Showing papers by "Anushka Patel published in 2012"

Association of HbA1c levels with vascular complications and death in patients with type 2 diabetes: evidence of glycaemic thresholds

Abstract: Aims/hypothesis There is conflicting evidence regarding appropriate glycaemic targets for patients with type 2 diabetes. Here, we investigate the relationship between HbA1c and the risks of vascular complications and death in such patients.

Resting heart Rate and the risk of death and cardiovascular complications in patients with type 2 diabetes mellitus

Abstract: Aims/hypothesis An association between resting heart rate and mortality has been described in the general population and in patients with cardiovascular disease. There are, however, few data exploring this relationship in patients with type 2 diabetes mellitus. The current study addresses this issue.

Low HDL Cholesterol and the Risk of Diabetic Nephropathy and Retinopathy Results of the ADVANCE study

Abstract: OBJECTIVE Although low HDL cholesterol (HDL-C) is an established risk factor for atherosclerosis, data on HDL-C and the risk of microvascular disease are limited. We tested the association between HDL-C and microvascular disease in a cohort of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 11,140 patients with type 2 diabetes and at least one additional vascular risk factor were followed a median of 5 years. Cox proportional hazards models were used to assess the association between baseline HDL-C and the development of new or worsening microvascular disease, defined prospectively as a composite of renal and retinal events. RESULTS The mean baseline HDL-C level was 1.3 mmol/L (SD 0.45 mmol/L [range 0.1–4.0]). During follow-up, 32% of patients developed new or worsening microvascular disease, with 28% experiencing a renal event and 6% a retinal event. Compared with patients in the highest third, those in the lowest third had a 17% higher risk of microvascular disease (adjusted hazard ratio 1.17 [95% CI 1.06–1.28], P = 0.001) after adjustment for potential confounders and regression dilution. This was driven by a 19% higher risk of renal events (1.19 [1.08–1.32], P = 0.0005). There was no association between thirds of HDL-C and retinal events (1.01 [0.82–1.25], P = 0.9). CONCLUSIONS In patients with type 2 diabetes, HDL-C level is an independent risk factor for the development of microvascular disease affecting the kidney but not the retina.

Socio-economic distribution of cardiovascular risk factors and knowledge in rural India

Abstract: Background To investigate the prevalence, screening and knowledge of cardiovascular risk factors (CVRFs) by socio-economic position (SEP) in rural India. Methods An age- and sex-stratified random sample of 4535 adults was recruited from rural Andhra Pradesh and a questionnaire was administered to assess prevalence, screening and knowledge of CVRFs and record recent attempts to modify behaviour. Education, income and occupation were used to measure SEP. Results Lower fruit intake and higher tobacco and alcohol use were found in those with lower SEP. Overweight, physical inactivity, diabetes, hypertension, family history of cardiovascular disease (CVD) and previous CVD (men only) were greater in higher SEP participants. Lower SEP participants had less blood pressure, glucose or cholesterol screening and less knowledge of nine CVRFs. Regardless of SEP, participants knowledgeable of the harms of a CVRF were more likely to have attempted to modify behaviour. For example, knowledge of benefits of smoking cessation was associated with an increased odds ratio (OR) for attempting to quit: in educated participants-OR 3.67, 95% confidence interval (CI) 2.10-6.42; in participants with no education-OR 3.98, 95% CI 2.27-6.97. Conclusions Some biological CVRFs were worse in higher SEP participants while some behavioural risk factors were worse in lower SEP participants. Lower SEP participants had less CVRF screening and knowledge of CVRFs. Those with knowledge of CVRFs were more likely to make healthy behavioural changes. Our findings suggest equipping rural Indians with knowledge about CVRFs may ameliorate projected future increases in CVD.

The Efficacy and Tolerability of ‘Polypills’: Meta-Analysis of Randomised Controlled Trials

Abstract: Background To assess the blood pressure and lipid-lowering efficacy and tolerability of ‘polypills’ used in cardiovascular disease prevention trials.

Resting Heart Rate and the Risk of Microvascular Complications in Patients With Type 2 Diabetes Mellitus

Abstract: Methods and Results-—The relation between baseline resting heart rate and the development of a major microvascular event was examined in 11 140 patients who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) study. Major microvascular events were defined as a composite of new or worsening nephropathy or new or worsening retinopathy. Patients with a higher baseline heart rate were at increased risk of a new major microvascular complication during follow-up (adjusted hazard ratio: 1.13 per 10 beats per minute; 95% confidence interval: 1.07– 1.20; P<0.001). The excess hazard was evident for both nephropathy (adjusted hazard ratio: 1.16 per 10 beats per minute; 95% confidence interval: 1.08–1.25) and retinopathy (adjusted hazard ratio: 1.11 per 10 beats per minute; 95% confidence interval: 1.02–1.21). Conclusion-—Patients with type 2 diabetes mellitus who have a higher resting heart rate experience a greater incidence of newonset or progressive nephropathy and retinopathy.

Cardiovascular risk management in chronic kidney disease in general practice (the AusHEART study)

Abstract: Background. Chronic kidney disease (CKD) is common and increasing in prevalence. Adverse outcomes of CKD can be prevented through early detection and treatment. There is limited data on the awareness of CKD and the quality of care offered to patients with CKD in the primary care setting. The objectives of this study were to assess the prevalence, general practitioner (GP) awareness and extent of current evidence–practice gaps in the management of CKD in Australian primary care. Methods. The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster stratified, cross-sectional survey among 322 GPs. Each GP was asked to provide data for 15–20 consecutive patients (age ≥ 55 years) who presented between April and June, 2008. The main outcome measures were CKD prevalence based on proteinuria and decreased estimated glomerular filtration rate. Evidence–practice gaps in management of patients with CKD were identified. Results. Among a total of 4966 patients with kidney function test data, 1845 (37%) had abnormal kidney function. Of the 1312 patients with abnormal kidney function known to the GP at the time of visit, only 235 were correctly identified as having CKD. GPs under-estimated cardiovascular (CV) risks in patients with CKD when compared with the prevailing guidelines at the time of survey and the recent national guidelines, particularly in later stages of CKD. Among CKD patients not prescribed blood pressure-lowering agents or lipid-lowering agents, treatment was indicated as per relevant guidelines in 51 and 46%, respectively. For CKD patients who were already prescribed blood pressure-lowering and lipid-lowering agents, 61 and 50%, respectively, did not meet the treatment targets recommended by the relevant guidelines. Conclusions. CKD is common, significantly under-recognized and under-treated in primary care. Effort to increase awareness and provide opportunities for improved screening and assessment should improve the management and outcome of these patients at high risk of CV disease.

The treatment of cardiovascular risk in primary care using electronic decision support (TORPEDO) study: Intervention development and protocol for a cluster randomised, controlled trial of an electronic decision support and quality improvement intervention in Australian primary healthcare

Abstract: Background Large gaps exist in the implementation of guideline recommendations for cardiovascular disease (CVD) risk management. Electronic decision support (EDS) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia. We have developed HealthTracker, a multifaceted EDS and quality improvement intervention to improve the management of CVD risk. Methods/design It is hypothesised that the use of HealthTracker over a 12-month period will result in: (1) an increased proportion of patients receiving guideline-indicated measurements of CVD risk factors and (2) an increased proportion of patients at high risk will receive guideline-indicated prescriptions for lowering their CVD risk. Sixty health services (40 general practices and 20 Aboriginal Community Controlled Health Services (ACCHSs) will be randomised in a 1:1 allocation to receive either the intervention package or continue with usual care, stratified by service type, size and participation in existing quality improvement initiatives. The intervention consists of point-of-care decision support; a risk communication interface; a clinical audit tool to assess performance on CVD-related indicators; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance. The control arm will continue with usual care without access to these intervention components. Quantitative data will be derived from cross-sectional samples at baseline and end of study via automated data extraction. Detailed process and economic evaluations will also be conducted. Ethics and dissemination The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee (HREC) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC. Formal agreements with each of the participating sites have been signed. In addition to the usual scientific forums, results will be disseminated via newsletters, study websites, face-to-face feedback forums and workshops. Trial registration The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910.

Disparities between prescribing of secondary prevention therapies for stroke and coronary artery disease in general practice.

Abstract: BackgroundExtensive evidence exists regarding the effectiveness of secondary prevention measures in patients with cardiovascular disease.AimWe aimed to examine the management and risk perceptions o...

Global randomized trials: the promise of India and China.

Abstract: Although modern clinical trials are traditionally conducted in Western countries, currently there is a shift to involve developing countries, particularly China and India. For these trials, the large population size of India and China means that substantial numbers of individuals affected by rare diseases may be found, increasing the likelihood of successfully completing enrollment in a clinical trial. Furthermore, the increasing involvement of Asian countries in global clinical trials is likely to lead to greater appreciation of the value of evidence-based treatment decisions in the region. These sites are more cost-effective, although this advantage is being eroded over time. Asian participants in clinical trials are also typically more likely to complete study follow-up and procedures, and to adhere to their randomized treatment allocation than individuals from Western countries. Challenges include relevance of the proposed trial to the region, capacity limitations because of undeveloped training, and ensuring research implementation quality and different intellectual property practices. There are specific challenges to conducting clinical trials in India, such as the status of ethics committees, health insurance and coverage for participants, and variability in languages and record-keeping. Challenges in both countries are substantial but are able to be managed with appropriate planning.

Two Decades of Research on Innovative Models of Care Delivery for Patients with Heart Failure: The End or Just the Beginning?

Abstract: The growing prevalence of heart failure and the cost associated with its management has become a major burden for most health care systems worldwide.We review the evidence from randomized studies of innovative models of care delivery for patients with heart failure, refer to some of the most in? uential non-randomized studies, and discuss the implications of the available evidence for practitioners, policy makers and researchers. Acknowledging that the relevance of evidence depends on the user’s needs, we conclude that the likely impact of most models of care on health outcomes and resource utilization is likely to be modest. New approaches for design and evaluation are therefore required. Given the dynamic complexity of the health service environments in which any such models of care must be implemented, the future development of innovative models of care delivery would beneo t from closer collaboration between service users, providers, policy makers and multi-disciplinary researchers, as well as more rigorous evaluation.

Women's cardiovascular health in India

Abstract: Cardiovascular diseases (CVDs) are the leading cause of death among adult women in many parts of India and a major cause of morbidity. In some parts of the world, gender inequities have been observed in cardiovascular healthcare and cardiovascular outcomes. The authors discuss the data for potential disparities in cardiovascular healthcare for women in India. Data on cardiovascular healthcare provision and CVD outcomes among women in India are generally lacking. The little available data suggest that women in rural areas, younger women and girl children with CVD are less likely to receive appropriate management than men, with this disparity most apparent in those of lower socioeconomic status and education. However, there is a particular lack of information about the prevention and management of atherosclerotic heart disease in women from a range of communities that comprise the extremely diverse population of India.

Study protocol: systematic review of the burden of heart failure in low- and middle-income countries

Abstract: Background Setting priorities for the prevention and management of heart failure requires an empirical understanding of the pattern of disease burden. We aim to describe the methods for a systematic review of the literature on burden of heart failure in low- and middle-income countries (LMIC) and how this information will be synthesized to produce useful estimates that can inform policy and practice.

Polypill (fixed-dose combination) in the prevention of cardiovascular disease: rationale and clinical data

Abstract: Cardiovascular diseases (CVDs) continue to be major contributors of death and disability globally. Control of CVD risk factors has been shown to be effective in reducing morbidity and mortality both in primary and secondary prevention settings. Given the cumulative benefits of concurrently controlling multiple CVD risk factors (high blood pressure, dyslipidemia and platelet activity) in individuals at high risk, administration of a polypill consisting of antihypertensive, antidyslipidemic and antiplatelet agents together could simultaneously lower multiple risk factors and applying such a population risk-reduction strategy has the potential to considerably reduce CVD burden. Furthermore, the availability of an inexpensive generic polypill might improve medication adherence and reduce the evidence–practice gap for individuals who already have an indication for long-term treatment with these agents. A few clinical trials have provided early evidence about the safety and efficacy of polypill in primary preve...

Study protocol: systematic review of the burden of heart failure in low- and middle-income countries

Abstract: Background Setting priorities for the prevention and management of heart failure requires an empirical understanding of the pattern of disease burden. We aim to describe the methods for a systematic review of the literature on burden of heart failure in low- and middle-income countries (LMIC) and how this information will be synthesized to produce useful estimates that can inform policy and practice.

Use of Secondary Prevention Medications in Patients Following Admission with Acute Coronary Syndrome in Australia—The CONCORDANCE Study

Abstract: Use of Secondary PreventionMedications in Patients Following Admission with Acute Coronary Syndrome in Australia—The CONCORDANCE Study C. Chow1,2,∗, I. Ranasinghe1,3, A. Blenkhorn4, K. Alford5, M. Ilton6, A. Patel 1 1 The George Institute for Global Health, University of Sydney, Australia 2 Department of Cardiology, Westmead Hospital, Australia 3 Department of Cardiology, Concord Hospital, Australia 4 Lismore Base Hospital, Australia 5 Port Macquarie Base Hospital, Australia 6 Royal Darwin Hospital, Australia