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INTRODUCTION: Blood pressure (BP) is normally measured on the upper arm, and guidelines for the diagnosis and treatment of high BP are based on such measurements. Leg BP measurement can be an alternative when brachial BP measurement is impractical, due to injury or disability. Limited data exist to guide interpretation of leg BP values for hypertension management; study-level systematic review findings suggest that systolic BP (SBP) is 17 mm Hg higher in the leg than the arm. However, uncertainty remains about the applicability of this figure in clinical practice due to substantial heterogeneity. AIMS: To examine the relationship between arm and leg SBP, develop and validate a multivariable model predicting arm SBP from leg SBP and investigate the prognostic association between leg SBP and cardiovascular disease and mortality. METHODS AND ANALYSIS: Individual participant data (IPD) meta-analyses using arm and leg SBP measurements for 33 710 individuals from 14 studies within the Inter-arm blood pressure difference IPD (INTERPRESS-IPD) Collaboration. We will explore cross-sectional relationships between arm and leg SBP using hierarchical linear regression with participants nested by study, in multivariable models. Prognostic models will be derived for all-cause and cardiovascular mortality and cardiovascular events. ETHICS AND DISSEMINATION: Data originate from studies with prior ethical approval and consent, and data sharing agreements are in place-no further approvals are required to undertake the secondary analyses proposed in this protocol. Findings will be published in peer-reviewed journal articles and presented at conferences. A comprehensive dissemination strategy is in place, integrated with patient and public involvement. PROSPERO REGISTRATION NUMBER: CRD42015031227.
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Hipertensión , Pierna , Presión Sanguínea , Determinación de la Presión Sanguínea , Estudios Transversales , Humanos , Hipertensión/diagnóstico , Metaanálisis como AsuntoAsunto(s)
Brazo , Hipertensión , Presión Sanguínea , Determinación de la Presión Sanguínea , Humanos , Hipertensión/diagnóstico , PiernaRESUMEN
An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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BACKGROUND: The original Manchester Acute Coronary Syndromes model (MACS) 'rules in' and 'rules out' acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as Troponin-only Manchester Acute Coronary Syndromes (T-MACS), cutting down the biomarkers to just hs-cTnT. METHODS: We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the ED with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularisation within 30â days. T-MACS was built in one cohort (derivation set) and validated in three external cohorts (validation set). RESULTS: At the 'rule out' threshold, in the derivation set (n=703), T-MACS had 99.3% (95% CI 97.3% to 99.9%) negative predictive value (NPV) and 98.7% (95.3%-99.8%) sensitivity for ACS, 'ruling out' 37.7% patients (specificity 47.6%, positive predictive value (PPV) 34.0%). In the validation set (n=1459), T-MACS had 99.3% (98.3%-99.8%) NPV and 98.1% (95.2%-99.5%) sensitivity, 'ruling out' 40.4% (n=590) patients (specificity 47.0%, PPV 23.9%). T-MACS would 'rule in' 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs MACS 0.90 on validation). CONCLUSIONS: T-MACS could 'rule out' ACS in 40% of patients, while 'ruling in' 5% at highest risk using a single hs-cTnT measurement on arrival. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources.
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Síndrome Coronario Agudo/diagnóstico , Técnicas de Apoyo para la Decisión , Troponina T/análisis , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/análisis , Biomarcadores/sangre , Estudios de Cohortes , Servicio de Urgencia en Hospital/organización & administración , Proteína 3 de Unión a Ácidos Grasos/análisis , Proteína 3 de Unión a Ácidos Grasos/sangre , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Estudios Prospectivos , Troponina T/sangreRESUMEN
BACKGROUND: In previous studies including patients with suspected cardiac chest pain, those who had acute myocardial infarction (AMI) reported more severe chest pain than those without AMI. However, many patients with AMI present with very mild pain or discomfort. We aimed to investigate whether peak pain severity, as reported by patients in the Emergency Department, has any potential role in the risk stratification of patients with suspected cardiac chest pain. METHODS: In this secondary analysis from a prospective diagnostic cohort study, we included patients presenting to the Emergency Department with suspected cardiac chest pain. Patients were asked to report their maximum pain severity using a 11-point numeric rating scale at the time of initial presentation. The primary outcome was a diagnosis of AMI, adjudicated by two independent investigators on the basis of reference standard (12 h) troponin testing. RESULTS: Of the 455 patients included in this analysis, 79 (17.4%) had AMI. Patients with AMI had marginally higher pain scores (eight, interquartile range 5-8) than those without AMI (seven, interquartile range 6-8, P=0.03). However, the area under the receiver operating characteristic curve for the numeric rating scale pain score was 0.58 (95% confidence interval 0.51-0.65), indicating poor overall diagnostic accuracy. AMI occurred in 12.1% of patients with pain score 0-3, 17.1% with pain score 4-6 and 18.8% with pain score 7-10. Among patients with AMI, pain score was not correlated with 12-h troponin levels (r=-0.001, P=0.99). CONCLUSION: Pain score has limited diagnostic value for AMI. Scores should guide analgesia but shift the probability of AMI very little, and should not guide other clinical management.
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Dolor en el Pecho/etiología , Infarto del Miocardio/diagnóstico , Anciano , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Dimensión del Dolor , Estudios ProspectivosRESUMEN
BACKGROUND: Initial reports suggest that concentrations of high-sensitivity cardiac troponin T (hs-cTnT) (Roche Diagnostics Elecsys(®)) below the limit of blank (LoB) (3 ng/L) or limit of detection (LoD) (5 ng/L) of the assay have almost 100% negative predictive value (NPV) for acute myocardial infarction (AMI), particularly among patients without electrocardiograph (ECG) evidence of ischemia. We aimed to prospectively validate those findings. METHODS: We included adults presenting to the emergency department with suspected cardiac chest pain. Standard troponin T (cTnT) and hs-cTnT (both Roche Elecsys) were tested in samples drawn on arrival. The primary outcome was AMI, adjudicated by 2 investigators on the basis of clinical data and ≥12-h cTnT testing. We also evaluated diagnostic performance when AMI was readjudicated on the basis of hs-cTnT (≥12-h) concentrations. RESULTS: Of 463 patients included, 79 (17.1%) had AMI. Twenty-four patients (5.2%) had hs-cTnT concentrations below the LoB, although none had AMI. Ninety-six patients (20.7%) had hs-cTnT concentrations below the LoD, 1 of whom had AMI. Thus, diagnostic sensitivity was 98.7% (95% CI 87.5%-98.6%) and NPV was 99.0% (95% CI 94.3%-100.0%). Of the 17.3% (n = 80) patients with hs-cTnT below the LoD and no ECG ischemia, none had AMI. Thus, diagnostic sensitivity was 100.0% (95% CI 95.4%-100.0%) and NPV was 100.0% (95% CI 95.5%-100.0%). Sensitivity and NPV were maintained when AMI was readjudicated on the basis of hs-cTnT. CONCLUSIONS: Our findings confirm that patients with nonischemic ECG and undetectable hs-cTnT at presentation have a very low probability of AMI, although the proportion of patients affected was smaller than in previous research.
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Biomarcadores/sangre , Infarto del Miocardio/diagnóstico , Troponina T/sangre , Enfermedad Aguda , Anciano , Dolor en el Pecho/diagnóstico , Electrocardiografía , Femenino , Humanos , Tiempo de Internación , Límite de Detección , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: With a high-sensitivity troponin assay, it may be possible to exclude acute myocardial infarction with a single blood test on arrival in the emergency department by using a novel 'rule out' cut-off set at the limit of detection of the assay. We aimed to determine whether this can also be achieved using a contemporary sensitive troponin assay that does not meet 'high-sensitivity' criteria. METHODS: In a prospective diagnostic cohort study, we included patients presenting to the emergency department with suspected cardiac chest pain. For this secondary analysis, serum samples drawn on arrival were tested using a contemporary sensitive troponin I assay (s-cTnI; Siemens Ultra ADVIA Centaur, 99th percentile 40 ng/L, limit of detection 6 ng/L). Acute myocardial infarction was adjudicated by two independent investigators based on reference standard troponin testing ≥12 h after symptom onset. RESULTS: Of 414 participants, 70 (16.9%) had acute myocardial infarction and 205 (49.5%) had initial s-cTnI concentrations below the limit of detection. Using the limit of detection as a 'rule out' cut-off gave a sensitivity of 94.3% (95% CI 86.0-98.4%) for acute myocardial infarction. If only patients with s-cTnI below the limit of detection and no electrocardiogram ischaemia were considered to have acute myocardial infarction 'ruled out' (41.8% of the cohort, n = 174), sensitivity would rise to 97.1% (90.1-99.7%) and negative predictive value to 98.8% (95.9-99.9%). CONCLUSIONS: Acute myocardial infarction cannot be excluded in patients with s-cTnI concentrations below the limit of detection using the contemporary sensitive assay evaluated. Future work with this assay should focus on serial sampling over 1-3 h and combination with clinical information and/or additional biomarkers.
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Servicio de Urgencia en Hospital/normas , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico , Troponina I/sangre , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Dolor en el Pecho/sangre , Dolor en el Pecho/diagnóstico , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de TiempoRESUMEN
OBJECTIVE: The Manchester Acute Coronary Syndromes (MACS) decision rule may enable acute coronary syndromes to be immediately 'ruled in' or 'ruled out' in the emergency department. The rule incorporates heart-type fatty acid binding protein (h-FABP) and high sensitivity troponin T levels. The rule was previously validated using a semiautomated h-FABP assay that was not practical for clinical implementation. We aimed to validate the rule with an automated h-FABP assay that could be used clinically. METHODS: In this prospective diagnostic cohort study we included patients presenting to the emergency department with suspected cardiac chest pain. Serum drawn on arrival was tested for h-FABP using an automated immunoturbidimetric assay (Randox) and high sensitivity troponin T (Roche). The primary outcome, a diagnosis of acute myocardial infarction (AMI), was adjudicated based on 12 h troponin testing. A secondary outcome, major adverse cardiac events (MACE; death, AMI, revascularisation or new coronary stenosis), was determined at 30 days. RESULTS: Of the 456 patients included, 78 (17.1%) had AMI and 97 (21.3%) developed MACE. Using the automated h-FABP assay, the MACS rule had the same C-statistic for MACE as the original rule (0.91; 95% CI 0.88 to 0.92). 18.9% of patients were identified as 'very low risk' and thus eligible for immediate discharge with no missed AMIs and a 2.3% incidence of MACE (n=2, both coronary stenoses). 11.1% of patients were classed as 'high-risk' and had a 92.0% incidence of MACE. CONCLUSIONS: Our findings validate the performance of a refined MACS rule incorporating an automated h-FABP assay, facilitating use in clinical settings. The effectiveness of this refined rule should be verified in an interventional trial prior to implementation. TRIAL REGISTRATION NUMBER: UK CRN 8376.
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Síndrome Coronario Agudo/diagnóstico , Técnicas de Apoyo para la Decisión , Proteínas de Unión a Ácidos Grasos/sangre , Síndrome Coronario Agudo/sangre , Adulto , Anciano , Biomarcadores/sangre , Dolor en el Pecho/diagnóstico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Proteína 3 de Unión a Ácidos Grasos , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Estudios Prospectivos , Curva ROC , Sensibilidad y Especificidad , Troponina I/sangre , Troponina T/sangreRESUMEN
OBJECTIVE: No universally accepted guideline exists for measurement of blood pressure for patients confined to bed. The aim was to establish areas of technique that might be open to standardization to improve measurement reliability similar to those used for office BP measurements. METHODS: In-patient blood pressure measurement (IPBPM) was closely observed in 100 patients in a variety of medical wards during routine vital signs observation rounds, comparing the methods observed with current office BPM guidelines. RESULTS: IPBPM, always taken initially with automated machines, was measured once only in 96% of patients. Around 7% patients were lying flat, 32% semi-reclined, 24% had their back unsupported, 15% crossed legs, 9% arms unsupported, 65% arm below heart level, 4% above, 36% incorrect cuff size for arm circumference, 43% bladder not centred over brachial artery and 14% had arrhythmia not documented by ward staff during the measurement. Staff and patients were conversing during 41% measurements. CONCLUSION: There is a lack of standardization of automated IPBPM technique including a failure to adhere to principles of measurement already established for office BP in a majority (97%) of patients. This may lead to potentially erroneous BP readings, which are an unreliable basis for clinical interpretation and decision making. There is a need for universal hospital-specific guidelines for IPBPM and programmes to train and monitor staff for adherence to these. Particular attention should be given to those factors well known to affect blood pressure measurement, including correct cuff size and placement, arm position and absence of talking during measurement as well as only using validated machines. Additional recommendations might include the routine use of manual BP readings where appropriate (such as with very low or irregular heart rates), BP measured in both arms on admission and the arm with the highest BP used thereafter and recording the side of IPBPM and patient position. We recommend that a task force is commissioned to develop universal guidelines for this important part of clinical assessment.
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Determinación de la Presión Sanguínea/normas , Presión Sanguínea , Guías de Práctica Clínica como Asunto , Adulto , Brazo , Reposo en Cama , Arteria Braquial , Femenino , Corazón , Humanos , Pacientes Internos , Pierna , Masculino , Auditoría Médica , Persona de Mediana Edad , Reproducibilidad de los ResultadosRESUMEN
OBJECTIVE: To determine the diagnostic accuracy of emergency physician gestalt in emergency department (ED) patients with suspected cardiac chest pain, both alone and in combination with initial troponin level and ECG findings. METHODS: We prospectively included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded their 'gestalt' at the time of presentation using a five-point Likert scale, blinded to outcome. Troponin T and high-sensitivity troponin T (hs-cTnT; both Roche Diagnostics Elecsys) levels were measured in admission blood samples. All patients underwent troponin testing at least 12â h after peak symptoms. The primary outcome was acute myocardial infarction (AMI). RESULTS: 458 patients were included in this study, 81 (17.7%) of whom had AMI. Clinician gestalt alone had an area under the receiver operating characteristic curve of 0.76 (95% CI 0.70 to 0.82) for AMI. Immediately discharging patients with normal initial troponin and ECG in whom the clinician felt the diagnosis was 'probably not' or 'definitely not' acute coronary syndrome (ACS) would have avoided admission for 23.1% (95% CI 19% to 28%) patients with 100% sensitivity (95% CI 95.6% to 100%). With hs-cTnT, 100% sensitivity could have been achieved even if only patients with 'probable' or 'definite' ACS were investigated further, which would have allowed 41.7% patients to be discharged immediately. CONCLUSIONS: Gestalt alone cannot be used to 'rule in' or 'rule out' ACS. By combining clinician gestalt with the admission ECG and troponin level, we found 100% sensitivity without the need for serial troponin testing. These findings have the potential to reduce unnecessary hospital admissions for suspected ACS but must be prospectively validated before considering clinical implementation.
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Competencia Clínica , Medicina de Emergencia , Infarto del Miocardio/diagnóstico , Biomarcadores/sangre , Diagnóstico Diferencial , Electrocardiografía , Humanos , Infarto del Miocardio/sangre , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , Troponina T/sangreRESUMEN
OBJECTIVE: We aimed to derive and validate a clinical decision rule (CDR) for suspected cardiac chest pain in the emergency department (ED). Incorporating information available at the time of first presentation, this CDR would effectively risk-stratify patients and immediately identify: (A) patients for whom hospitalisation may be safely avoided; and (B) high-risk patients, facilitating judicious use of resources. METHODS: In two sequential prospective observational cohort studies at heterogeneous centres, we included ED patients with suspected cardiac chest pain. We recorded clinical features and drew blood on arrival. The primary outcome was major adverse cardiac events (MACE) (death, prevalent or incident acute myocardial infarction, coronary revascularisation or new coronary stenosis >50%) within 30 days. The CDR was derived by logistic regression, considering reliable (κ>0.6) univariate predictors (p<0.05) for inclusion. RESULTS: In the derivation study (n=698) we derived a CDR including eight variables (high sensitivity troponin T; heart-type fatty acid binding protein; ECG ischaemia; diaphoresis observed; vomiting; pain radiation to right arm/shoulder; worsening angina; hypotension), which had a C-statistic of 0.95 (95% CI 0.93 to 0.97) implying near perfect diagnostic performance. On external validation (n=463) the CDR identified 27.0% of patients as 'very low risk' and potentially suitable for discharge from the ED. 0.0% of these patients had prevalent acute myocardial infarction and 1.6% developed MACE (n=2; both coronary stenoses without revascularisation). 9.9% of patients were classified as 'high-risk', 95.7% of whom developed MACE. CONCLUSIONS: The Manchester Acute Coronary Syndromes (MACS) rule has the potential to safely reduce unnecessary hospital admissions and facilitate judicious use of high dependency resources.
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Síndrome Coronario Agudo/diagnóstico , Técnicas de Apoyo para la Decisión , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/terapia , Adulto , Anciano , Biomarcadores/metabolismo , Servicio de Urgencia en Hospital , Inglaterra/epidemiología , Hospitalización , Humanos , Incidencia , Modelos Logísticos , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Revascularización Miocárdica , Alta del Paciente , Selección de Paciente , Valor Predictivo de las Pruebas , Prevalencia , Pronóstico , Estudios Prospectivos , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Procedimientos InnecesariosRESUMEN
BACKGROUND: Individuals of lower socioeconomic status have an adverse cardiovascular disease risk factor profile. We examined whether deprivation status influences within-individual change over time in blood pressure (BP), cholesterol and smoking status during middle life. METHODS: Records of participants of a primary care-based cardiovascular disease risk factor screening programme who were aged 35-55 years and had a first screening episode between 1989 and 1993 and a subsequent screening episode, were analysed. Deprivation status was defined using quintiles of the Townsend score. Using regression, mean annual change in BP, and total cholesterol was calculated for each deprivation group; and the effect of deprivation group status was examined. The probability of quitting smoking was also examined by deprivation group. RESULTS: Of all participants, 13,812 (72.1%) men and 16 932 (77.0%) women had complete follow-up (i.e. two screening episodes). Mean annual increase in systolic BP was significantly greater with increasing deprivation group [by +0.24 and +0.28 mmHg/incremental deprivation group in men and women, respectively (95% confidence interval: +0.09 to +0.39 men, and +0.13 to +0.42 women)]. Deprivation status did not influence change in cholesterol (P=0.620, men, P=0.289, women). The probability of quitting smoking was significantly greater with increasing deprivation group in women [odds ratio 1.06 (95% confidence interval: 1.01-1.12)], but no effect was observed in men (P=0.389). DISCUSSION: The results are suggestive of a 'mixed' picture of widening (e.g. systolic and diastolic BP) as well as narrowing (e.g. smoking in women) socioeconomic inequalities in cardiovascular risk factor inequalities.
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Presión Sanguínea/fisiología , Índice de Masa Corporal , Enfermedades Cardiovasculares/epidemiología , Colesterol/sangre , Fumar/epidemiología , Adulto , Factores de Edad , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Prevalencia , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Distribución por Sexo , Factores Socioeconómicos , Factores de Tiempo , Reino Unido/epidemiologíaAsunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Bloqueadores de los Canales de Calcio/uso terapéutico , Hipertensión/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Antagonistas Adrenérgicos beta/economía , Adulto , Antagonistas de Receptores de Angiotensina , Inhibidores de la Enzima Convertidora de Angiotensina/economía , Bloqueadores de los Canales de Calcio/economía , Análisis Costo-Beneficio , Femenino , Humanos , Hipertensión/economía , Masculino , Persona de Mediana Edad , EmbarazoRESUMEN
BACKGROUND: Individuals of South-Asian origin have a comparatively higher cardiovascular disease burden, but there is uncertainty about whether this is due to differences in risk factor levels and trends. We therefore studied comparative levels and time trends in blood pressure (BP), total cholesterol, body mass index (BMI) and current smoking among UK Caucasian and South-Asian individuals. METHODS: Repeatable cross-sectional survey of men and women aged 35-60 attending for first screening as part of a primary-care based cardiovascular risk factor screening programme 1989 and 1999. RESULTS: Of 34,122 men and 37,294 women participants, 499 men (1.5%)and 381 women (1%) were of South-Asian origin. South-Asian men had lower systolic [(-4.91 mmHg (95% Confidence Iterval (CI): -3.58 to -6.23)] and diastolic BP [-2.87 mmHg (-2.02 to -3.72)], with no significant differences in cholesterol and BMI. South-Asian women had lower systolic BP [-1.77 mmHg, 95% (-0.21 to -3.33)], diastolic BP [-1.87 mmHg (-0.92 to -2.82)], cholesterol [-0.24 mmol/l (-0.08 to -0.39)]; and higher BMI [+0.78 kg/m2 (0.25 to 1.3)]. South-Asian men and women had significantly lower prevalence of self-reported current smoking (29.0% and 1.8% respectively). With the exception of self-reported current smoking, between ethnic group risk factor trends were not converging. CONCLUSION: With the exception of women's BMI, South-Asian individuals had either lower or similar levels of the examined cardiovascular risk factor levels, compared with Caucasian individuals. Although time trends in smoking were converging, other risk factors trends were similar between the two ethnic groups. Overall the findings do not support the hypothesis that the relatively high cardiovascular disease burden in UK South-Asians is due to higher levels exposure to the examined risk factors. Other hypotheses, such as higher frequency of diabetes and increased genetic predisposition, require further exploration.
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Enfermedades Cardiovasculares/etnología , Tamizaje Masivo , Nativos de Hawái y Otras Islas del Pacífico/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Medición de Riesgo , Población Blanca/estadística & datos numéricos , Adulto , Consumo de Bebidas Alcohólicas/etnología , Asia Sudoriental/etnología , Presión Sanguínea/fisiología , Índice de Masa Corporal , Enfermedades Cardiovasculares/epidemiología , Colesterol/sangre , Femenino , Humanos , Hipertensión/etnología , Masculino , Persona de Mediana Edad , Prevalencia , Factores de Riesgo , Fumar/etnología , Reino Unido/epidemiologíaRESUMEN
BACKGROUND: In the UK, obesity is associated with a clear socioeconomic gradient, with individuals of lower socioeconomic status being more likely to be obese. Several previous studies, using individual measures of soecioeconomic status, have shown a more rapid increase in Body Mass Index (BMI) over time among adults of lower socioeconomic status. We conducted a study to further examine whether ecologically defined deprivation status influences within-individual BMI change during middle life, as the answer to this question can help determine optimal preventive strategies both for obesity per se, and its' associated socioeconomic disparities. METHODS: Anonymised records of participants to the Stockport population-based cardiovascular disease risk factor screening programme were analysed. Individuals aged 35-55 who had a first screening episode between 1989 and 1993, and a subsequent screening episode were included in the study. Deprivation status was defined using quintiles of the Townsend score. Mean annual BMI change by deprivation group was calculated using linear regression. Subsequently, deprivation group was included in the model as an ordinal variable, to test for trend. The modelling was repeated separately for individuals who were obese (BMI < 30) and non-obese at the time of first screening. In supplementary analysis, regression models were also adjusted for baseline BMI. RESULTS: Of 21,976 women and 19,158 men initially screened, final analysis included just over half of all individuals [11,158 (50.8%) women and 9,831 (51.3%) men], due to the combined effect of loss to follow-up and incomplete BMI ascertainment. In both sexes BMI increased by 0.19 kg/m2 annually (95% Confidence Intervals 0.15-0.24 for women and 0.16-0.23 for men). All deprivation groups had similar mean annual change, and there was no evidence of a significant deprivation trend (p = 0.801, women and 0.892, men). Restricting the analysis to individuals who were non-obese at baseline did not alter the results in relation to the lack of a deprivation effect. When restricting the analysis to individuals who were obese at baseline however, the findings were suggestive of an association of BMI increase with higher deprivation group, which was further supported by a significant association when adjusting for baseline BMI. CONCLUSION: In the study setting, the BMI of non-obese individuals aged 35-55 was increasing over time independently of deprivation status; among obese individuals a positive association with higher deprivation was found. The findings support that socioeconomic differences in mean BMI and obesity status are principally attained prior to 35 years of age. Efforts to tackle inequalities in mean BMI and obesity status should principally concentrate in earlier life periods, although there may still be scope for focusing inequality reduction efforts on obese individuals even in middle life.
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Índice de Masa Corporal , Tamizaje Masivo , Obesidad/epidemiología , Clase Social , Poblaciones Vulnerables/estadística & datos numéricos , Aumento de Peso , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Obesidad/economía , Calidad de Vida , Análisis de Regresión , Encuestas y Cuestionarios , Reino Unido/epidemiologíaRESUMEN
Limb blood flow is widely used as an indicator of the human vascular properties. There are only few non-invasive methods for its measurement such as venous occlusion plethysmography. However, several authors have questioned its validity. The problems appear to be related to the process of venous occlusion. We developed two methods to measure forearm blood flow by plethysmography without venous occlusion in combination with Doppler velocimetry (without imaging). Method 1: the gradient of a tangent drawn on the latter part of the down stroke of the plethysmographic volume pulse is an approximation of venous blood flow in the absence of diastolic blood flow. At equilibrium, it equals the average arterial flow in a cardiac cycle. The Doppler velocity waveform recorded simultaneously allows improvement of this approximation when there is diastolic blood flow. Method 2: the volume pulse detected by a plethysmograph calibrated in absolute volume is used to calibrate the velocity waveform recorded simultaneously to produce an approximation of arterial volumetric flow waveform. Bland-Altman analysis shows both methods have good correlation and agreement with venous occlusion plethysmography at rest. Method 1: mean difference (blood flow measured by venous occlusion minus calculated flow) = 0.10 ml/pulse (+/-0.18), limits of agreement = -0.41 and 0.61 ml/pulse. Method 2: mean difference = -0.041 ml/pulse (+/-0.15), limits of agreement = -0.45 and 0.37 ml/pulse. During hyperaemia, venous occlusion plethysmography grossly underestimated relative to the new methods. The new methods are not dependent on venous occlusion and produce consistent results with or without hyperaemia.
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Algoritmos , Velocidad del Flujo Sanguíneo/fisiología , Antebrazo/irrigación sanguínea , Antebrazo/diagnóstico por imagen , Interpretación de Imagen Asistida por Computador/métodos , Pletismografía/métodos , Ultrasonografía Doppler de Pulso/métodos , Adulto , Femenino , Antebrazo/fisiología , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether clopidogrel is superior to aspirin in preventing adverse events post coronary arterial bypass grafting. Altogether 220 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that if aspirin is not tolerated, clopidogrel is an acceptable alternative, but there is no strong evidence that clopidogrel is superior to aspirin postcoronary surgery.
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether an early invasive approach (involving early coronary angiography followed by revascularisation if suitable) is superior to a conservative approach (with revascularisation only in patients with failed medical therapy) in patients with acute coronary syndrome. Altogether 282 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that in patients diagnosed with acute coronary syndrome, an early invasive approach is clearly superior to a conservative approach.
RESUMEN
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether Troponin I or T can effectively diagnose a perioperative myocardial infarction after cardiac surgery. Altogether 191 papers were found using the reported search, of which 17 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that Troponin I and T can both be used to indicate myocardial damage, with the level correlating well with the level of injury. However until issues such as a 'gold standard' for peri-operative MI are addressed, one single cut-off point cannot be recommended for either test.