Impact of cardiology referral: clinical outcomes and factors associated with physicians' adherence to recommendations.

OBJECTIVES: Cardiology referral is common for patients admitted for non-cardiac diseases. Recommendations from cardiologists may involve complex and aggressive treatments that could be ignored or denied by other physicians. The purpose of this study was to compare the outcomes of patients who were given recommendations during cardiology referrals and to examine the clinical outcomes of patients who did not follow the recommendations. METHODS: We enrolled 589 consecutive patients who received in-hospital cardiology consultations. Data on recommendations, implementation of suggestions and outcomes were collected. RESULTS: Regarding adherence of the referring service to the recommendations, 77% of patients were classified in the adherence group and 23% were classified in the non-adherence group. Membership in the non-adherence group (p<0.001; odds ratio: 10.25; 95% CI: 4.45-23.62) and advanced age (p = 0.017; OR: 1.04; 95% CI: 1.01-1.07) were associated with unfavorable outcomes. Multivariate analysis identified four independent predictors of adherence to recommendations: follow-up notes in the medical chart (p<0.001; OR: 2.43; 95% CI: 1.48-4.01); verbal reinforcement (p = 0.001; OR: 1.86; 95% CI: 1.23-2.81); a small number of recommendation (p = 0.001; OR: 0.87; 95% CI: 0.80-0.94); and a younger patient age (p = 0.002; OR: 0.98; 95% CI: 0.96-0.99). CONCLUSIONS: Poor adherence to cardiology referral recommendations was associated with unfavorable clinical outcomes. Follow-up notes in the medical chart, verbal reinforcement, a limited number of recommendations and a patient age were associated with greater adherence to recommendations.

Impact of cardiology referral: clinical outcomes and factors associated with physicians' adherence to recommendations

OBJECTIVES: Cardiology referral is common for patients admitted for non-cardiac diseases. Recommendations from cardiologists may involve complex and aggressive treatments that could be ignored or denied by other physicians. The purpose of this study was to compare the outcomes of patients who were given recommendations during cardiology referrals and to examine the clinical outcomes of patients who did not follow the recommendations. METHODS: We enrolled 589 consecutive patients who received in-hospital cardiology consultations. Data on recommendations, implementation of suggestions and outcomes were collected. RESULTS: Regarding adherence of the referring service to the recommendations, 77% of patients were classified in the adherence group and 23% were classified in the non-adherence group. Membership in the non-adherence group (p<0.001; odds ratio: 10.25; 95% CI: 4.45-23.62) and advanced age (p = 0.017; OR: 1.04; 95% CI: 1.01-1.07) were associated with unfavorable outcomes. Multivariate analysis identified four independent predictors of adherence to recommendations: follow-up notes in the medical chart (p<0.001; OR: 2.43; 95% CI: 1.48-4.01); verbal reinforcement (p = 0.001; OR: 1.86; 95% CI: 1.23-2.81); a small number of recommendation (p = 0.001; OR: 0.87; 95% CI: 0.80-0.94); and a younger patient age (p = 0.002; OR: 0.98; 95% CI: 0.96-0.99). CONCLUSIONS: Poor adherence to cardiology referral recommendations was associated with unfavorable clinical outcomes. Follow-up notes in the medical chart, verbal reinforcement, a limited number of recommendations and a patient age were associated with greater adherence to recommendations. .

Cardiovascular prevention in HIV patients: results from a successful intervention program.

OBJECTIVES: To analyze the effect of a prevention program on the estimated cardiovascular risk calculated by three risk scores. METHODS: We prospectively evaluated 87 HIV+patients with elevated cardiovascular risk estimation. Framingham (FRS), PROCAM and National Cholesterol Education Program (ATP-III) were applied. Cardiovascular risk was defined as elevated if >10%. All patients received non-pharmacological (diet, exercise, smoking cessation) and, when appropriate, pharmacological therapy. RESULTS: Mean age was 52 years, 92% were male, 39.1% were smokers, 70.1% had hypertension, 18.4% had diabetes. All patients were under HAART, 56.3% were receiving protease inhibitors (PI). After 6 months, intervention was associated to significant changes on triglycerides (298+/-242 and 206+/-135 mg/dL, p<0.05), total-cholesterol (224+/-47 and 189+/-38 mg/dL, p<0.001), LDL-cholesterol (129+/-44 and 109+/-30 mg/dL, p<0.001). Frequencies of patients with elevated cardiac risk before and 6 months after intervention were 92% x 27.6% (p<0.0001), 80.5% x 50.6% (p<0.0002), and 25.3% x 14.9% (p=0.12), for FRS, ATP III and PROCAM, respectively. CONCLUSIONS: An intervention program focused on reduction of traditional risk factors was able to decrease the frequency of patients with HIV infection and elevated cardiovascular risk estimation. FRS showed greater sensitivity than the other scores.

Terapia hipolipemiante em situações especiais: síndrome de imunodeficiência adquirida / Hypolipidemic therapy under special conditions: acquired immune deficiency syndrome

Dislipidemias podem ser observadas precocemente entre pacientes com AIDS. Frequentemente, estas anormalidades lipídicas incluem HDL baixo e moderado aumento dos triglicérides sanguíneos. A terapia anti-retroviral combinada (HAART) pode agravar a dislipidemia nestes pacientes, com importante aumento nos triglicérides e no LDL. Vários mecanismos são propostos para explicar a dislipidemia mista observada nestes indivíduos, incluindo diferentes etapas do metabolismo lipídico. A importância do tratamento desses distúrbios lipídicos tem se tornado evidente com o aumento da expectativa de vida e os relatos de complicações cardiovasculares nestes pacientes. Existe um estado de resistência à insulina nos pacientes com AIDS em tratamento com HAART,que apresentam lipodistrofia, hipertrigliceridemia e baixos níveis de HDL. Drogas retro-antivirais são metabolizadas pelo CYP P450 3A4 e interações com algumas estatinas, especialmente com sinvastatina podem ocorrer. O tratamento com agentes hipolipemiantes deve ser baseado no perfil lipídico e no risco de coronariopatia. Para hipertrigliceridemias, fibratos (principalmente fenofibrato ou bezafibrato) devem ser as drogas de escolha, bem como as estatinas (principalmente pravastatina). Terapia combinada usando estatinas mais fibratos é recomendada para dislipidemias mistas graves e sempre sob rigoroso monitoramento de efeitos adversos.

[Hypolipidemic therapy under special conditions: acquired immune deficiency syndrome]. / Terapia hipolipemiante em situações especiais--síndrome de imunodeficiência adquirida.

Lipid alterations can be observed early among patients with AIDS disease. Commonly, these lipid abnormalities include low HDL-C and modest increase in triglyceride plasma levels. Highly Active Anti-Retroviral Therapy (HAART) in these patients may aggravate the dyslipidemia, with notable increases in triglycerides as well as in LDL-C. There are several mechanisms proposed to explain the mixed hyperlipidemia observed in these subjects, including different steps in lipid metabolism. The importance of the treatment of dyslipidemia became evident with the increased life expectancy and reports of cardiovascular complications in these individuals. There is an insulin resistance state in patients with AIDS disease under treatment with HAART, who present with lipodystrophy, hypertriglyceridemia, low levels of HDL-C. Antiretroviral drugs are metabolized by CYP P450 3A4 and interactions with some statins, especially with simvastatin are expected to occur. Treatment with lipid-lowering agents should be based on lipid profile and coronary risk. For hypertriglyceridemias, fibrates (mainly fenofibrate or bezafibrate) should be the drugs of choice, as well as statins (mainly pravastatin). Combined treatment using fibrates plus statins are recommended for severe mixed hyperlipidemias under very close monitoring for adverse effects.