Does use of pooled cohort risk score overestimate the use of statin?: a retrospective cohort study in a primary care setting

BACKGROUND: Initiation of statin therapy as primary prevention particularly in those with mildly elevated cardiovascular disease risk factors is still being debated. The 2013 ACC/AHA blood cholesterol guideline recommends initiation of statin by estimating the 10-year atherosclerotic cardiovascular disease (ASCVD) risk using the new pooled cohort risk score. This paper examines the use of the pooled cohort risk score and compares it to actual use of statins in daily clinical practice in a primary care setting. METHODS: We examined the use of statins in a randomly selected sample of patients in a primary care clinic. The demographic data and cardiovascular risk parameters were captured from patient records in 1998. The pooled cohort risk score was calculated based on the parameters in 1998. The use of statins in 1998 and 2007, a 10-year interval, was recorded. RESULTS: A total of 847 patients were entered into the analysis. Mean age of the patients was 57.2 ± 8.4 years and 33.1% were male. The use of statins in 1998 was only 10.2% (n = 86) as compared to 67.5% (n = 572) in 2007. For patients with LDL 70-189 mg/dl and estimated 10-year ASCVD risk ≥7.5% (n = 190), 60% (n = 114) of patients were on statin therapy by 2007. There were 124 patients in whom statin therapy was not recommended according to ACC/AHA guideline but were actually receiving statin therapy. CONCLUSIONS: An extra 40% of patients need to be treated with statin if the 2013 ACC/AHA blood cholesterol guideline is used. However the absolute number of patients who needed to be treated based on the ACC/AHA guideline is lower than the number of patients actually receiving it in a daily clinical practice. The pooled cohort risk score does not increase the absolute number of patients who are actually treated with statins. However these findings and the use of the pooled cohort risk score need to be validated further

Visit-to-visit SBP variability and cardiovascular disease in amultiethnic primary care setting:10-year retrospective cohort study

Objectives: The current study aims to determine the relationship of long-term visit-to-visit variability of SBP to cardiovascular disease (CVD) in a multiethnic primary care setting. Method: This is a retrospective study of a cohort of 807 hypertensive patients over a period of 10 years. Three-monthly clinic blood pressure readings were used to derive blood pressure variability (BPV), and CVD events were captured from patient records. Results: Mean age at baseline was 57.2 ± 9.8 years with 63.3% being women. The BPV and mean SBP over 10 years were 14.7 ± 3.5 and 142 ± 8 mmHg, respectively. Prevalence of cardiovascular event was 13%. In multivariate logistic regression analysis, BPV was the predictor of CVD events, whereas the mean SBP was not independently associated with cardiovascular events in this population. Those with lower SBP and lower BPV had fewer cardiovascular events than those with the same low mean SBP but higher BPV (10.5 versus 12.8%). Similarly those with higher mean SBP but lower BPV also had fewer cardiovascular events than those with the same high mean and higher BPV (11.6 versus 16.7%). Other variables like being men, diabetes and Indian compared with Chinese are more likely to be associated with cardiovascular events. Conclusion: BPV is associated with an increase in CVD events even in those who have achieved lower mean SBP. Thus, we should prioritize not only control of SBP levels but also BPV to reduce CVD events further

Number of blood pressure measurements needed to estimate long-term visit-to-visit systolic blood pressure variability for predicting cardiovascular risk: a 10-year retrospective cohort study in a primary care clinic in Malaysia

Objective: To determine the reproducibility of visit-to-visit blood pressure variability (BPV) in clinical practice. We also determined the minimum number of blood pressure (BP) measurements needed to estimate long-term visit-to-visit BPV for predicting 10-year cardiovascular (CV) risk. Design: Retrospective study Setting: A primary care clinic in a university hospital in Malaysia. Participants: Random sampling of 1403 patients aged 30 years and above without any CV event at baseline. Outcomes measures: The effect of the number of BP measurement for calculation of long-term visit-to-visit BPV in predicting 10-year CV risk. CV events were defined as fatal and non-fatal coronary heart disease, fatal and non-fatal stroke, heart failure and peripheral vascular disease. Results: The mean 10-year SD of systolic blood pressure (SBP) for this cohort was 13.8±3.5 mm Hg. The intraclass correlation coefficient (ICC) for the SD of SBP based on the first eight and second eight measurements was 0.38 (p<0.001). In a primary care setting, visit-to-visit BPV (SD of SBP calculated from 20 BP measurements) was significantly associated with CV events (adjusted OR 1.07, 95% CI 1.02 to 1.13, p=0.009). Using SD of SBP from 20 measurement as reference, SD of SBP from 6 measurements (median time 1.75 years) has high reliability (ICC 0.74, p<0.001), with a mean difference of 0.6 mm Hg. Hence, a minimum of six BP measurements is needed for reliably estimating intraindividual BPV for CV outcome prediction. Conclusion: Long-term visit-to-visit BPV is reproducible in clinical practice. We suggest a minimum of six BP measurements for calculation of intraindividual visit-to-visit BPV. The number and duration of BP readings to derive BPV should be taken into consideration in predicting long-term CV risk

Implementation Strategies for Web-Based Apps for Screening: Scoping Review

Background: Screening is an effective primary prevention strategy in health care, as it enables the early detection of diseases. However, the uptake of such screening remains low. Different delivery methods for screening have been developed and found to be effective in increasing the uptake of screening, including the use of web-based apps. Studies have shown that web-based apps for screening are effective in increasing the uptake of health screening among the general population. However, not much is known about the effective implementation of such web-based apps in the real-world setting. Implementation strategies are theory-based methods or techniques used to enhance the adoption, implementation, and sustainability of evidence-based interventions. Implementation strategies are important, as they allow us to understand how to implement an evidence-based intervention. Therefore, a scoping review to identify the various implementation strategies for web-based apps for screening is warranted. Objective: This scoping review aims to identify (1) strategies used to implement web-based apps for health screening, (2) frameworks used for implementing web-based apps for health screening, (3) outcome measures of implementation strategies, and (4) effective implementation strategies. Methods: This scoping review was conducted based on Arksey and O’Malley’s framework. After identifying the review question, two researchers independently screened and selected relevant literature from PubMed, Embase, Cochrane, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, International Standard Randomised Controlled Trial Number Registry, OpenGrey, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Web of Science. This was followed by charting the data using a standardized form. Finally, we collated, summarized, and reported the results quantitatively and qualitatively based on the review objectives. Results: A total of 16,476 studies were retrieved, of which 5669 were duplicates. From a total of 10,807 studies, 10,784 studies were excluded based on their titles and abstracts. There were 23 full-text articles reviewed, and 4 articles were included in the final analysis. Many studies were excluded because they focused on the effectiveness and not on the implementation of web-based apps. Facilitation was the most cited implementation strategy used, followed by reminders, clinical champions, and educational meetings and materials. Only 2 studies used implementation frameworks to guide the evaluation of their studies. Common outcome measures for implementation strategies were feasibility, fidelity, and penetration. Implementation strategies reported to be effective were quality improvement meetings, facilitation, educational meetings, and clinical champions. Conclusions: There is a dearth of literature on the implementation of web-based apps for health screening. Implementation strategies were developed without any reported use of implementation theories or frameworks in most studies. More research on the development and evaluation of web-based screening app implementations is needed

Implementation strategies for web-based applications for screening : a scoping review

Introduction: Screening is an effective primary prevention strategy in healthcare. However, uptake of screening remains low. Many strategies have been developed and found to be effective in increasing uptake of screening including using web-based applications (web-apps). However, not much is known about effective implementation of web-apps for screening in the real-world setting. Objectives: This scoping review aimed to identify (1) implementation strategies to implement web-apps for screening; (2) implementation frameworks used for implementing web-apps for screening; (3) outcome measures of implementation strategies and (4) implementation strategies that were effective. Method: This scoping review was conducted based on Arksey O’Malley’s framework. After identifying the review question, two researchers independently screened and selected relevant literature from PubMed, Embase, Cochrane, CINAHL, PsycINFO, ISRCTN registry, OpenGrey, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform and Web of Science. This was followed by charting of the data using a standardized form. Finally, a researcher collated, summarised, and reported the results quantitatively and qualitatively based on the review objectives. Results: 16476 studies were retrieved where 5669 were duplicates. From a total of 10807 studies, 10784 studies were excluded based on screening of title and abstract. Twenty-three full-text articles were reviewed and 4 articles were included in the final analysis. Many studies were excluded because they did not focus on implementation of web-apps. Facilitation was the most cited implementation strategy used followed by reminders, clinical champions, educational meetings and materials. Only 2 studies used implementation frameworks to guide the evaluation of their studies. Common outcome measures for implementation strategies were feasibility, fidelity and penetration. Implementation strategies reported to be effective were quality improvement meetings, facilitation, educational meetings and clinical champions. Discussion/ Conclusion: There is a dearth of literature on implementation of web-apps for screening and therefore there is a need to conduct more research in development and evaluation of implementation of web-apps screening interventions

Validation of the framingham general cardiovascular risk score in a multi-ethnic Asian population a retrospective cohort study

Objective This study aims to examine the validity of the Framingham general cardiovascular disease (CVD) risk chart in a primary care setting. Design This is a 10-year retrospective cohort study. Setting A primary care clinic in a teaching hospital in Malaysia. Participants 967 patients’ records were randomly selected from patients who were attending follow-up in the clinic. Main outcome measures Baseline demographic data, history of diabetes and smoking, blood pressure (BP), and serum lipids were captured from patient records in 1998. Each patient's Framingham CVD score was computed from these parameters. All atherosclerotic CVD events occurring between 1998 and 2007 were counted. Results In 1998, mean age was 57 years with 33.8% men, 6.1% smokers, 43.3% diabetics and 59.7% hypertensive. Median BP was 140/80 mm Hg and total cholesterol 6.0 mmol/L (1.3). The predicted median Framingham general CVD risk score for the study population was 21.5% (IQR 1.2–30.0) while the actual CVD events that occurred in the 10 years was 13.1% (127/967). The median CVD points for men was 30.0, giving them a CVD risk of more than 30%; for women it is 18.5, a CVD risk of 21.5%. Our study found that the Framingham general CVD risk score to have moderate discrimination with an area under the receiver operating characteristic curve (AUC) of 0.63. It also discriminates well for Malay (AUC 0.65, p=0.01), Chinese (AUC 0.60, p=0.03), and Indians (AUC 0.65, p=0.001). There was good calibration with Hosmer-Lemeshow test χ2=3.25, p=0.78. Conclusions Taking into account that this cohort of patients were already on treatment, the Framingham General CVD Risk Prediction Score predicts fairly accurately for men and overestimates somewhat for women. In the absence of local risk prediction charts, the Framingham general CVD risk prediction chart is a reasonable alternative for use in a multiethnic group in a primary care setting

Curbing Bribe-Giving in Malaysia: The Role of Attitudes and Parents

© The Author(s). Published with license by Taylor & Francis Group, LLC. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/).One of the main challenges developing nations face is curbing bribery. While there are many efforts to curb bribery, most focused at macro level, such as law, while little has been examined at the micro level, e.g., individual behavior and intention. Those who did investigate at the micro level tend to focus on the recipients rather than the ones giving the bribe. We explored eight factors that influence Malaysian young adults’ bribe giving intention based on the Reasoned Action Approach (RAA). A total of 345 respondents (M age = 20.68, SD = 2.01, 189 are females) completed questionnaires about all RAA variables. Partial Least Squares Structural Equation Modelling (PLS-SEM) was carried out using smartPLS3.0 to analyze the result. The result revealed that out of the eight variables, four variables—Instrumental attitudes, Experiential Attitudes, Parents’ descriptive norms and Capacity—explain 74% of the variance in bribe giving intention. An important take-away is that young adult’s perception of whether their parents gave or did not give bribes in a given situation is important in influencing their bribe giving intention. Bribe giving prevention messages must be targeted explicitly toward parents, where they play a crucial role in curbing this dishonesty.Peer reviewe

Potential medicinal herb for cardiovascular health : a comprehensive review on Salviae miltiorrhizae

Cardiovascular disease (CVD) and its associated risk factors have been ranked the number 1 cause of mortality in noncommunicable diseases worldwide and Malaysia. The high statistic in CVD mortality indicates gaps and limitations in current treatment strategies using long-term drug prescription therapies. Hence, an immediate quest for alternative and effective treatments is needed. Medicinal herbs, which are ethnopharmacologically used to treat a wide range of conditions, have been used as an alternative or supplementary treatment for CVDs and their associated risk factors. The roots of Salviae miltiorrhizae have been traditionally used for centuries to treat various diseases including neurological disorders, cancer, and even coronary heart disease. Increasing evidence demonstrated a pharmacological basis for the action of S. miltiorrhizae and its active compounds, suggesting its potential in treating CVD. The objectives of this review were first to summarize published literature and synthesize the new body of knowledge on the use of S. miltiorrhizae as the potential medicinal herb that will positively impact the cardiovascular system, and secondly to elucidate the underlying mechanisms involved in promoting cardiovascular health. It is hoped that identification of key regulatory pathways by lipophilic and hydrophilic active compounds from S. miltiorrhizae will aid further investigation of its safety and efficacy to promote the use of evidence-based traditional medicinal herbs in alleviating symptoms and improve the prognosis of CVDs and their associated risk factors

Exosomal microRNAs in the development of essential hypertension and its potential as biomarkers

MicroRNAs (miRNAs) are small regulatory molecules that are involved in posttranscriptional modifications. These noncoding RNAs are usually ferried by extracellular carriers such as exosomes or other protein and lipid carriers inside a range of body fluids including plasma and urine. Due to their ability to withstand harsh external conditions, exosomal miRNAs possess enormous potential as noninvasive disease biomarkers for, notably hypertension, whereby exosomal miRNAs have been implicated in its pathophysiological processes. More importantly, alterations in the microenvironment as a result of disease progression can induce active and selective loading of miRNAs into exosomes. In this paper, we first review the mechanisms of miRNA loading into exosomes, followed by the roles of exosomal miRNAs in the development of hypertension, and the potentials of exosomal miRNAs as biomarkers in comparison with other free circulating miRNAs. Finally, challenges and future research surrounding exosomal miRNAs will also be discussed. This review will aid in the understanding of noninvasive biomarkers for the early diagnosis of hypertension and for probing therapeutic efficacy

Knowledge on the action to be taken and recognition of symptoms of stroke in a community: findings from the May Measurement Month 2017 blood pressure screening Programme in Malaysia

Background: Information regarding the knowledge on the action to be taken during stroke and good recognition of stroke symptoms is mandatory in helping to plan out educational strategies to deliver health education to the community. Methods: This is a cross-sectional study of adults aged 18 and above attending a blood pressure screening program in community in conjunction with May Measurement Month 2017 in Malaysia. A structured self-administered questionnaire was given to the participants who gave verbal consent. Data analysis was done using SPSS v. 23 and multiple logistic regression was used to identify the determinants of knowledge on actions to be taken during stroke and recognition of stroke symptoms. Results: Out of 4096 respondents, 82.9–92.1% of them able to recognise the common stroke symptoms. and 74.2% of the study respondents will go to hospital within 4.5 h of stroke onset. According to binomial logistic regression analyses, adults aged 45 years old and above (OR 1.39 95%CI 1.01–1.92), being Malay (OR 1.74, 95% CI 1.27–2.40), being non-smokers (OR = 2.491, 95% CI: 1.64–3.78), hypertensives (OR: 1.57, 95% CI: 1.02–2.42)and diabetics (OR: 2.54, 95% CI:1.38–4.69) are determinants of right actions to be taken during stroke. Meanwhile, respondents aged 45 years old and older (OR = 1.68, 95% CI: 1.39–2.03), being Malay (OR = 1.49, 95% CI: 1.24–1.79), hypertensive (OR = 1.32, 95% CI: 1.04–1.66) and those who had a previous history of stroke (OR = 2.25, 95% CI: 1.01–5.00) are determinants of good recognition of stroke symptoms. Conclusions: The overall knowledge of stroke in our study population was good. Older age, being Malay, non-smokers, hypertensives and diabetics are determinants of right actions to be taken during stroke. Meanwhile, older age, being Malay, hypertensive and those who had a previous history of stroke are determinants of good recognition of stroke symptoms