Hypertension is a leading cause of premature death worldwide and the most important modifiable risk factor for cardiovascular disease. Effective screening programs, communication with patients, ...regular monitoring, and adherence to treatment are essential to successful management but may be challenging in health systems facing resource constraints. This qualitative study explored patients' knowledge, attitudes, behaviour and health care seeking experiences in relation to detection, treatment and control of hypertension in Colombia. We conducted in-depth interviews and focus group discussions with 26 individuals with hypertension and 4 family members in two regions. Few participants were aware of ways to prevent high blood pressure. Once diagnosed, most reported taking medication but had little information about their condition and had a poor understanding of their treatment regime. The desire for good communication and a trusting relationship with the doctor emerged as key themes in promoting adherence to medication and regular attendance at medical appointments. Barriers to accessing treatment included co-payments for medication; costs of transport to health care facilities; unavailability of drugs; and poor access to specialist care. Some patients overcame these barriers with support from social networks, family members and neighbours. However, those who lacked such support, experienced loneliness and struggled to access health care services. The health insurance scheme was frequently described as administratively confusing and those accessing the state subsidized system believed that the treatment was inferior to that provided under the compulsory contributory system. Measures that should be addressed to improve hypertension management in Colombia include better communication between health care professionals and patients, measures to improve understanding of the importance of adherence to treatment, reduction of co-payments and transport costs, and easier access to care, especially in rural areas.
Background Preliminary evidence suggests that providing longer duration prescriptions at discharge may improve long-term adherence to secondary preventative cardiac medications among post-myocardial ...infarction (MI) patients. We implemented and assessed the effects of two hospital-based interventions--(1) standardized prolonged discharge prescription forms (90-day supply with 3 repeats for recommended cardiac medications) plus education and (2) education only--on long-term cardiac medication adherence among elderly patients post-MI. Methods We conducted an interrupted time series study of all post-MI patients aged 65-104 years in Ontario, Canada, discharged from hospital between September 2015 and August 2018 with greater than or equai to 1 dispensation(s) for a statin, beta blocker, angiotensin system inhibitor, and/or secondary antiplatelet within 7 days post-discharge. The standardized prolonged discharge prescription forms plus education and education-only interventions were implemented at 2 (1,414 patients) and 4 (926 patients) non-randomly selected hospitals in September 2017 for 12 months, with all other Ontario hospitals (n = 143; 18,556 patients) comprising an external control group. The primary outcome, long-term cardiac medication adherence, was defined at the patient-level as an average proportion of days covered (over 1-year post-discharge) greater than or equai to 80% across cardiac medication classes dispensed at their index fill. Primary outcome data were aggregated within hospital groups (intervention 1, 2, or control) to monthly proportions and independently analyzed using segmented regression to evaluate intervention effects. A process evaluation was conducted to assess intervention fidelity. Results At 12 months post-implementation, there was no statistically significant effect on long-term cardiac medication adherence for either intervention--standardized prolonged discharge prescription forms plus education (5.4%; 95% CI - 6.4%, 17.2%) or education only (1.0%; 95% CI - 28.6%, 30.6%)--over and above the counterfactual trend; similarly, no change was observed in the control group (- 0.3%; 95% CI - 3.6%, 3.1%). During the intervention period, only 10.8% of patients in the intervention groups received greater than or equai to 90 days, on average, for cardiac medications at their index fill. Conclusions Recognizing intervention fidelity was low at the pharmacy level, and no statistically significant post-implementation differences in adherence were found, the trends in this study--coupled with other published retrospective analyses of administrative data--support further evaluation of this simple intervention to improve long-term adherence to cardiac medications. Trial registration ClinicalTrials.gov: NCT03257579, registered June 16, 2017 Protocol available at: Keywords: Post-myocardial infarction, Adherence, Standardized discharge prescription form, Secondary prevention, Policy change
Poor health-related quality of life (HRQL) is common in heart failure (HF), but there are few data on HRQL in HF and the association between HRQL and mortality outside Western countries.
We used the ...Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) to record HRQL in 23 291 patients with HF from 40 countries in 8 different world regions in the G-CHF study (Global Congestive Heart Failure). We compared standardized KCCQ-12 summary scores (adjusted for age, sex, and markers of HF severity) among regions (scores range from 0 to 100, with higher score indicating better HRQL). We used multivariable Cox regression with adjustment for 15 variables to assess the association between KCCQ-12 summary scores and the composite of all-cause death, HF hospitalization, and each component over a median follow-up of 1.6 years.
The mean age of participants was 65 years; 61% were men; 40% had New York Heart Association class III or IV symptoms; and 46% had left ventricular ejection fraction ≥40%. Average HRQL differed between regions (lowest in Africa mean± SE, 39.5±0.3, highest in Western Europe 62.5±0.4). There were 4460 (19%) deaths, 3885 (17%) HF hospitalizations, and 6949 (30%) instances of either event. Lower KCCQ-12 summary score was associated with higher risk of all outcomes; the adjusted hazard ratio (HR) for each 10-unit KCCQ-12 summary score decrement was 1.18 (95% CI, 1.17-1.20) for death. Although this association was observed in all regions, it was less marked in South Asia, South America, and Africa (weakest association in South Asia: HR, 1.08 95% CI, 1.03-1.14; strongest association in Eastern Europe: HR, 1.31 95% CI, 1.21-1.42; interaction
<0.0001). Lower HRQL predicted death in patients with New York Heart Association class I or II and III or IV symptoms (HR, 1.17 95% CI, 1.14-1.19 and HR, 1.14 95% CI, 1.12-1.17; interaction
=0.13) and was a stronger predictor for the composite outcome in New York Heart Association class I or II versus class III or IV (HR 1.15 95% CI, 1.13-1.17 versus 1.09 95% CI, 1.07-1.11; interaction
<0.0001). HR for death was greater in ejection fraction ≥40 versus <40% (HR, 1.23 95% CI, 1.20-1.26 and HR, 1.15 95% CI, 1.13-1.17; interaction
<0.0001).
HRQL is a strong and independent predictor of all-cause death and HF hospitalization across all geographic regions, in mildly and severe symptomatic HF, and among patients with preserved and reduced ejection fraction. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078166.
Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and ...middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control.
Conventional clinical risk scores and diagnostic algorithms are proving to be suboptimal in the prediction of obstructive coronary artery disease, contributing to the low diagnostic yield of invasive ...angiography. Machine learning could help better predict which patients would benefit from invasive angiography vs other noninvasive diagnostic modalities.
To reduce patient risk and cost to the healthcare system by improving the diagnostic yield of invasive coronary angiography through optimized outpatient selection.
Retrospective analysis of 12 years of referral data from a provincial cardiac registry, including all patients referred for invasive angiography of more than 1.4 million individuals in Ontario, Canada. Stable outpatients undergoing coronary angiography during the study period were included in the analysis. The training set (80% random sample, n = 23,750) was used to develop 8 prediction models in Python using grid-search cross-validation. The test set (20% random sample, n = 5938), evaluated the discrimination performance of each model.
The machine-learning model achieved a substantially better performance (area under the receiver operating characteristics curve: 0.81) than existing models for predicting obstructive coronary artery disease in patients referred for invasive angiography. It significantly outperformed both the reference model and current clinical practice with a net reclassification index of 27.8% (95% confidence interval CI: 24.9%–30.8%, P value <.01) and 44.7% (95% CI: 42.4%–47.0%, P value <.01), respectively.
This prediction model, when coupled with a point-of-care, online decision support tool to be used by referring physicians, could improve the diagnostic yield of invasive coronary angiography in stable, elective outpatients, thus improving patient safety and reducing healthcare costs.
Background Guidelines recommend cardiac rehabilitation and long-term use of cardiac medications for most patients who have had a myocardial infarction (MI), but adherence to these secondary ...prevention treatments is suboptimal. Methods This is a multicenter, pragmatic, 3-arm randomized trial. Eligible patients (n = 2,742) with obstructive coronary artery disease are randomized post-MI to usual care or 1 of 2 intervention arms. Patients in the first intervention arm receive mail-outs sent on behalf of their cardiologist at 4, 8, 20, 32, and 44 weeks post-MI; content is designed to address determinants of adherence and facilitate discussion between the patient and their health care team. Patients in the second intervention arm receive mail-outs plus automated interactive voice response system telephone calls 2 weeks after each letter, as well as a telephone call by trained lay health workers if the interactive voice response system identifies challenges with adherence. Outcomes are assessed 12 months post-MI via patient self-report and administrative data sources. Co-primary outcomes are adherence to cardiac medications and completion of cardiac rehabilitation. Secondary outcomes include cardiovascular events and mortality. An embedded, theory-informed process evaluation will explore the mechanism of action; an economic evaluation is also planned. Conclusions We describe a complete program evaluation of a highly pragmatic, health-system intervention to support adherence to recommended treatments. Research ethics boards approved waiver of consent for patients enrolled in the trial with provision of multiple opportunities to opt out and a debrief at the time of outcome assessment. The methods used here may provide a model for similar interventions.
There is a gap between evidence and practice in the management of cardiovascular (CV) risk. Previous research indicated benefits from community-based, multi-faceted interventions to screen, diagnose, ...and manage CV risk in people with hypertension.
The Heart Outcomes Prevention and Evaluation 4 Canada pilot study (HOPE 4) was a quasi-experimental pre–post interventional study, involving one community each in Hamilton, Ontario and Surrey, British Columbia, Canada. Individuals aged ≥50 years with newly diagnosed or poorly controlled hypertension were included. The intervention was comprised of: (i) simplified diagnostic/treatment algorithms implemented by community health workers (firefighters in British Columbia and community health workers in Ontario) guided by decision support and counselling software; (ii) recommendations for evidence-based CV medications and lifestyle modifications; and (iii) support from family/friends to promote healthy behaviours. The intervention was developed as part of the international Heart Outcomes Prevention and Evaluation 4 Canada pilot study trial and adapted to the Canadian context. The primary outcome was the change in Framingham Risk Score 10-year CV disease risk estimate between baseline and 6 months.
Between 2016 and 2017, a total of 193 participants were screened, with 37 enrolled in Surrey, and 19 in Hamilton. Mean age was 69 years (standard deviation 11), with 54% female, 27% diabetic, and 73% with a history of hypertension. An 82% follow-up level had been obtained at 6 months. Compared to baseline, there were significant improvements in the Framingham Risk Score 10-year risk estimate (30.6% vs 24.7%, P < 0.01), and systolic blood pressure (153.1 vs 136.7 mm Hg, P < 0.01). No significant changes in lipids or healthy behaviours were noted.
A comprehensive approach to health care delivery, using a community-based intervention with community health workers, supported by mobile-health technologies, has the potential to significantly reduce cardiovascular risk, but further evaluation is warranted.
Il existe un écart entre les données probantes et la pratique en matière de prise en charge du risque cardiovasculaire (CV). Les résultats d’études antérieures montrent que des interventions à volets multiples en milieu communautaire visant à dépister, à diagnostiquer et à prendre en charge le risque CV chez les personnes atteintes d’hypertension peuvent être bénéfiques.
L’étude pilote HOPE4 (Heart Outcomes Prevention and Evaluation 4 Canada) était une étude interventionnelle quasi expérimentale évaluant des patients avant et après certaines interventions, menée au sein de deux communautés canadiennes, l’une située à Hamilton, en Ontario et l’autre à Surrey, en Colombie-Britannique. L’étude réunissait des participants âgés de 50 ans ou plus venant de recevoir un diagnostic d’hypertension ou souffrant d’hypertension mal maîtrisée. Les interventions comprenaient : i) l’utilisation d’algorithmes de diagnostic et de traitement simplifiés par les intervenants en santé du milieu communautaire (pompiers en Colombie-Britannique et agents de santé communautaire en Ontario), à l’aide d’un logiciel d’aide à la décision et de counselling; ii) la formulation de recommandations fondées sur des données probantes concernant la prise de médicaments et l’adoption d’habitudes de vie favorisant la santé CV; et iii) la sollicitation du soutien des membres de la famille et des amis afin de promouvoir l’adoption de comportements favorisant la santé. Ces interventions ont été mises au point dans le cadre de l’étude pilote internationale HOPE4 et adaptées au contexte canadien. Le critère d’évaluation principal était la variation du score de risque de Framingham, qui estime le risque de maladie CV à 10 ans, entre le début et le 6e mois de l’étude.
De 2016 à 2017, un nombre total de 193 participants ont été soumis au processus de sélection; 37 patients du centre de Surrey et 19 patients du centre de Hamilton ont été admis à l’étude. L’âge moyen des participants était de 69 ans (écart-type : 11 ans); 54 % d’entre eux étaient des femmes, 27 % étaient atteints de diabète et 73 % avaient des antécédents d’hypertension. Au 6e mois, 82 % des sujets participaient toujours à l’étude. Des améliorations significatives ont été observées comparativement au placebo en ce qui concerne le score de risque de Framingham estimant le risque à 10 ans (30,6 % vs 24,7 %, p < 0,01) et la pression artérielle systolique (153,1 vs 136,7 mmHg, p < 0,01). Aucune variation significative n’a été observée quant à la lipidémie ou aux comportements favorisant la santé.
Une approche exhaustive de la prestation des soins de santé reposant sur des interventions de la part des agents de santé communautaire au moyen de technologies de santé mobiles pourrait aider à réduire significativement le risque CV; une évaluation plus poussée est toutefois nécessaire.
A polypill comprising statins, multiple blood-pressure-lowering drugs, and aspirin has been proposed to reduce the risk of cardiovascular disease.
Using a 2-by-2-by-2 factorial design, we randomly ...assigned participants without cardiovascular disease who had an elevated INTERHEART Risk Score to receive a polypill (containing 40 mg of simvastatin, 100 mg of atenolol, 25 mg of hydrochlorothiazide, and 10 mg of ramipril) or placebo daily, aspirin (75 mg) or placebo daily, and vitamin D or placebo monthly. We report here the outcomes for the polypill alone as compared with matching placebo, for aspirin alone as compared with matching placebo, and for the polypill plus aspirin as compared with double placebo. For the polypill-alone and polypill-plus-aspirin comparisons, the primary outcome was death from cardiovascular causes, myocardial infarction, stroke, resuscitated cardiac arrest, heart failure, or revascularization. For the aspirin comparison, the primary outcome was death from cardiovascular causes, myocardial infarction, or stroke. Safety was also assessed.
A total of 5713 participants underwent randomization, and the mean follow-up was 4.6 years. The low-density lipoprotein cholesterol level was lower by approximately 19 mg per deciliter and systolic blood pressure was lower by approximately 5.8 mm Hg with the polypill and with combination therapy than with placebo. The primary outcome for the polypill comparison occurred in 126 participants (4.4%) in the polypill group and in 157 (5.5%) in the placebo group (hazard ratio, 0.79; 95% confidence interval CI, 0.63 to 1.00). The primary outcome for the aspirin comparison occurred in 116 participants (4.1%) in the aspirin group and in 134 (4.7%) in the placebo group (hazard ratio, 0.86; 95% CI, 0.67 to 1.10). The primary outcome for the polypill-plus-aspirin comparison occurred in 59 participants (4.1%) in the combined-treatment group and in 83 (5.8%) in the double-placebo group (hazard ratio, 0.69; 95% CI, 0.50 to 0.97). The incidence of hypotension or dizziness was higher in groups that received the polypill than in their respective placebo groups.
Combined treatment with a polypill plus aspirin led to a lower incidence of cardiovascular events than did placebo among participants without cardiovascular disease who were at intermediate cardiovascular risk. (Funded by the Wellcome Trust and others; TIPS-3 ClinicalTrials.gov number, NCT01646437.).
Hypertension is the leading cause of cardiovascular disease globally. Despite proven benefits, hypertension control is poor. We hypothesised that a comprehensive approach to lowering blood pressure ...and other risk factors, informed by detailed analysis of local barriers, would be superior to usual care in individuals with poorly controlled or newly diagnosed hypertension. We tested whether a model of care involving non-physician health workers (NPHWs), primary care physicians, family, and the provision of effective medications, could substantially reduce cardiovascular disease risk.
HOPE 4 was an open, community-based, cluster-randomised controlled trial involving 1371 individuals with new or poorly controlled hypertension from 30 communities (defined as townships) in Colombia and Malaysia. 16 communities were randomly assigned to control (usual care, n=727), and 14 (n=644) to the intervention. After community screening, the intervention included treatment of cardiovascular disease risk factors by NPHWs using tablet computer-based simplified management algorithms and counselling programmes; free antihypertensive and statin medications recommended by NPHWs but supervised by physicians; and support from a family member or friend (treatment supporter) to improve adherence to medications and healthy behaviours. The primary outcome was the change in Framingham Risk Score 10-year cardiovascular disease risk estimate at 12 months between intervention and control participants. The HOPE 4 trial is registered at ClinicalTrials.gov, NCT01826019.
All communities completed 12-month follow-up (data on 97% of living participants, n=1299). The reduction in Framingham Risk Score for 10-year cardiovascular disease risk was −6·40% (95% CI 8·00 to −4·80) in the control group and −11·17% (−12·88 to −9·47) in the intervention group, with a difference of change of −4·78% (95% CI −7·11 to −2·44, p<0·0001). There was an absolute 11·45 mm Hg (95% CI −14·94 to −7·97) greater reduction in systolic blood pressure, and a 0·41 mmol/L (95% CI −0·60 to −0·23) reduction in LDL with the intervention group (both p<0·0001). Change in blood pressure control status (<140 mm Hg) was 69% in the intervention group versus 30% in the control group (p<0·0001). There were no safety concerns with the intervention.
A comprehensive model of care led by NPHWs, involving primary care physicians and family that was informed by local context, substantially improved blood pressure control and cardiovascular disease risk. This strategy is effective, pragmatic, and has the potential to substantially reduce cardiovascular disease compared with current strategies that are typically physician based.
Canadian Institutes of Health Research; Grand Challenges Canada; Ontario SPOR Support Unit and the Ontario Ministry of Health and Long-Term Care; Boehringer Ingelheim; Department of Management of Non-Communicable Diseases, WHO; and Population Health Research Institute.
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