited from the database of the department of Pathology of the Leiden University Medical Centre from December 2008 to December 2018. A textual search was applied for “heart*”,” sudden”, *card*”, “OHCA”, “out of hospital”, “cardiac” and “arrest” in the autopsy reports. Of included cases the complete autopsy report was read, and cause of death retrieved. Cases with non-cardiac death or congenital heart disease were excluded. Cases were then analyzed by in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) and further categorized to cardiomyopathy (CMP), coronary (CHD) or electric heart disease (EHD) or sudden unexplained cardiac death (SUD).

Results: Of 1177 cases, 96 (8%) cases with SCD were analyzed according to OHCA vs. IHCA; (67;70% vs. 29; 30%, p<0.001). Mean age was <50 yrs. (47.8 yrs. in OHCA vs. 49.7 yrs. in OHCA, respectively p=0.75). CHD was present in 31(46%) OHCA vs. 12(42%) IHCA cases (p=NS); CMP in 7 (10%) vs. 15 (52%), p<0.001; EHD 1(2%) vs. 1(3%), p=NS) and SUD 28 (42%) vs. 1 (3%), p<0.001). In SUD a genetic cause was suspected in 5/28 (18%) of cases.

Conclusion: SCD was more frequent in OHCA (p<0.001). In SUDs a genetic cause was suspected in 18% of cases.