Welcome to the first issue of BJPCN for 2010 – a new year and a new decade! How are you doing on your New Year’s resolutions? I have recently lost quite a bit of weight and feel so much better, both physically and mentally. This has prompted me to reflect on how people decide to change and how they act on that decision, so I would like to share some of my thoughts and the approach I have adopted as a result.
People living in deprived areas show three times the risk of stroke deaths
People living in deprived areas are around three times more likely to die from a stroke than those in the least deprived, according to a report from the Stroke Association and the British Heart Foundation, which shows that death rates from stroke vary with social and economic conditions.
The report, which is the first comprehensive collection of national statistics on the burden of stroke, confirms that the stroke mortality rate for men and women of working age (under 65) has fallen consistently since the late 1970s. However, it shows that the rate has fallen more quickly in adults of higher social classes, resulting in an increase in inequalities in stroke death rates. The data show that stroke mortality increases with deprivation for both men and women. For premature mortality, the rate in the most deprived 5% of the population in England and Wales is more than three and a half times higher for men, and over two and a half times higher for women, than for those in the least deprived sector.
The statistics also show that people from lower social economic backgrounds are more likely to have major risk factors of stroke, including cigarette smoking and obesity. Professor Peter Weissberg, Medical Director at the British Heart Foundation said: “The picture these data on stroke present strongly mirrors figures for heart disease, which is also much more common in deprived communities. Many of the risk factors for heart disease and stroke, such as smoking and high blood pressure, are the same and potentially modifiable. The statistics argue for a concerted effort to identify and modify risk factors, by lifestyle and drug interventions, in those communities with the highest risks.-
New treatment option for comprehensive management of LDL-C, HDL-C and triglycerides
Tredaptive (nicotinic acid/laropiprant) has been launched as a new treatment option for dyslipidaemia. It is indicated for patients with combined mixed dyslipidaemia or primary hypercholesterolaemia, and should be used in combination with a statin when the cholesterol-lowering effect of statin monotherapy is inadequate, or as monotherapy when statins are considered inappropriate or not tolerated.
An efficacy study showed that treatment with the drug, with or without a statin, lowered LDL-C levels by 18% and triglycerides by 26% and raised HDL-C levels by 20% (placebo-adjusted) for a 24-week period. “Many patients do not achieve sufficient LDL cholesterol lowering on a statin alone and a significant CVD residual risk remains in some patients,” commented Dr Marc Evans, Consultant Diabetologist, Llandough. “Furthermore, low HDL-C and high triglyceride levels also contribute to cardiovascular risk and are particularly prevalent in certain patient groups, such as those with diabetes and people of South Asian origin,” he added.
Dr Evans considered that a new treatment option that can address the wider lipid profile is welcome, and will be particularly useful for secondary prevention patients and those patients with dyslipidaemia at ‘high risk’. Nicotinic acid has been widely recognised as an effective lipid-modifying therapy for over 50 years, but its use has been limited due to a flushing sideeffect. The laropiprant component in Tredaptive is an anti-flushing agent. Treatment with Tredaptive is associated with significantly lower percentages of patients with moderate or greater flushing than extended-release nicotinic acid, and any flushing that does occur subsides over time, according to trials. This reduction in flushing has led to patients on Tredaptive being less likely to discontinue treatment due to flushing compared to those on extended-release nicotinic acid (10.2% vs 22.2%, respectively; p <0.001).
Tredaptive contains 1,000 mg of nicotinic acid and 20 mg of laropiprant in each tablet. The starting dose is one tablet once a day. After four weeks, it is recommended that patients be advanced to the maintenance dose of 2,000 mg/ 40 mg taken as two tablets once daily.
Report calls for improvements in statin prescribing and CVD risk reduction in poorest areas
A renewed drive to cut numbers of people with cardiovascular disease (CVD), which is still responsible for one in three deaths in England, is called for in a recent report from the Care Quality Commission (CQC), the independent health regulator. The report, Closing the gap, welcomes the reduction in CVD death rates already achieved, driven by reductions in both smoking and cholesterol levels, meeting the target of reducing total deaths among people under 75 by at least 40% by 2010. But the Commission points out that the UK still has one of the highest CVD rates in Europe, and warns that patients get different standards of care in different parts of the country. The regulator analysed data on 8,300 practices and 152 primary care trusts in statin prescribing, cholesterol management and smoking cessation.
Findings include:
-¢ Incentives to manage cholesterol levels have improved performance and there is now room for more stretching goals.
-¢ In 2007/8, overall, 83% of patients with coronary heart disease were recorded as having an acceptable cholesterol level, compared with 72% in 2004/5. Practices currently get maximum payment when they record acceptable cholesterol levels for 70% of patients on the register. This has improved but the report shows this is levelling off, so the CQC recommends increasing the payment threshold. It argues that nearly one in five patients on heart disease registers does not have their cholesterol levels recorded as being acceptable.
-¢ There is still too much unrecorded CVD and this is a particular problem in the most deprived areas of the country. The audit showed that practices in deprived areas were less likely to record whether someone has CVD. The median unrecorded prevalence across PCTs was 1.1% of the total population, which suggests that around 350,000 people in England with CVD are not recorded. But in the most deprived areas, up to 7% of the population with CVD was unrecorded. The CQC suggests PCTs should use outreach programmes to target people at most risk when commissioning practices to carry out vascular screening.
-¢ Higher than recommended rates of prescribing of branded statins. The Commission found that some practices were not reaching the recommended level of generic statin prescribing (78%). It suggests that PCTs ‘should strongly encourage practices to prescribe non-branded statins, where clinically appropriate, and monitor this systematically’. PCTs should feed back to practices any inequalities in prescribing and take action where necessary to ensure prescribing is cost-efficient.
-¢ Practices in deprived areas are less likely to prescribe nicotine replacement products to patients. Smoking rates have fallen from 28% of the population in 1998 to 21% in 2006, but this masks variations across the population. The audit has shown that, in deprived areas, the prescribing of nicotine replacement products does not increase in line with higher smoking prevalence. The Commission recommends extending QOF indicators so that all smokers registered with a practice are offered advice or referral to NHS stop smoking services, as well as medicines that are proven to help.
-¢ Stop smoking services in deprived areas need to find more innovative ways of helping people stay off cigarettes.
Approximately one in five PCTs (37 out of 152) failed to meet NICE guidance that they should get 5% of the smoking population to take advantage of stop smoking services. There was also too much variation between trusts in recruitment and quit rates, with the proportion of people who quit for four weeks ranging from 33% in one PCT to more than 80% in another, with quit rates lower in more deprived areas.
New smoking quit kit
The NHS has launched an innovative free Quit Kit to give smokers the right tools to help them successfully stop smoking. The NHS Stop Smoking Quit Kit, which has been designed by experts and smokers, contains calming audio downloads, a ‘stress toy’ and a tool to help smokers work out how much money they are saving by quitting. A recent survey of smokers in the East of England showed that nearly half (44%) wanted help to manage cravings, one third of smokers wanted tools and advice to strengthen willpower and 30% simply want something to do with their hands. Nicotine gum and patches were the most popular aids to quitting, with 30% of smokers planning on using a nicotine replacement therapy (NRT) such as gum or patches this New Year. The new free Quit Kit contains tools that have either been scientifically proven to help reduce cravings or have been developed in response to smokers’ needs. It includes:
· a “train to win” willpower assessor helping quitters to identify smoking triggers and providing tips on how to avoid them;
· two MP3 downloads that are scientifically proven to reduce cravings;
· a “tangle” – a new stress-relieving distraction tool for the hands, to help manage cravings;
· a toothbrush – to remind quitters of the benefits of fresher breath and so they can see the difference when they brush (smokers get a yellow residue on their toothbrush);
· a health/wealth wheel to work out how much money quitters can save and the immediate health benefits of quitting smoking;
· an A3 “Quit plan” wall chart so that quitters can mark their progress over 28 days and stay focused;
· details of local NHS Stop Smoking Services, where people can access NRT and stop smoking medicines, and tailored support – either through one-to-one or group sessions.
The free Quit Kits are being publicised in a series of adverts that show smokers how the right tools for the job can help them stop smoking. These are running alongside a powerful advertising campaign aimed at motivating smokers to quit by demonstrating how much their smoking affects their loved ones.
Prevention review
Sexual activity and erectile dysfunction in men with cardiovascular disease: assessing and managing riskProfessor Michael Kirby
This article reviews latest recommendations on how to assess the risk of sexual activity in men with cardiovascular disease (CVD), and how to safely manage erectile dysfunction (ED) in these patients.
Concise consultation
Assessing cardiovascular risk in the 10-minute consultationSafia Debar, Simon de Lusignan, Juan Carlos Kaski
Cardiovascular disease is a major cause of mortality and morbidity which can be managed successfully in primary care. However, despite the quality of the evidence base and the universal use of practice-based information systems that can flag suboptimally managed patients and calculate risk for individuals opportunistically, there remains a gap in the primary care management of cardiovascular disease.
New drug review
Tredaptive: treating raised LDL-cholesterol and beyondGeorge Kassianos
Significant reductions in cardiovascular risk have been achieved over the past 20 years using statins to reduce levels of low-density lipoprotein (LDL) cholesterol and total cholesterol. However, there is growing evidence that managing only this lipid fraction may not optimally reduce patients’ CVD risk, particularly in those with type 2 diabetes or the metabolic syndrome. Low levels of high-density lipoprotein (HDL) cholesterol and raised triglycerides are important, but often overlooked, elements of the dyslipidaemic profile that commonly occur in these patients. Tredaptive offers the potential for reaching optimal nicotinic acid dosage and thereby a convenient option for achieving significant improvements on all three fronts of lipid modification – LDL cholesterol, HDL cholesterol and triglycerides, primarily because of significant reduction in the most troublesome sideeffect of nicotinic acid, facial flushing.
Hot topic review
How to estimate cardiovascular risk in practicePaul Durrington
The assessment of cardiovascular disease (CVD) risk is important in clinical practice in order to deploy statins, antihypertensive agents and aspirin most effectively and with the greatest likelihood that such treatment will confer benefit rather than harm.
Is general practice the optimal setting for the recognition of statin-induced myotoxicity?
David Sciberras, Victor Robinson, Neville Calleja
: Previous research has shown that routine monitoring appears to add little to the prognostication of incipient statininduced myotoxicity (SIM) in the primary care setting. In view of this, and the fact that there are now millions of patients on statins, it seems of practical value to delve deeper into the symptomatology of SIM. : To estimate the prevalence of SIM in statin users as compared to non-users, and whether family practice is the ideal setting to identify SIM.
Is general practice the optimal setting for the recognition of statin-induced myotoxicity?
Previous research has shown that routine monitoring appears to add little to the prognostication of incipient statininduced myotoxicity (SIM) in the primary care setting. In view of this, and the fact that there are now millions of patients on statins, it seems of practical value to delve deeper into the symptomatology of SIM. : To estimate the prevalence of SIM in statin users as compared to non-users, and whether family practice is the ideal setting to identify SIM.
hands on
Diabetes affects approximately 3-4% of the British population but is thought to be significantly under-diagnosed. How can we improve the number of patients who are diagnosed early and so improve their risk of long-term complications?
