[Prevention of stroke and dementia in general practice: evaluation of the project INVADE]. / Prävention von Schlaganfall und Demenz in der Hausarztpraxis: Evaluation des Projektes INVADE.

BACKGROUND: Stroke and dementia have several modifiable risk factors in common. In the primary care prevention project INVADE (INtervention project on VAscular brain diseases and Dementia in the district of Ebersberg), these vascular risk factors were recorded systematically and treated according to evidence-based guidelines. METHODS: All insurants of the AOK Bayern who were ≥ 50 years of age and lived in the Upper Bavarian district of Ebersberg received the offer to participate in INVADE, about one-third enrolled in the program. Examinations by the family doctor, self-reports of the participants, laboratory analyses, and a duplex sonography of the extracranial neck vessels were used to create individual risk profiles, from which the intervention measures were derived. GPs documented the treatment and health status of the participants at quarterly intervals. The entire examination program was repeated every two years. The success of the intervention was determined in comparison with the district of Dachau, where the insurants received the primary care treatment as usual. Administrative data of the health and long-term care fund for the period from 2013 to 2016 were used as clinical endpoints. Primary endpoints included mortality and onset of long-term care, secondary endpoints were inpatient treatments due to cerebrovascular disease. RESULTS: The comparison between the district of Ebersberg (N = 10.663) and the district of Dachau (N = 13.225) was in favor of the prevention program for both the primary clinical endpoints and the combined secondary endpoint. Mortality risk (HR = 0.90; 95 % confidence interval: 0.84-0.97), long-term care risk (HR = 0.88; 0.81-0.96), and the likelihood of inpatient treatment for cerebrovascular disease (OR = 0.87; 0.77-0.97) were significantly reduced. CONCLUSIONS: The results support the assumption that the incidence of cerebrovascular disease and dementia can be reduced by a systematic general-practice based identification and treatment of vascular risk factors and can thus increase life expectancy and disability-free life time. REGISTRATION: clinicaltrials.gov, NCT1107548, registration date: 21.04.2010, drks.de, DRKS00011348, registration date: 29.12.2016.

Depressive symptoms and the risk of ischemic stroke in the elderly--influence of age and sex.

Although a relationship between depression and cardiovascular events has been suggested, past study results regarding the risk of stroke in relation to depression by subgroups are ambiguous. The aim of this study was to investigate the influence of depressive symptoms on risk of incident ischemic stroke in elderly according to age and sex. This prospective cohort study followed up 3852 subjects older than 55 years. Baseline depressive symptoms were defined by a score ≥ 5 on the Geriatric Depression Scale or antidepressant intake. The outcome measure was incident ischemic stroke within 6 years of follow-up. Multivariate Cox-proportional hazard models as well as cumulative survival analyses were computed. A total of 156 ischemic strokes occurred during the study period (24 strokes in the age-group<65 years and 132 strokes in the age-group ≥ 65 years). The distribution of strokes in sex-subgroups was 4.5% in men and 3.7% in women. The multivariate analysis showed an elevated stroke risk (Hazard Ratio (HR): 2.84, 95% CI 1.11-7.29, p = 0.030) in subjects from 55 to 64 years with depressive symptoms at baseline but not in subjects older than 65 years. In the multivariate analysis according to sex the risk was increased in women (HR: 1.62, 95% CI 1.02-2.57, P = 0.043) but not in men. The Cox-regression model for interaction showed a significant interaction between age and sex (HR: 3.24, 95% CI 1.21-8.69, P = 0.020). This study corroborates that depressive symptoms pose an important risk for ischemic stroke, which is particularly remarkable in women and patients younger than 65 years.

Reduction of Long-Term Care Dependence After an 8-Year Primary Care Prevention Program for Stroke and Dementia: The INVADE Trial.

BACKGROUND: Stroke and dementia are the major causes for long-term care (LTC) dependence in old age. This intervention trial compared a multidomain prevention program for stroke and dementia with usual medical care in reducing the need for LTC. METHODS AND RESULTS: The Intervention Project on Cerebrovascular Disease and Dementia in the District of Ebersberg (INVADE) was a general practice-based 8-year trial in 2 defined catchment areas in Upper Bavaria, Germany. All 11 317 insurants of a statutory health insurance plan who were ≥55 years of age and lived in the intervention district were offered the opportunity to participate in a prevention program; 3908 enrolled. The 13 301 insurants in the reference district received usual medical care. The intervention consisted of the systematic identification and evidence-based treatment of vascular risk factors. The primary clinical end point was incidence of LTC dependence according to external assessment by a special medical service in the framework of the statutory German LTC insurance. Age- and sex-specific incidence rates from the reference district were used to calculate the expected number of cases of LTC dependence under usual medical care. The expected number was compared with the observed number of cases in the intervention district. Analysis was by intention to treat. During the 5 years after completion of the recruitment period, significantly fewer incident cases of LTC dependence arose in the intervention district than expected (χ(2)=13.25; P<0.001). In women, the incidence was reduced by 10% (P<0.01). In men, the incidence was reduced by 9.6% (P<0.05). CONCLUSIONS: Our results support the feasibility and effectiveness of a primary care prevention program for stroke and dementia to reduce the risk of developing LTC dependence. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01107548. (J Am Heart Assoc. 2012;1:e000786 doi: 10.1161/JAHA.112.000786.).

Use of an atrial lead with very short tip-to-ring spacing avoids oversensing of far-field R-wave.

OBJECTIVE: The AVOID-FFS (Avoidance of Far-Field R-wave Sensing) study aimed to investigate whether an atrial lead with a very short tip-to-ring spacing without optimization of pacemaker settings shows equally low incidence of far-field R-wave sensing (FFS) when compared to a conventional atrial lead in combination with optimization of the programming. METHODS: Patients receiving a dual chamber pacemaker were randomly assigned to receive an atrial lead with a tip-to-ring spacing of 1.1 mm or a lead with a conventional tip-to-ring spacing of 10 mm. Postventricular atrial blanking (PVAB) was programmed to the shortest possible value of 60 ms in the study group, and to an individually determined optimized value in the control group. Atrial sensing threshold was programmed to 0.3 mV in both groups. False positive mode switch caused by FFS was evaluated at one and three months post implantation. RESULTS: A total of 204 patients (121 male; age 73±10 years) were included in the study. False positive mode switch caused by FFS was detected in one (1%) patient of the study group and two (2%) patients of the control group (p = 0.62). CONCLUSION: The use of an atrial electrode with a very short tip-to-ring spacing avoids inappropriate mode switch caused by FFS without the need for individual PVAB optimization. TRIAL REGISTRATION: ClinicalTrials.gov NCT00512915.

Effect of an intensive nurse-managed medical care programme on ambulatory blood pressure in hypertensive patients.

BACKGROUND: Uncontrolled hypertension is a major primary healthcare problem. AIM: To investigate whether blood pressure (BP) control in primary care could be improved by nurses taking responsibility for managing hypertensive patients. METHODS: Randomized trial with two groups: usual or intensive care. Patients diagnosed previously as hypertensive and with a systolic office BP greater than 140mmHg were randomized to an intensive care programme managed by trained nurses or to usual care. The intensive care programme included a visit every 6 weeks to the general practitioner's office, with standardized BP measurement, self-measurement training, risk factor checks and advice on BP reduction. The intervention lasted for 1 year. The primary endpoints were systolic BP obtained by 24-hour ambulatory BP monitoring after 1 year and the change compared with baseline. RESULTS: Two hundred patients from 19 physicians were enrolled (102 in the intensive care group). Data on ambulatory BP were available from 140 patients. Systolic BP declined from 134.4+/-14.0 to 126.3+/-10.4mmHg in the intensive care group and from 132.4+/-13.5 to 128.2+/-13.0mmHg in the usual care group. There was no statistically significant difference in values after 1 year (p=0.332). The reduction in systolic BP was significantly greater in the intensive care group (7.6 vs 3.3mmHg in the usual care group; p=0.036). Similar results were observed for diastolic BP and day- and night-time measurements. CONCLUSIONS: An intensive medical care programme in the office setting managed by trained nurses can improve BP control effectively. Nurses could take more responsibility for managing hypertensive patients.