Increasing blood pressure checks in community pharmacy: cardiovascular disease impact

Estimates of the cardiovascular disease events and costs avoided from increasing blood pressure checks in community pharmacies in England | Office for Health Improvement and Disparities

This document contains data for possible scenarios of cardiovascular disease avoided from increasing the numbers of people seen for blood pressure checks in community pharmacies in England. This supports policy options on increasing community pharmacy blood pressure services and supports statements on the impact of these policies.

The data provides estimates of disease avoidance over a potential 20-year period. This includes data on the estimated number of events avoided and their potential cost, as well as mortality avoided and quality-adjusted life years gained from disease event avoidance.

Full detail: Increasing blood pressure checks in community pharmacy: cardiovascular disease impact

Cardiovascular-related conditions and risk factors in primary care for deprived communities before and during the COVID-19 pandemic

Fu Y, Price C, Haining S, et al | Cardiovascular-related conditions and risk factors in primary care for deprived communities before and during the COVID-19 pandemic: an observational study in Northern England | BMJ Open 2022;12:e066868. | doi: 10.1136/bmjopen-2022-066868

This study aimed to compare CVD-related conditions and risk factors for deprived practice populations with other general practice (GP) populations in Northern England to England overall, before and during COVID-19 to identify changes in recorded CVD-related risk factors and conditions and evidence-based lipid prescribing behaviour.

34 practices that fall into the 15% most deprived practice populations in England were identified as the most deprived communities in the North East and North Cumbria (Deep End).

The study found that recorded CVD-related risk factors and conditions remained comparable before and during COVID-19. These are higher in the Deep End than in England and similar or lower than the non-Deep End, with a higher optimal statin prescribing rate. More work is needed to estimate the consequences of the pandemic on disadvantaged communities and to compare whether the findings are replicated in other areas of deprivation.

Full paper: Cardiovascular-related conditions and risk factors in primary care for deprived communities before and during the COVID-19 pandemic: an observational study in Northern England

Inclusive Pharmacy Practice

via NHS England

The Inclusive Pharmacy Practice (IPP) is a joint initiative by NHS England with the Royal Pharmaceutical Society and the Association of Pharmacy Technicians UK and 13 other national partner organisations. This is the first IPP Bulletin, and focusses on CVD prevention. It explores how pharmacy teams across the nation are helping to reduce health inequalities in this area.

Receive further updates about IPP including the next Bulletin in December by completing this form.

Full detail: Inclusive Pharmacy Practice Bulletin

See also: Inclusive Pharmacy Practice | NHS England

Cardiovascular disease toolkit

via elearning for healthcare

The Cardiovascular Disease (CVD) elearning programme has been developed to provide an overview of CVD care across the entire patient pathway and promote better patient care. It aims to provide all health and social care professionals and multidisciplinary teams with the appropriate level of knowledge, skills and experience they need to deliver effective CVD prevention and care to people with CVD, and at risk of CVD.

CVD has been identified as the single biggest condition where lives can be saved by the NHS. It affects approximately 7 million people in the United Kingdom, with more than 100,000 hospital admissions each year due to heart attacks (British Heart Foundation, 2021). The British Heart Foundation (2020) estimates that more than half of people in the UK will develop a heart or circulatory condition in their lifetime. In addition, CVD has been identified as clinical priority in the NHS Long Term Plan (LTP).

The Cardiovascular Diseases (CVD) Toolkit aligns to the NHS Long Term Plan and provides learners with a comprehensive list of online resources that can be used to support workforce upskilling, training and development.

Full detail: Cardiovascular disease toolkit

Associations of cereal grains intake with cardiovascular disease and mortality across 21 countries in Prospective Urban and Rural Epidemiology study

Objective To evaluate the association between intakes of refined grains, whole grains, and white rice with cardiovascular disease, total mortality, blood lipids, and blood pressure in the Prospective Urban and Rural Epidemiology (PURE) study.

Design Prospective cohort study.

Setting PURE study in 21 countries.

Participants 148 858 participants with median follow-up of 9.5 years.

Exposures Country specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice.

Main outcome measure Composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios were estimated for associations of grain intakes with mortality, major cardiovascular events, and their composite by using multivariable Cox frailty models with random intercepts to account for clustering by centre.

Results Analyses were based on 137 130 participants after exclusion of those with baseline cardiovascular disease. During follow-up, 9.2% (n=12 668) of these participants had a composite outcome event. The highest category of intake of refined grains (≥350 g/day or about 7 servings/day) was associated with higher risk of total mortality (hazard ratio 1.27, 95% confidence interval 1.11 to 1.46; P for trend=0.004), major cardiovascular disease events (1.33, 1.16 to 1.52; P for trend<0.001), and their composite (1.28, 1.15 to 1.42; P for trend<0.001) compared with the lowest category of intake (<50 g/day). Higher intakes of refined grains were associated with higher systolic blood pressure. No significant associations were found between intakes of whole grains or white rice and health outcomes.

Conclusion High intake of refined grains was associated with higher risk of mortality and major cardiovascular disease events. Globally, lower consumption of refined grains should be considered.

Reference: BMJ 2021;372:m4948

Association Between Depressive Symptoms and Incident Cardiovascular Diseases

Question  Are depressive symptoms associated with incident cardiovascular diseases?

Findings  In a pooled analysis of individual-participant data from 563 255 participants in 22 prospective cohorts, depressive symptoms (assessed by the Center for Epidemiologic Studies Depression [CES-D] scale and other validated scales) were significantly associated with incident cardiovascular disease, including scores lower than the threshold typically indicative of depressive disorders (CES-D ≥16; hazard ratio per 1-SD higher log CES-D, 1.06).

Meaning  Depressive symptoms, even at levels lower than what is typically indicative of potential clinical depression, were associated with risk of incident cardiovascular disease although the magnitude of the association was modest.

Reference: JAMA. 2020;324(23):2396-2405.

Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review

Objective To consolidate evidence from systematic reviews and meta-analyses investigating the association between reproductive factors in women of reproductive age and their subsequent risk of cardiovascular disease.

Design Umbrella review.

Data sources Medline, Embase, and Cochrane databases for systematic reviews and meta-analyses from inception until 31 August 2019.

Review methods Two independent reviewers undertook screening, data extraction, and quality appraisal. The population was women of reproductive age. Exposures were fertility related factors and adverse pregnancy outcomes. Outcome was cardiovascular diseases in women, including ischaemic heart disease, heart failure, peripheral arterial disease, and stroke.

Results 32 reviews were included, evaluating multiple risk factors over an average follow-up period of 7-10 years. All except three reviews were of moderate quality. A narrative evidence synthesis with forest plots and tabular presentations was performed. Associations for composite cardiovascular disease were: twofold for pre-eclampsia, stillbirth, and preterm birth; 1.5-1.9-fold for gestational hypertension, placental abruption, gestational diabetes, and premature ovarian insufficiency; and less than 1.5-fold for early menarche, polycystic ovary syndrome, ever parity, and early menopause. A longer length of breastfeeding was associated with a reduced risk of cardiovascular disease. The associations for ischaemic heart disease were twofold or greater for pre-eclampsia, recurrent pre-eclampsia, gestational diabetes, and preterm birth; 1.5-1.9-fold for current use of combined oral contraceptives (oestrogen and progesterone), recurrent miscarriage, premature ovarian insufficiency, and early menopause; and less than 1.5-fold for miscarriage, polycystic ovary syndrome, and menopausal symptoms. For stroke outcomes, the associations were twofold or more for current use of any oral contraceptive (combined oral contraceptives or progesterone only pill), pre-eclampsia, and recurrent pre-eclampsia; 1.5-1.9-fold for current use of combined oral contraceptives, gestational diabetes, and preterm birth; and less than 1.5-fold for polycystic ovary syndrome. The association for heart failure was fourfold for pre-eclampsia. No association was found between cardiovascular disease outcomes and current use of progesterone only contraceptives, use of non-oral hormonal contraceptive agents, or fertility treatment.

Conclusions From menarche to menopause, reproductive factors were associated with cardiovascular disease in women. In this review, presenting absolute numbers on the scale of the problem was not feasible; however, if these associations are causal, they could account for a large proportion of unexplained risk of cardiovascular disease in women, and the risk might be modifiable. Identifying reproductive risk factors at an early stage in the life of women might facilitate the initiation of strategies to modify potential risks. Policy makers should consider incorporating reproductive risk factors as part of the assessment of cardiovascular risk in clinical guidelines.

Systematic review registration PROSPERO CRD42019120076.

Reference:  BMJ 2020;371:m3502

Plasma ACE2 and risk of death or cardiometabolic diseases: a case-cohort analysis

Background

Angiotensin-converting enzyme 2 (ACE2) is an endogenous counter-regulator of the renin–angiotensin hormonal cascade. We assessed whether plasma ACE2 concentrations were associated with greater risk of death or cardiovascular disease events.

Methods

We used data from the Prospective Urban Rural Epidemiology (PURE) prospective study to conduct a case-cohort analysis within a subset of PURE participants (from 14 countries across five continents: Africa, Asia, Europe, North America, and South America). We measured plasma concentrations of ACE2 and assessed potential determinants of plasma ACE2 levels as well as the association of ACE2 with cardiovascular events.

Findings

We included 10 753 PURE participants in our study. Increased concentration of plasma ACE2 was associated with increased risk of total deaths (hazard ratio [HR] 1·35 per 1 SD increase [95% CI 1·29–1·43]) with similar increases in cardiovascular and non-cardiovascular deaths. Plasma ACE2 concentration was also associated with higher risk of incident heart failure (HR 1·27 per 1 SD increase [1·10–1·46]), myocardial infarction (HR 1·23 per 1 SD increase [1·13–1·33]), stroke (HR 1·21 per 1 SD increase [1·10–1·32]) and diabetes (HR 1·44 per 1 SD increase [1·36–1·52]). These findings were independent of age, sex, ancestry, and traditional cardiac risk factors. With the exception of incident heart failure events, the independent relationship of ACE2 with the clinical endpoints, including death, remained robust after adjustment for BNP. The highest-ranked determinants of ACE2 concentrations were sex, geographic ancestry, and body-mass index (BMI). When compared with clinical risk factors (smoking, diabetes, blood pressure, lipids, and BMI), ACE2 was the highest ranked predictor of death, and superseded several risk factors as a predictor of heart failure, stroke, and myocardial infarction.

Interpretation

Increased plasma ACE2 concentration was associated with increased risk of major cardiovascular events in a global study.

Funding

Canadian Institute of Health Research, Heart & Stroke Foundation of Canada, and Bayer.

Reference: The Lancet, VOLUME 396, ISSUE 10256, P968-976, OCTOBER 03, 2020

Risk of amputation with canagliflozin across categories of age and cardiovascular risk in three US nationwide databases: cohort study

Objective To estimate the rate of lower limb amputation among adults newly prescribed canagliflozin according to age and cardiovascular disease.

Design Population based, new user, cohort study.

Data sources Two commercial and Medicare claims databases, 2013-17.

Participants Patients newly prescribed canagliflozin were propensity score matched 1:1 with patients newly prescribed a glucagon-like peptide-1 (GLP-1) receptor agonist. Hazard ratios and rate differences per 1000 person years were computed for the rate of lower limb amputation in the following four groups: group 1, patients aged less than 65 years without baseline cardiovascular disease; group 2, patients aged less than 65 with baseline cardiovascular disease; group 3, patients aged 65 or older without baseline cardiovascular disease; group 4, patients aged 65 or older with baseline cardiovascular disease. Within each group, pooled hazard ratio and rate difference per 1000 person years were calculated by meta-analysis.

Intervention Canagliflozin versus a GLP-1 agonist.

Main outcome measures Lower limb amputation requiring surgery.

Results Across the three databases, 310 840 propensity score matched adults who started canagliflozin or a GLP-1 agonist were identified. The hazard ratio and rate difference per 1000 person years for amputation in adults receiving canagliflozin compared with a GLP-1 agonist for each group was: group 1, hazard ratio 1.09 (95% confidence interval 0.83 to 1.43), rate difference 0.12 (−0.31 to 0.55); group 2, hazard ratio 1.18 (0.86 to 1.62), rate difference 1.06 (−1.77 to 3.89); group 3, hazard ratio 1.30 (0.52 to 3.26), rate difference 0.47 (−0.73 to 1.67); and group 4, hazard ratio 1.73 (1.30 to 2.29), rate difference 3.66 (1.74 to 5.59).

Conclusions The increase in rate of amputation with canagliflozin was small and most apparent on an absolute scale for adults aged 65 or older with baseline cardiovascular disease, resulting in a number needed to treat for an additional harmful outcome of 556 patients at six months (that is, 18 more amputations per 10 000 people who received canagliflozin). These results help to contextualize the risk of amputation with canagliflozin in routine care.

Reference: BMJ 2020;370:m2812

Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis

Objective To evaluate the associations between prediabetes and the risk of all cause mortality and incident cardiovascular disease in the general population and in patients with a history of atherosclerotic cardiovascular disease.

Design Updated meta-analysis.

Data sources Electronic databases (PubMed, Embase, and Google Scholar) up to 25 April 2020.

Review methods Prospective cohort studies or post hoc analysis of clinical trials were included for analysis if they reported adjusted relative risks, odds ratios, or hazard ratios of all cause mortality or cardiovascular disease for prediabetes compared with normoglycaemia. Data were extracted independently by two investigators. Random effects models were used to calculate the relative risks and 95% confidence intervals. The primary outcomes were all cause mortality and composite cardiovascular disease. The secondary outcomes were the risk of coronary heart disease and stroke.

Results A total of 129 studies were included, involving 10 069 955 individuals for analysis. In the general population, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.13, 95% confidence interval 1.10 to 1.17), composite cardiovascular disease (1.15, 1.11 to 1.18), coronary heart disease (1.16, 1.11 to 1.21), and stroke (1.14, 1.08 to 1.20) in a median follow-up time of 9.8 years. Compared with normoglycaemia, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 7.36 (95% confidence interval 9.59 to 12.51), 8.75 (6.41 to 10.49), 6.59 (4.53 to 8.65), and 3.68 (2.10 to 5.26) per 10 000 person years, respectively. Impaired glucose tolerance carried a higher risk of all cause mortality, coronary heart disease, and stroke than impaired fasting glucose. In patients with atherosclerotic cardiovascular disease, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.36, 95% confidence interval 1.21 to 1.54), composite cardiovascular disease (1.37, 1.23 to 1.53), and coronary heart disease (1.15, 1.02 to 1.29) in a median follow-up time of 3.2 years, but no difference was seen for the risk of stroke (1.05, 0.81 to 1.36). Compared with normoglycaemia, in patients with atherosclerotic cardiovascular disease, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 66.19 (95% confidence interval 38.60 to 99.25), 189.77 (117.97 to 271.84), 40.62 (5.42 to 78.53), and 8.54 (32.43 to 61.45) per 10 000 person years, respectively. No significant heterogeneity was found for the risk of all outcomes seen for the different definitions of prediabetes in patients with atherosclerotic cardiovascular disease (all P>0.10).

Conclusions Results indicated that prediabetes was associated with an increased risk of all cause mortality and cardiovascular disease in the general population and in patients with atherosclerotic cardiovascular disease. Screening and appropriate management of prediabetes might contribute to primary and secondary prevention of cardiovascular disease.

Reference: BMJ 2020;370:m2297