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O002 Roadmap to 25x25: A Systematic Review of the Effectiveness and Cost-Effectiveness of Interventions to Improve Adherence to Cardiovascular Medications in Low- and Middle-Income Countries
ORAL ABSTRACTS
O001 Is Geography Destiny? Pre-hospital Delay in Primary Percutaneous Coronary Intervention (PCI) and Correlation with Area of Residence Arul Baradi*1, Nick Andrianopoulos2, Angela L. Brennan2, Damon K. Jackson1, Andrew Teh1, Thomas Yip3, Ernesto Oquiel4, Louise Roberts1, Gishel New1, Melanie Freeman1 1 Cardiology, Eastern Health, Box Hill, 2Cardiology, CCRET - Monash University, Melbourne, 3 Cardiology, Barwon Health, Geelong, 4Cardiology, Ballarat Health, Ballarat, Australia Introduction: Delay in access from first medical contact (system delay), resulting in increased symptom to balloon time (STBT), affects outcomes in primary PCI. Guidelines recommend a door-to-balloon-time (DTBT) of 90 minutes and now suggest a first medical contact to door time of 30 minutes. Socioeconomic status (SES), including area of residence, has been shown to impact on symptom to door time (STDT) in the USA and New Zealand. Objectives: We evaluated whether area of residence impacts on pre-hospital delay utilising a large multicenter registry. Methods: We identified 3205 consecutive patients undergoing primary PCI from the Melbourne Interventional Group registry between 2005-2011. Patients were categorised by SES derived from patient postcode using the Socio-Economic Indexes for Areas compiled by the Australian Bureau of Statistics. Patients were divided into quintiles; the most disadvantaged as Quintile 1 and the least disadvantaged as Quintile 5. Baseline data, STEMI timings and outcomes were described as a function of socioeconomic quintile, using the non-parametric trend test. Results: Those who were least disadvantaged were older, with lower BMI. Those who were more disadvantaged were more likely to have diabetes, hyperlipidaemia, and a previous MI. There were no other differences in baseline characteristics between the quintiles, including gender. Patients of lower SES were more likely to initially present to a non-PCI capable hospital and, when transferred for PCI, had significantly longer transfer times. Conclusion: Lower SES is correlated with increased symptom to door time, and hence STEMI timings and outcomes as a function of SES Median minutes (IQR) STEMI timings STDT
Lowest SES Quintile1
Quintile 2
Quintile 3
Quintile 4
Highest SES Quintile 5
p value
100 (64,188)
120 (75,224)
119 (75,203)
110 (75,180)
96 (64,165)
0.01
<0.01
STBT
200(147,276)
202(157,286)
200(149,285)
192(150,267)
188(144,260)
DTBT
80 (53,110)
75 (50,109)
72 (45,100)
74 (45,102)
80 (56,107)
0.78
MACE (%) 30-day 12-month
11
11
9
9
10
0.49
21
19
19
17
16
0.04
Conclusion: Although improving adherence to cardiovascular medications will be central to achieving the World Health Organization’s goal of 25x25, evidence about the effectiveness and cost-effectiveness of interventions to boost adherence in low- and middleincome countries is disappointingly sparse. Prospective randomized trials addressing this critical issue are urgently needed. Disclosure of Interest: None Declared O003
symptom to balloon time, in patients undergoing primary PCI in Victoria, as well as greater likelihood of requiring transfer to a PCI-capable hospital. Lower SES was associated with increased 12-month MACE. The apparent inequity for patients of different areas of residence and SES in Victoria suggests a role for public health measures including health education and improvement in system delays in lower socioeconomic areas. Disclosure of Interest: None Declared O002 Roadmap to 25x25: A Systematic Review of the Effectiveness and Cost-Effectiveness of Interventions to Improve Adherence to Cardiovascular Medications in Low- and Middle-Income Countries Arul Thangavel*1, Reto Auer2, Dhruv S. Kazi1,2,3 1 Medicine, 2Epidemiology and Biostatistics, University of California San Francsico, 3Medicine/ Cardiology, San Francisco General Hospital, San Francisco, United States Introduction: Improving adherence to cardiovascular medications will be critical to achieving the World Health Organization’s target of 25 % reduction in premature mortality from non-communicable diseases by 2025. Whether educational or m-health interventions can improve medication adherence in low- and middle-income countries is unclear. Objectives: We conducted a systematic review of all published, randomized clinical trials to evaluate the effectiveness and cost-effectiveness of interventions to boost adherence to cardiovascular medications in low- and middle- income countries. Methods: The Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase, CINAHL, WHO regional databases, PsychInfo and Web of Science were searched for eligible trials. Randomized controlled trials of community or home-based interventions to improve medication adherence in cardiovascular disease among adults in low- or middleincome contries (as defined by the IMF) were included. Results: Out of 7684 abstracts identified by the search strategy, nine trials (including 1666 patients) fulfilled inclusion criteria after full-text review. Eight trials were from Asia and one was from Africa; there were no trials from Latin America. Interventions studied included counseling (7 studies), pill-diaries (1 study), and combined interventions (1 study); no studies examined mobile phone-based interventions. Most studies were small with short follow-up (median, 6 months; IQR: 3-6months). Studies were of low quality (Jadad score: Median, 3; IQR: 2-3), with substantial differences in study definition of adherence. Quantitative synthesis of effectiveness data (see figures) showed extremely large heterogeneity between trials (I2>90%), and small, if any, improvements in adherence with the interventions. No studies evaluated cost-effectiveness.
GHEART Vol 9/1S/2014
j
March, 2014
j
ORAL/2014 WCC Orals
Vitamin D levels are associated with the presence and severity of coronary artery disease but not peripheral vascular disease in patients undergoing coronary angiography Jonathan Liew*1, Stella Sasha2, Josephine Warren2, Philip Ngu3, Anthony Dart3, James Shaw3 1 Cardiology, Monash University, Alfred Hospital Baker IDI Heart and Diabetes Institute, 2 Cardiology, Monash University, Alfred Hospital, 3Cardiology, Alfred Hospital Baker IDI Heart and Diabetes Institute, Melbourne, Australia Introduction: Although multiple risk factors for coronary artery disease (CAD) are well established, novel risk factors continue to emerge. Recent studies have shown the association between vitamin D deficiency (VDD), cardiac risk factors and CAD. Globally, VDD is a re-emerging public health problem as it is present in upto 50% of the general population. Objectives: The goal of this study is to investigate the association between VDD and extent of CAD, peripheral vascular disease (PVD) and arterial stiffness. Methods: 375 patients undergoing coronary angiography at Alfred Hospital Cardiac Catheterisation Laboratory between the period of November 2012 to Sept 2013 were prospectively recruited. We measured 25-hydroxyvitamin D (25OHD) serum levels, performed ankle brachial index (ABI) and pulse wave velocity (PWV) tests. Based on the findings of the coronary angiogram, patients were divided into subgroups: Absent, Single, Double and Triple Vessel Disease (as defined by >50% stenosis in each major coronary artery). All data are presented as mean SEM unless stated. Results: 265 patients not taking vitamin D supplements were included in the analysis. Mean age was 66.0 11.2 (mean SD). Levels of 25(OH)D were significantly lower in patients with CAD when compared with patients without CAD (57.0 1.73 versus 70.1 2.46 nnmol/L; p <0.01). One way ANOVA revealed triple vessel disease patients had significantly lower 25(OH)D levels when compared to single vessel disease patients (50.6 2.84 nmol/L versus 61.3 3.16 p<0.01)and trended to be lower when compared to double vessel disease patients (50.6 2.84 versus 59.0 2.99 nmol/L; p¼ 0.06). Patients with CAD had negative correlation with serum 25(OH)D levels (r¼ -0.263; p<0.01), positive correlation with age (r¼ 0.205; p<0.01) and pulse wave velocity (r¼ 0.198 and 0.252 respectively; p <0.01). However, there was no correlation between 25(OH)D levels, ABI and PWV (p > 0.05). Conclusion: Low levels of Vitamin D are associated with the presence and extent of angiographic CAD but not arterial stiffness or PVD. Further studies should be conducted to determine whether vitamin D supplementation prevents the development and progression of CAD. Disclosure of Interest: None Declared
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O001 Is Geography Destiny? Pre-hospital Delay in Primary Percutaneous Coronary Intervention (PCI) and Correlation with Area of Residence Arul Baradi*1, Nick Andrianopoulos2, Angela L. Brennan2, Damon K. Jackson1, Andrew Teh1, Thomas Yip3, Ernesto Oquiel4, Louise Roberts1, Gishel New1, Melanie Freeman1 1 Cardiology, Eastern Health, Box Hill, 2Cardiology, CCRET - Monash University, Melbourne, 3 Cardiology, Barwon Health, Geelong, 4Cardiology, Ballarat Health, Ballarat, Australia Introduction: Delay in access from first medical contact (system delay), resulting in increased symptom to balloon time (STBT), affects outcomes in primary PCI. Guidelines recommend a door-to-balloon-time (DTBT) of 90 minutes and now suggest a first medical contact to door time of 30 minutes. Socioeconomic status (SES), including area of residence, has been shown to impact on symptom to door time (STDT) in the USA and New Zealand. Objectives: We evaluated whether area of residence impacts on pre-hospital delay utilising a large multicenter registry. Methods: We identified 3205 consecutive patients undergoing primary PCI from the Melbourne Interventional Group registry between 2005-2011. Patients were categorised by SES derived from patient postcode using the Socio-Economic Indexes for Areas compiled by the Australian Bureau of Statistics. Patients were divided into quintiles; the most disadvantaged as Quintile 1 and the least disadvantaged as Quintile 5. Baseline data, STEMI timings and outcomes were described as a function of socioeconomic quintile, using the non-parametric trend test. Results: Those who were least disadvantaged were older, with lower BMI. Those who were more disadvantaged were more likely to have diabetes, hyperlipidaemia, and a previous MI. There were no other differences in baseline characteristics between the quintiles, including gender. Patients of lower SES were more likely to initially present to a non-PCI capable hospital and, when transferred for PCI, had significantly longer transfer times. Conclusion: Lower SES is correlated with increased symptom to door time, and hence STEMI timings and outcomes as a function of SES Median minutes (IQR) STEMI timings STDT
Lowest SES Quintile1
Quintile 2
Quintile 3
Quintile 4
Highest SES Quintile 5
p value
100 (64,188)
120 (75,224)
119 (75,203)
110 (75,180)
96 (64,165)
0.01
<0.01
STBT
200(147,276)
202(157,286)
200(149,285)
192(150,267)
188(144,260)
DTBT
80 (53,110)
75 (50,109)
72 (45,100)
74 (45,102)
80 (56,107)
0.78
MACE (%) 30-day 12-month
11
11
9
9
10
0.49
21
19
19
17
16
0.04
Conclusion: Although improving adherence to cardiovascular medications will be central to achieving the World Health Organization’s goal of 25x25, evidence about the effectiveness and cost-effectiveness of interventions to boost adherence in low- and middleincome countries is disappointingly sparse. Prospective randomized trials addressing this critical issue are urgently needed. Disclosure of Interest: None Declared O003
symptom to balloon time, in patients undergoing primary PCI in Victoria, as well as greater likelihood of requiring transfer to a PCI-capable hospital. Lower SES was associated with increased 12-month MACE. The apparent inequity for patients of different areas of residence and SES in Victoria suggests a role for public health measures including health education and improvement in system delays in lower socioeconomic areas. Disclosure of Interest: None Declared O002 Roadmap to 25x25: A Systematic Review of the Effectiveness and Cost-Effectiveness of Interventions to Improve Adherence to Cardiovascular Medications in Low- and Middle-Income Countries Arul Thangavel*1, Reto Auer2, Dhruv S. Kazi1,2,3 1 Medicine, 2Epidemiology and Biostatistics, University of California San Francsico, 3Medicine/ Cardiology, San Francisco General Hospital, San Francisco, United States Introduction: Improving adherence to cardiovascular medications will be critical to achieving the World Health Organization’s target of 25 % reduction in premature mortality from non-communicable diseases by 2025. Whether educational or m-health interventions can improve medication adherence in low- and middle-income countries is unclear. Objectives: We conducted a systematic review of all published, randomized clinical trials to evaluate the effectiveness and cost-effectiveness of interventions to boost adherence to cardiovascular medications in low- and middle- income countries. Methods: The Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase, CINAHL, WHO regional databases, PsychInfo and Web of Science were searched for eligible trials. Randomized controlled trials of community or home-based interventions to improve medication adherence in cardiovascular disease among adults in low- or middleincome contries (as defined by the IMF) were included. Results: Out of 7684 abstracts identified by the search strategy, nine trials (including 1666 patients) fulfilled inclusion criteria after full-text review. Eight trials were from Asia and one was from Africa; there were no trials from Latin America. Interventions studied included counseling (7 studies), pill-diaries (1 study), and combined interventions (1 study); no studies examined mobile phone-based interventions. Most studies were small with short follow-up (median, 6 months; IQR: 3-6months). Studies were of low quality (Jadad score: Median, 3; IQR: 2-3), with substantial differences in study definition of adherence. Quantitative synthesis of effectiveness data (see figures) showed extremely large heterogeneity between trials (I2>90%), and small, if any, improvements in adherence with the interventions. No studies evaluated cost-effectiveness.
GHEART Vol 9/1S/2014
j
March, 2014
j
ORAL/2014 WCC Orals
Vitamin D levels are associated with the presence and severity of coronary artery disease but not peripheral vascular disease in patients undergoing coronary angiography Jonathan Liew*1, Stella Sasha2, Josephine Warren2, Philip Ngu3, Anthony Dart3, James Shaw3 1 Cardiology, Monash University, Alfred Hospital Baker IDI Heart and Diabetes Institute, 2 Cardiology, Monash University, Alfred Hospital, 3Cardiology, Alfred Hospital Baker IDI Heart and Diabetes Institute, Melbourne, Australia Introduction: Although multiple risk factors for coronary artery disease (CAD) are well established, novel risk factors continue to emerge. Recent studies have shown the association between vitamin D deficiency (VDD), cardiac risk factors and CAD. Globally, VDD is a re-emerging public health problem as it is present in upto 50% of the general population. Objectives: The goal of this study is to investigate the association between VDD and extent of CAD, peripheral vascular disease (PVD) and arterial stiffness. Methods: 375 patients undergoing coronary angiography at Alfred Hospital Cardiac Catheterisation Laboratory between the period of November 2012 to Sept 2013 were prospectively recruited. We measured 25-hydroxyvitamin D (25OHD) serum levels, performed ankle brachial index (ABI) and pulse wave velocity (PWV) tests. Based on the findings of the coronary angiogram, patients were divided into subgroups: Absent, Single, Double and Triple Vessel Disease (as defined by >50% stenosis in each major coronary artery). All data are presented as mean SEM unless stated. Results: 265 patients not taking vitamin D supplements were included in the analysis. Mean age was 66.0 11.2 (mean SD). Levels of 25(OH)D were significantly lower in patients with CAD when compared with patients without CAD (57.0 1.73 versus 70.1 2.46 nnmol/L; p <0.01). One way ANOVA revealed triple vessel disease patients had significantly lower 25(OH)D levels when compared to single vessel disease patients (50.6 2.84 nmol/L versus 61.3 3.16 p<0.01)and trended to be lower when compared to double vessel disease patients (50.6 2.84 versus 59.0 2.99 nmol/L; p¼ 0.06). Patients with CAD had negative correlation with serum 25(OH)D levels (r¼ -0.263; p<0.01), positive correlation with age (r¼ 0.205; p<0.01) and pulse wave velocity (r¼ 0.198 and 0.252 respectively; p <0.01). However, there was no correlation between 25(OH)D levels, ABI and PWV (p > 0.05). Conclusion: Low levels of Vitamin D are associated with the presence and extent of angiographic CAD but not arterial stiffness or PVD. Further studies should be conducted to determine whether vitamin D supplementation prevents the development and progression of CAD. Disclosure of Interest: None Declared
e1