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Cardiovascular disease and diabetes or renal insufficiency: the risk of ischemic stroke and risk factor intervention
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

In patients with diabetes mellitus (DM) or chronic kidney disease (CKD), established cardiovascular disease (CVD) is associated with an increased risk of recurrent events and poor outcome. Ischemic stroke after an acute myocardial infarction (AMI) is a devastating event that carries high risks of decreased patient independence and death. Among patients with DM or CKD, the risk of an ischemic stroke within a year following an AMI is not known. Improved risk factor control is required to reduce the likelihood of CVD recurrence. Guidelines recommend target lipid profile and blood pressure values; however, data show that these targets are often not met. Therefore, there remains an urgent need for improved cardiovascular secondary preventive follow- up.

Aims

The aims of the present studies were to define trends in the incidence and predictors of ischemic stroke after an AMI in patients with DM or CKD. Furthermore to assess whether secondary preventive follow-up with nurse-based telephone follow-up including medication titration after CVD improves risk factor values in patients with DM or CKD and to investigate if this method performs better than usual care to implement a new treatment guideline in diabetic patients.

Methods

To assess the risk of post-AMI ischemic stroke, patient data were obtained from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA). In separate studies, we compared a total of 173 233 AMI patients with and without DM, and 118 434 AMI patients with and without CKD.

Within the nurse-based age-independent intervention to limit evolution of disease (NAILED) trial, we investigated a nurse-based cardiovascular secondary preventive follow-up protocol. Patients with acute coronary syndrome, stroke, or transient ischemic attack were randomized to receive either nurse-based telephone follow-up (intervention) or usual care (control). Low-density lipoprotein (LDL-C) levels and blood pressure (BP) were measured at 1 month (baseline) and 12 months post- discharge. Intervention patients with above-target baseline values received medication titration to achieve treatment goals, while the measurements for control patients were forwarded to their general practitioners for assessment. We calculated the changes in LDL-C level and BP between baseline and 12 months post-discharge, and compared 

these changes between 225 intervention patients and 215 control patients with concurrent DM or CKD. During the course of the NAILED trial, new secondary preventive guidelines for DM patients were released, including a new LDL-C target value. To assess adherence to the new guidelines within the NAILED trial, we compared LDL-C levels in the 101 intervention patients and 100 control patients with DM.

Results

Ischemic stroke after AMI

The rates of ischemic stroke within one-year after admission for an AMI decreased over time, from 7.1% in 1998–2000 to 4.7% in 2007–2008 among DM patients, and from 4.2% to 3.7% during the same time periods for non-diabetic patients. Lower stroke risk was associated with percutaneous coronary intervention (PCI) and initiation of secondary preventive treatments in-hospital.

In-hospital ischemic stroke occurred in 2.3% of CKD patients and 1.2% of non-CKD patients, with no change in these incidences over time. The rates of one-year post- discharge ischemic stroke decreased between 2003–2004 and 2009–2010 from 4.1% to 2.5% among CKD patients, and from 2.0% to 1.3% among non-CKD patients. Lower rates of post-discharge stroke were associated with PCI and statins.

Cardiovascular secondary preventive follow-up

Among DM and CKD patients with above-target baseline values in the NAILED trial, the median LDL-C value at 12 months was 2.2 versus 3.0 mmol/L (p<0.001) and median systolic BP was 140 versus 145 mmHg (p=0.26) for intervention and control patients, respectively.

Before the guideline change, 96% of the intervention and 70% of the control patients reached the target LDL-C value (p<0.001). After the guideline change, the corresponding respective proportions were 65% and 36% (p<0.001).

Conclusion

Ischemic stroke is a fairly common post-AMI complication among patients with DM and CKD. This risk of stroke has decreased during recent years, possibly due to the increased use of evidence-based therapies. Compared with usual care, cardiovascular secondary prevention including nurse-based telephone follow-up improved LDL-C values at 12 months after discharge in patients with DM or CVD, and led to more efficient implementation of new secondary preventive guidelines. 

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2015. , 55 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1743
Keyword [en]
cardiovascular disease, secondary prevention, diabetes mellitus, chronic kidney disease, acute coronary syndrome, stroke, randomized control trial
National Category
Cardiac and Cardiovascular Systems
Research subject
Medicine, cardiovascular disease
Identifiers
URN: urn:nbn:se:umu:diva-109785ISBN: 978-91-7601-320-5 (print)OAI: oai:DiVA.org:umu-109785DiVA: diva2:859870
Public defence
2015-11-06, Hörsalen, Östersunds sjukhus, Östersund, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2015-10-16 Created: 2015-10-06 Last updated: 2015-10-16Bibliographically approved
List of papers
1. Risk of ischemic stroke after an acute myocardial infarction in patients with diabetes mellitus
Open this publication in new window or tab >>Risk of ischemic stroke after an acute myocardial infarction in patients with diabetes mellitus
Show others...
2014 (English)In: Circulation. Cardiovascular Quality and Outcomes, ISSN 1941-7713, E-ISSN 1941-7705, Vol. 7, no 1, 95-101 p.Article in journal (Refereed) Published
Abstract [en]

Background Incidence, any trend over time, and predictors of ischemic stroke after an acute myocardial infarction (AMI) in diabetic patients are unknown.

Methods and Results Data for 173 233 unselected patients with an AMI, including 33 503 patients with diabetes mellitus, were taken from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) during 1998 to 2008. Ischemic stroke events were recorded during 1 year of follow-up. Patients with diabetes mellitus more often had a history of cardiovascular disease, received less reperfusion therapy, and were treated with acetylsalicylic acid, P2Y12 inhibitors, and statins to a lesser extent compared with patients without diabetes mellitus. However, the use of evidence-based therapies increased markedly in both groups during the study period. The incidence of ischemic stroke during the first year after AMI decreased from 7.1% to 4.7% in patients with diabetes mellitus and from 4.2% to 3.7% in patients without diabetes mellitus. Risk reduction was significantly larger in the diabetic subgroup. Reperfusion therapy, acetylsalicylic acid, P2Y12 inhibitors, and statins were independently associated with the reduced stroke risk.

Conclusions Ischemic stroke is a fairly common complication after an AMI in patients with diabetes mellitus, but the risk of stroke has decreased during recent years. The increased use of evidence-based therapies contributes importantly to this risk reduction, but there is still room for improvement.

National Category
Family Medicine
Identifiers
urn:nbn:se:umu:diva-87182 (URN)10.1161/CIRCOUTCOMES.113.000311 (DOI)000331071200014 ()
Available from: 2014-03-25 Created: 2014-03-24 Last updated: 2017-12-05Bibliographically approved
2. The Risk of Ischemic Stroke after an Acute Myocardial Infarction in Patients with Decreased Renal Function
Open this publication in new window or tab >>The Risk of Ischemic Stroke after an Acute Myocardial Infarction in Patients with Decreased Renal Function
Show others...
2014 (English)In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 37, no 6, 460-469 p.Article in journal (Refereed) Published
Abstract [en]

Background: Data on the incidence, trends over time and predictors of ischemic stroke after an acute myocardial infarction (AMI) are sparse for patients with chronic kidney disease (CKD). Methods: Data for unselected AMI patients were obtained from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) between 2003 and 2010. Patients with and without CKD were compared. Multiple logistic regression was performed to identify predictors of ischemic stroke during the hospitalization for AMI, Kaplan-Meier analysis was used to analyze the 1-year postdischarge ischemic stroke trends over time and Cox regression analysis was used to identify predictors. Results: Of 118,434 AMI patients, 40,679 had CKD. The CKD patients had more extensive previous cardiovascular disease and received less reperfusion and secondary preventive therapies than the patients without CKD. An inhospital ischemic stroke occurred in 2.3 and 1.2% of CKD and non-CKD patients, respectively. The incidence of ischemic stroke during hospitalization for AMI was stable during the study period. The occurrence of ischemic stroke after hospital discharge decreased between 2003-2004 and 2009-2010 from 4.1 to 2.5% in CKD patients and from 2.0 to 1.3% in non-CKD patients, respectively. Percutaneous coronary intervention (PCI) and statins were independently associated with a reduced risk of stroke after discharge from hospital. Conclusions: Ischemic stroke is a more common complication after an AMI in CKD patients than in non-CKD patients, but the risk has decreased in recent years. The increased use of PCI and statins may have contributed to this reduction.

Keyword
Ischemic stroke, Myocardial infarction, Chronic kidney disease
National Category
Neurosciences Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-102484 (URN)10.1159/000363616 (DOI)000350823700010 ()25073588 (PubMedID)
Available from: 2015-04-26 Created: 2015-04-26 Last updated: 2017-12-04Bibliographically approved
3. Implementation of a new guideline in cardiovascular secondary preventive care: subanalysis of a randomized controlled trial
Open this publication in new window or tab >>Implementation of a new guideline in cardiovascular secondary preventive care: subanalysis of a randomized controlled trial
2016 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16, 77Article in journal (Refereed) Published
Abstract [en]

Background

Cardiovascular secondary preventive recommendations are often not reached. We investigated whether a nurse-led telephone-based follow-up could improve the implementation of a new guideline within a year after its release.

Methods

In February 2013, a new secondary preventive guideline for diabetic patients was released in the county of Jämtland, Sweden. It included a changed of the low-density lipoprotein cholesterol (LDL-C) target value from <2.5 mmol/L to <1.8 mmol/L. In the Nurse-Based Age-Independent Intervention to Limit Evolution of Disease (NAILED) trial, patients with an acute coronary syndrome, stroke, or transient ischemic attack were randomized to secondary preventive care with nurse-based telephone follow-up (intervention) or usual care (control). Patient data were obtained from the NAILED trial to study the implementation of the new LDL-C guideline by comparing telephone follow-up with usual care. The Mann–Whitney U-test was used for continuous variables, and Person’s χ 2 test was used for categorical variables to assess between-group differences.

Results

Out of the 1267 patients that entered the study period, 101 intervention and 100 control patients with diabetes fulfilled the inclusion criteria and completed the study period. Before the guideline change, 96 % of the intervention patients and 70 % of the control patients reached the target LDL-C value (p < 0.001). After the guideline change, the corresponding respective proportions were 65 % and 36 % (p < 0.001). The main reason that intervention patients did not achieve the target LDL-C value was that they received full-dose treatment; for control patients, the main reason was that medication was not adjusted, for an unknown reason.

Conclusions

One year after a change in the cardiovascular secondary preventive guideline, nurse-based telephone follow-up performed better than usual care to implement the new recommendation.

Keyword
Acute coronary syndrome, Cardiovascular disease, Myocardial infarction, Randomized controlled trial, Secondary prevention, Stroke, Transient ischemic attack
National Category
Cardiac and Cardiovascular Systems
Research subject
Medicine, cardiovascular disease
Identifiers
urn:nbn:se:umu:diva-109782 (URN)10.1186/s12872-016-0252-0 (DOI)000375098300001 ()
Note

Originally included in thesis in manuscript form

Available from: 2015-10-06 Created: 2015-10-06 Last updated: 2017-12-01Bibliographically approved
4. Cardiovascular secondary prevention in high-risk patients: a randomized controlled trial sub-study
Open this publication in new window or tab >>Cardiovascular secondary prevention in high-risk patients: a randomized controlled trial sub-study
2015 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 15, 125Article in journal (Refereed) Published
Abstract [en]

Background: Enhanced cardiovascular secondary preventive follow-up is needed to improve adherence to recommended low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) levels. Patients with diabetes mellitus (DM) or chronic kidney disease (CKD) have a high risk of recurrent events. Secondary prevention is therefore essential in these patients.

Methods: Patients with acute coronary syndrome, stroke, or transient ischemic attack were randomized to nurse-based telephone follow-up (intervention) or usual care (control). LDL-C and BP were measured at 1 month (baseline) and 12 months post-discharge. Intervention patients with above-target values at baseline received medication titration to achieve treatment goals. Values measured for control patients were given to the patient’s general practitioner for assessment.

Results: The final analyses included 225 intervention and 215 control patients with DM or CKD. Among patients with above-target baseline values, the following 12-month values were recorded for intervention and control patients, respectively: LDL-C, 2.2 versus 3.0 mmol/L (p < 0.001); and median systolic BP (SBP), 140 versus 145 mmHg (p = 0.26). Among patients with above-target values at baseline, 52.3% of intervention patients reached target LDL-C values at 12 months versus 21.3% of control patients (absolute difference of 30.9%, 95% CI 16.1 to 43.8%), and there was a non-significant trend of more intervention patients reaching target SBP (49.4% versus 36.8%; absolute difference of 12.6%, 95% CI -1.7 to 26.2%).

Conclusions: Cardiovascular secondary prevention with nurse-based telephone follow-up was more effective than usual care in improving LDL-C levels 12 months after discharge for patients with DM or CKD. 

Place, publisher, year, edition, pages
BioMed Central, 2015
Keyword
acute coronary syndrome, myocardial infarction, stroke, transient ischemic attack, diabetes mellitus, chronic renal insufficiency, secondary prevention, cardiovascular disease
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-109784 (URN)10.1186/s12872-015-0115-0 (DOI)000363367500003 ()26466804 (PubMedID)
Note

8 sidor

Available from: 2015-10-06 Created: 2015-10-06 Last updated: 2017-12-01Bibliographically approved

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