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EXCEED projects focus on prevention and treatment of cardiovascular disease

Three recent studies conducted by the Medical University of South Carolina Excellence Center to Eliminate Ethnic and Racial Disparities (EXCEED) focused on ways to reduce and control cardiovascular disease. The studies, which are summarized here, were supported in part by the Agency for Healthcare Research and Quality (HS10871).

The first study demonstrates that controlling blood pressure in half of all hypertensive patients by 2010 is a formidable goal, but it could be achieved with a coordinated strategic plan. The second study focuses on the potential of primary care audit and feedback programs to better control patients' cardiovascular risk factors and identify group disparities in treatment and outcomes. The third study suggests that a diet high in fiber may reduce inflammation associated with cardiovascular disease.

Egan, B.M., and Basile, J.N. (2003, November). "Controlling blood pressure in 50 percent of all hypertensive patients: An achievable goal in the Healthy People 2010 report." Journal of Investigative Medicine 51(6), pp. 373-385.

Treatment of hypertension dramatically reduces the occurrence of congestive heart failure, stroke, and coronary heart disease. However, only about 3 in 10 adult Americans with hypertension have blood pressure (BP) values that are controlled to the goal of less than 140/90 mm Hg. The Healthy People 2010 report has set a goal for Americans and their health care providers to raise BP control rates from the current 31 percent to 50 percent of all hypertensive patients. Despite formidable barriers to this goal, it may be achievable with a coordinated strategic plan, according to this study.

To control hypertension in half of all treated patients would require raising awareness of hypertension (at least or greater than 140 systolic and greater than 90 diastolic) to 80 percent of all hypertensives (from the current 63 percent); ensuring treatment of 90 percent (from the current 84 percent) of aware hypertensives; and controlling BP to less than 140/90 mm Hg in 70 percent (compared with the current 53 percent) of treated patients, explain the researchers. They briefly reviewed selected research studies to assess the cardiovascular benefits of controlling hypertension, focusing particularly on factors that affect hypertension awareness, treatment, and control.

Based on the review, they identified four barriers to optimizing BP control: systems, providers, patients, and treatment factors. For example, systems factors range from limited access to regular primary care and medication to lack of appointment reminders. Providers often are not aware of the BP control rate in patients or fail to adjust medications when BP is not controlled. Patients fail to seek or receive preventive care services or don't adhere to medication or lifestyle recommendations. Finally, lack of treatment efficacy is a major impediment to reaching the Healthy People 2010 goal.

Hendrix, K.H., Lackland, D.T., and Egan, B.M. (2003, November). "Cardiovascular risk factor control and treatment patterns in primary care." Managed Care Interface 16(11), pp. 21-26.

The researchers worked collaboratively with 201 providers at 63 primary care sites in South Carolina to assess BP control rates, treatment patterns, and disparities among patients with hypertension, diabetes, and dyslipidemia (lipoprotein metabolism disorders such as high total cholesterol). They asked the providers to contribute medical record information regarding patient risk factor levels, medications, and coexisting illnesses to the Hypertension Initiative database, which was launched in January 2000.

Providers received quarterly reports summarizing the risk-group distribution and percentages of their patients who reached BP, cholesterol, and blood-sugar (glycosylated hemoglobin) goals. Providers also received a list detailing the medications used for patients in each risk group. Nearly half (49 percent) of patients with hypertension achieved a normal BP of less than 140/90 mm Hg. Also, 62 percent of hypertensive patients who also had dyslipidemia achieved a low-density lipoprotein cholesterol (so-called "bad" cholesterol) of less than 130 mg/dL, although fewer than one-third met the more stringent goal of less than 100 mg/dL.

In 49 percent of patients with hypertension and diabetes, glycosylated hemoglobin levels reached the target of less than 7 percent. However, control of more than one cardiovascular risk factor in an individual was low, especially among women and blacks. This suggests that more specifically tailored treatment guidelines are needed for these very high-risk groups.

King, D.E., Egan, B.M., and Geesey, M.E. (2003, December). "Relation of dietary fat and fiber to elevation of C-reactive protein." American Journal of Cardiology 92, pp. 1335-1339.

Dietary fiber may reduce inflammation associated with cardiovascular disease, suggests this study. To investigate whether consumption of specific food components is associated with elevation of C-reactive protein (CRP), an indicator of inflammation that is thought to increase the risk of cardiovascular disease (CVD), the researchers examined the relation of dietary fiber, fat, and other dietary factors to CRP levels in 4,900 adults who participated in the 1999 to 2000 National Health and Nutrition Examination Survey (NHANES).

After controlling for demographic factors, body mass index, smoking, alcohol consumption, exercise, and total caloric intake, those in the third and fourth highest quartiles of fiber consumption had a 36 percent lower risk of elevated CRP (>3.0 mg/L)) compared with those in the lowest quartile. Each additional gram of fiber consumed per day was associated with a 2 percent lower risk of elevated CRP.

Saturated fat was modestly associated with elevated CRP. Individuals in the third and fourth highest quartile of consumption had 58 percent and 44 percent higher risk of elevated CRP, respectively. Consumption of other types of fat was not consistently related to greater risk of elevated CRP. Total calories, protein, carbohydrate, fish, and cholesterol consumption were not associated with the risk of elevated CRP.

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