A UK consensus on optimising CVD secondary prevention care: perspectives from multidisciplinary team members

Although overall cardiovascular (CV) mortality has declined in recent years, patients with clinically manifest cardiovascular disease (CVD) remain at increased risk of recurrent CV events. To minimise the likelihood of future CV events following an acute myocardial infarction (MI), changes in diet and lifestyle, alongside pharmaceutical interventions, such as dual antiplatelet therapy, a β-blocker, an ACE inhibitor, and a statin, are recommended within current clinical guidelines. The use of cardiac rehabilitation (CR) programmes has been shown to be highly effective in reducing mortality and morbidity following MI, and a cost-benefit analysis suggests that increasing the uptake of CR to 65% among eligible patient would result in potential cost savings of over £30 million annually for the NHS. The involvement of a multidisciplinary team (MDT) of healthcare professionals is central to delivering post-MI care, with initial and/or ongoing input from cardiologists, hospital-based specialist pharmacists, specialist nurses, GPs, dietitians, smoking cessation specialists and practice-based and community pharmacists, among others. This consensus statement was developed based on a meeting of HCPs actively involved in delivering CV secondary prevention care at primary and secondary care centres across the UK. Recognising that HCP team configuration and availability of resources/services vary by location, the authors have focused on three common themes which have broad relevance in CVD secondary prevention, specifically: integration of care, medicines optimisation, and encouraging patient activation. Opportunities for MDT members to improve outcomes in post-MI patients are suggested and examples of best practice models which have been implemented successfully are described

Elevated Baseline C-Reactive Protein as a Predictor of Outcome After Aneurysmal Subarachnoid Hemorrhage: Data From the Simvastatin in Aneurysmal Subarachnoid Hemorrhage (STASH) Trial.

BACKGROUND: There remains a proportion of patients with unfavorable outcomes after aneurysmal subarachnoid hemorrhage, of particular relevance in those who present with a good clinical grade. A forewarning of those at risk provides an opportunity towards more intensive monitoring, investigation, and prophylactic treatment prior to the clinical manifestation of advancing cerebral injury. OBJECTIVE: To assess whether biochemical markers sampled in the first days after the initial hemorrhage can predict poor outcome. METHODS: All patients recruited to the multicenter Simvastatin in Aneurysmal Hemorrhage Trial (STASH) were included. Baseline biochemical profiles were taken between time of ictus and day 4 post ictus. The t-test compared outcomes, and a backwards stepwise binary logistic regression was used to determine the factors providing independent prediction of an unfavorable outcome. RESULTS: Baseline biochemical data were obtained in approximately 91% of cases from 803 patients. On admission, 73% of patients were good grade (World Federation of Neurological Surgeons grades 1 or 2); however, 84% had a Fisher grade 3 or 4 on computed tomographic scan. For patients presenting with good grade on admission, higher levels of C-reactive protein, glucose, and white blood cells and lower levels of hematocrit, albumin, and hemoglobin were associated with poor outcome at discharge. C-reactive protein was found to be an independent predictor of outcome for patients presenting in good grade. CONCLUSION: Early recording of C-reactive protein may prove useful in detecting those good grade patients who are at greater risk of clinical deterioration and poor outcome.Financial support: British Heart Foundation. None of the authors have any personal or institutional financial interest in drugs or materials in the manuscript. PJK and PJH are supported by the Cambridge NIHR BRC and PJH is supported by a NIHR Research Professorship. We also acknowledge the support of the Cambridge Clinical Trials Unit, UK Clinical Research Network and all 35 participating sites.This is the final version of the article. It first appeared from Wolters Kluwer via http://dx.doi.org/10.1227/NEU.000000000000096

The Familial Intracranial Aneurysm (FIA) study protocol

BACKGROUND: Subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysms (IAs) occurs in about 20,000 people per year in the U.S. annually and nearly half of the affected persons are dead within the first 30 days. Survivors of ruptured IAs are often left with substantial disability. Thus, primary prevention of aneurysm formation and rupture is of paramount importance. Prior studies indicate that genetic factors are important in the formation and rupture of IAs. The long-term goal of the Familial Intracranial Aneurysm (FIA) Study is to identify genes that underlie the development and rupture of intracranial aneurysms (IA). METHODS/DESIGN: The FIA Study includes 26 clinical centers which have extensive experience in the clinical management and imaging of intracerebral aneurysms. 475 families with affected sib pairs or with multiple affected relatives will be enrolled through retrospective and prospective screening of potential subjects with an IA. After giving informed consent, the proband or their spokesperson invites other family members to participate. Each participant is interviewed using a standardized questionnaire which covers medical history, social history and demographic information. In addition blood is drawn from each participant for DNA isolation and immortalization of lymphocytes. High- risk family members without a previously diagnosed IA undergo magnetic resonance angiography (MRA) to identify asymptomatic unruptured aneurysms. A 10 cM genome screen will be performed to identify FIA susceptibility loci. Due to the significant mortality of affected individuals, novel approaches are employed to reconstruct the genotype of critical deceased individuals. These include the intensive recruitment of the spouse and children of deceased, affected individuals. DISCUSSION: A successful, adequately-powered genetic linkage study of IA is challenging given the very high, early mortality of ruptured IA. Design features in the FIA Study that address this challenge include recruitment at a large number of highly active clinical centers, comprehensive screening and recruitment techniques, non-invasive vascular imaging of high-risk subjects, genome reconstruction of dead affected individuals using marker data from closely related family members, and inclusion of environmental covariates in the statistical analysis

Chapter 3 - Case study: Does PM2.5 contribute to the incidence of lung and bronchial cancers in the United States?

Air quality has been long known to be strongly related to human health. Many studies have assessed the impact of air pollution on human health. This case study illustrates how to conduct a statistical study related to air pollution and health issues using the statistical methods introduced in the previous chapter. This case study is to examine if PM2.5 contributes to the incidence of lung and bronchial cancers in the United States. Statistical analyses, such as descriptive statistics, scatter plots, time series analyses, generalized linear regression models, and lagged regression, are used to explore the relationship between the lung and bronchial cancer annual rates and PM2.5 values at both national and state levels