Thierry Christiaens

Bio: Thierry Christiaens is an academic researcher from Ghent University. The author has contributed to research in topics: Randomized controlled trial & Population. The author has an hindex of 32, co-authored 141 publications receiving 25754 citations. Previous affiliations of Thierry Christiaens include Ghent University Hospital & Rabin Medical Center.

Cardiovascular risk tables

Abstract: In the linked study, Hippisley-Cox and colleagues develop and validate the second version of the QRISK cardiovascular disease risk algorithm (QRISK2), an attempt to more accurately estimate cardiovascular risk in patients from different ethnic groups in England and Wales.1 The advent of the first Framingham risk tables in the early 1990s was a challenge for most doctors. Since the second world war the management of cardiovascular risk has been part of the core business of general practice, but the single risk model dominated. Hypertension, diabetes, and hypercholesterolaemia were islands, each with its own experts fighting for bigger kingdoms by pushing for ever stricter boundaries and demanding more attention. Framingham taught us to look at the different risk factors, and provided a major lesson: a cumulative average risk could be more important than one peak. Yet soon the extrapolation of these US tables to European populations seemed to overshoot the real risk in these groups.2 3 The SCORE tables used the same risk factors to calculate corrected European cardiovascular mortality.4 More recently the ASSIGN5 and now the QRISK tables tried to incorporate some other known risk factors, especially deprivation and family history. Again, a major step: for several decades the medical community has had to face the troubling fact that cardiovascular morbidity and mortality are strongly and independently related to deprivation.6 7 If we ignore this we overestimate the risk for rich people (and overtreat them) and underestimate that for poor people. It’s probably naive to think that we can close the gap in cardiovascular risk just by giving more statins to poor people. If epidemiologists could estimate cardiovascular risk accurately, would it solve our problems in managing our patients? Not at all. Risk calculation itself is based on evidence. However, using risk calculation in managing patientsrelies on consensus. When does a “risk” become a “high risk”? At what moment does a high risk justify starting lifelong drug treatment? The SCORE tables are useful, but when the European Guidelines tried to implement these tables and defined a 5% risk of death within the coming 10 years as high risk (comparable to a 20% risk in the Framingham tables),8 it led to an enormous medicalisation of many healthy elderly people, as proved by the Nordic Risk Group.9 Nearly all Norwegian men aged 60 years and older and allwomen aged 65 years and older were classified as at “high risk”—in a population with one of the highest life expectancies in the world. To use an absolute risk score as a threshold for starting drugs is dangerous and not evidence based. It is therefore surprising that the recent NICE guidelines strongly recommend statins for anyone with a cardiovascular risk score of 20 or more in the Framingham tables.10 Age is such an important risk factor for developing cardiovascular problems within the next 10 years that all risk tables are misleading. Becoming older is by far the strongest predictor for morbidity and mortality—this is a biological fact. By looking at the risk tables, anyone can see what happens: by age 65, a large group has reached the 20% risk threshold, and lipid lowering drugs are prescribed for the rest of their lives. A non-smoking man of 70 with a systolic blood pressure of 130 mm Hg and a total cholesterol concentration of 5 mmol (far below the median cholesterol concentration in most European countries) is at high risk according to the SCORE criteria. Unfortunately most of the trials of statins include only a few people older than 70.11 The PROSPER trial, which specifically looked at this elderly population, showed that the primary composite endpoint (cardiovascular death or non-fatal infarction orcerebrovascular accident) was lowered by only 15% (48 people have to be given statins for three years to prevent one event), a marginally significant gain for cardiovascular death (relative risk 0.76, 95% confidence interval 0.58 to 0.99; NNT 112 for three years) and no effect at all on total mortality.12 In contrast, a male smoker aged 50 with a systolic blood pressure of 145 mm Hg and a total cholesterol of 6.5 mmol/l is at low risk on SCORE. A better way of using risk tables would be to compare the risk of an individual with the minimal risk of people of the same sex and age. Treatment should be considered when he or she has, for example, three times that minimal risk for his or her age and sex. This will prevent overtreatment of elderly people whose high risk is related to age and undertreatment of younger people who are at high risk. For our two examples the treatment options would be totally different. All attempts to make risk tables more accurate, as done by Hippisley-Cox and colleagues in the QRISK2 algorithm,1 are necessary and should be welcomed. However, this is not the key problem. We have to fundamentally rethink how to use risk tables when making treatment decisions in practice, taking into consideration the medicalisation of healthy older people and the correct use of drugs.

Associations of potentially inappropriate medication use with four year survival of an inception cohort of nursing home residents

Abstract: Background Survival in older adults has a high variability. The possible association of length of survival with potentially inappropriate medication (PIM) use remains unclear. Aim To examine the four-year survival rate, the prevalence of polypharmacy and PIM use at admission, and the association between the two, in an inception cohort of newly admitted nursing home residents Methods Data were used from ageing@NH, a prospective observational cohort study in nursing homes. Residents (n = 613) were followed for four years after admission or until death. PIM use was measured at admission, using STOPPFrail. The Kaplan-Meier method was used to estimate survival, using log-rank tests for subgroup analyses. Cox regression analyses was used to explore associations with PIM use and polypharmacy, corrected for covariates Results Mean age was 84, 65% were females. After one, two, three and four years the survival rates were respectively 79%, 60.5%, 47% and 36%. At admission, 47% had polypharmacy and 40% excessive polypharmacy, 11% did not use any PIMs, and respectively 28%, 29%, and 32% used one, two and three or more PIMs. No difference in survival was found between polypharmacy and no polypharmacy, and PIM use and no PIM use at admission. Neither polypharmacy nor PIM use at admission were associated with mortality. Conclusion Residents survived a relatively short time after NH admission. Polypharmacy and PIM use at admission were relatively high in this cohort, although neither was associated with mortality.

Eye drop technique and patient-reported problems in a real-world population of eye drop users.

Abstract: To assess eye drop technique and patient-reported problems with eye drop instillation in a primary care sample of eye drop users. Cross-sectional observational study in 136 community pharmacies in Belgium. Patient inclusion criteria were being age ≥ 18 years and using eye drops for ≥ 1 month (to ensure that patients were already familiar with eye drop instillation). Participants demonstrated their eye drop technique and completed a self-administered questionnaire. Participants (n = 678) had a mean age of 68.9 ± 12.4 years. During the demonstration, almost everyone (98.0%) successfully instilled at least one drop in the eye, although 14% required multiple attempts to achieve this. Only 3% of the sample exhibited perfect drop technique, meaning that they performed correctly all the steps. Most common deviations were touching the bottle to the eye or eyelid (40.7% of patients), and failing to close the eye (67.8%) and perform nasolacrimal occlusion for at least 1 min (94.7%) after drop instillation. Importantly, we found that 20% of ophthalmic suspensions were not shaken before use. Forty percent of patients reported ≥ 1 problem with eye drop instillation. Most common problems were difficulties with getting a drop in the eye (18.3% of patients), too many drops coming out of the bottle (14.6%), and difficulty squeezing the bottle (12.2%). About half of the sample recalled having had education in eye drop instillation technique. This study showed suboptimal eye drop technique in real-world clinical practice. A proactive role of community pharmacists in detecting and resolving these problems could be helpful.

Regulatory reliance to approve new medicinal products in Latin American and Caribbean countries

Abstract: Objective. To describe the current status of regulatory reliance in Latin America and the Caribbean (LAC) by assessing the countries’ regulatory frameworks to approve new medicines, and to ascertain, for each country, which foreign regulators are considered as trusted regulatory authorities to rely on. Methods. Websites from LAC regulators were searched to identify the official regulations to approve new drugs. Data collection was carried out in December 2019 and completed in June 2020 for the Caribbean countries. Two independent teams collected information regarding direct recognition or abbreviated processes to approve new drugs and the reference (trusted) regulators defined as such by the corresponding national legislation. Results. Regulatory documents regarding marketing authorization were found in 20 LAC regulators’ websites, covering 34 countries. Seven countries do not accept reliance on foreign regulators. Thirteen regulatory authorities (Argentina, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Mexico, Panama, Paraguay, Peru, Uruguay, and the unique Caribbean Regulatory System for 15 Caribbean States) explicitly accept relying on marketing authorizations issued by the European Medicines Agency, United States Food and Drug Administration, and Health Canada. Ten countries rely also on marketing authorizations from Australia, Japan, and Switzerland. Argentina, Brazil, Chile, and Mexico are reference authorities for eight LAC regulators. Conclusions. Regulatory reliance has become a common practice in the LAC region. Thirteen out of 20 regulators directly recognize or abbreviate the marketing authorization process in case of earlier approval by a regulator from another jurisdiction. The regulators most relied upon are the European Medicines Agency, United States Food and Drug Administration, and Health Canada.

2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).

Abstract: ABCD : Appropriate Blood pressure Control in Diabetes ABI : ankle–brachial index ABPM : ambulatory blood pressure monitoring ACCESS : Acute Candesartan Cilexetil Therapy in Stroke Survival ACCOMPLISH : Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension ACCORD : Action to Control Cardiovascular Risk in Diabetes ACE : angiotensin-converting enzyme ACTIVE I : Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events ADVANCE : Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation AHEAD : Action for HEAlth in Diabetes ALLHAT : Antihypertensive and Lipid-Lowering Treatment to Prevent Heart ATtack ALTITUDE : ALiskiren Trial In Type 2 Diabetes Using Cardio-renal Endpoints ANTIPAF : ANgioTensin II Antagonist In Paroxysmal Atrial Fibrillation APOLLO : A Randomized Controlled Trial of Aliskiren in the Prevention of Major Cardiovascular Events in Elderly People ARB : angiotensin receptor blocker ARIC : Atherosclerosis Risk In Communities ARR : aldosterone renin ratio ASCOT : Anglo-Scandinavian Cardiac Outcomes Trial ASCOT-LLA : Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm ASTRAL : Angioplasty and STenting for Renal Artery Lesions A-V : atrioventricular BB : beta-blocker BMI : body mass index BP : blood pressure BSA : body surface area CA : calcium antagonist CABG : coronary artery bypass graft CAPPP : CAPtopril Prevention Project CAPRAF : CAndesartan in the Prevention of Relapsing Atrial Fibrillation CHD : coronary heart disease CHHIPS : Controlling Hypertension and Hypertension Immediately Post-Stroke CKD : chronic kidney disease CKD-EPI : Chronic Kidney Disease—EPIdemiology collaboration CONVINCE : Controlled ONset Verapamil INvestigation of CV Endpoints CT : computed tomography CV : cardiovascular CVD : cardiovascular disease D : diuretic DASH : Dietary Approaches to Stop Hypertension DBP : diastolic blood pressure DCCT : Diabetes Control and Complications Study DIRECT : DIabetic REtinopathy Candesartan Trials DM : diabetes mellitus DPP-4 : dipeptidyl peptidase 4 EAS : European Atherosclerosis Society EASD : European Association for the Study of Diabetes ECG : electrocardiogram EF : ejection fraction eGFR : estimated glomerular filtration rate ELSA : European Lacidipine Study on Atherosclerosis ESC : European Society of Cardiology ESH : European Society of Hypertension ESRD : end-stage renal disease EXPLOR : Amlodipine–Valsartan Combination Decreases Central Systolic Blood Pressure more Effectively than the Amlodipine–Atenolol Combination FDA : U.S. Food and Drug Administration FEVER : Felodipine EVent Reduction study GISSI-AF : Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation HbA1c : glycated haemoglobin HBPM : home blood pressure monitoring HOPE : Heart Outcomes Prevention Evaluation HOT : Hypertension Optimal Treatment HRT : hormone replacement therapy HT : hypertension HYVET : HYpertension in the Very Elderly Trial IMT : intima-media thickness I-PRESERVE : Irbesartan in Heart Failure with Preserved Systolic Function INTERHEART : Effect of Potentially Modifiable Risk Factors associated with Myocardial Infarction in 52 Countries INVEST : INternational VErapamil SR/T Trandolapril ISH : Isolated systolic hypertension JNC : Joint National Committee JUPITER : Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin LAVi : left atrial volume index LIFE : Losartan Intervention For Endpoint Reduction in Hypertensives LV : left ventricle/left ventricular LVH : left ventricular hypertrophy LVM : left ventricular mass MDRD : Modification of Diet in Renal Disease MRFIT : Multiple Risk Factor Intervention Trial MRI : magnetic resonance imaging NORDIL : The Nordic Diltiazem Intervention study OC : oral contraceptive OD : organ damage ONTARGET : ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial PAD : peripheral artery disease PATHS : Prevention And Treatment of Hypertension Study PCI : percutaneous coronary intervention PPAR : peroxisome proliferator-activated receptor PREVEND : Prevention of REnal and Vascular ENdstage Disease PROFESS : Prevention Regimen for Effectively Avoiding Secondary Strokes PROGRESS : Perindopril Protection Against Recurrent Stroke Study PWV : pulse wave velocity QALY : Quality adjusted life years RAA : renin-angiotensin-aldosterone RAS : renin-angiotensin system RCT : randomized controlled trials RF : risk factor ROADMAP : Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention SBP : systolic blood pressure SCAST : Angiotensin-Receptor Blocker Candesartan for Treatment of Acute STroke SCOPE : Study on COgnition and Prognosis in the Elderly SCORE : Systematic COronary Risk Evaluation SHEP : Systolic Hypertension in the Elderly Program STOP : Swedish Trials in Old Patients with Hypertension STOP-2 : The second Swedish Trial in Old Patients with Hypertension SYSTCHINA : SYSTolic Hypertension in the Elderly: Chinese trial SYSTEUR : SYSTolic Hypertension in Europe TIA : transient ischaemic attack TOHP : Trials Of Hypertension Prevention TRANSCEND : Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease UKPDS : United Kingdom Prospective Diabetes Study VADT : Veterans' Affairs Diabetes Trial VALUE : Valsartan Antihypertensive Long-term Use Evaluation WHO : World Health Organization ### 1.1 Principles The 2013 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology …

2007 Guidelines for the Management of Arterial Hypertension : The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).

Abstract: 2007 Guidelines for the Management of Arterial Hypertension : The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

Abstract: ACC/AHA : American College of Cardiology/American Heart Association ACCF/AHA : American College of Cardiology Foundation/American Heart Association ACE : angiotensin-converting enzyme ACEI : angiotensin-converting enzyme inhibitor ACS : acute coronary syndrome AF : atrial fibrillation