Management of hypertension and chronic kidney disease in a primary care setting

Objective: To determine patients’ perceptions of the benefits of participating in outpatient cardiac rehabilitation and the reasons why some decline to take part. Method: Data collected included patients’ responses to the self-administrated ‘Outpatient Cardiac Rehabilitation Program Evaluation’ form, after attending a cardiac rehabilitation program. The evaluation involved analysis of 9 binary and open ended questions. A retrospective study was completed on data collected from January 2010 to December 2015 (6 years) and included 643 adult cases comprising 500 men and 143 women. A between subject t-Test was used to compare patient means before and after attendance of perceived changes to their lifestyle, and overall sense of physical and emotional wellbeing. Fishers Exact Test was used to compare attendance percentages, gender distribution, and primary diagnosis. Results: Two hundred and seventy nine (43.4%) of the 643 invited patients participated in the cardiac rehabilitation program, while 364 (56.6%) declined, with this result being significantly lower (p < 0.001) than those reported in other Australian locations. The sex distribution of those that participated was 234 (83.8%) males and 45 (16.2%) females while those that declined were 266 (73.1%) males and 98 (23.9%) females. The male prevalence of both attendance and non-attendance was significant (p < 0.001). Patients with a primary referral diagnosis of having a percutaneous coronary intervention and acute myocardial infarction were significantly (p < 0.05) more likely to decline cardiac rehabilitation. Of those who participated, 96.1% indicated they received benefits from attending the cardiac rehabilitation program, with 96.8% identifying significant changes to their lifestyle (p < 0.01) and sense of well-being improvement (p < 0.001) as key benefits, in addition to perceived quicker recovery. According to participants, these positive outcomes resulted from a healthier diet, exercise, better stress management, and support from other patients with similar conditions. The major reasons for declining participation was ‘not wanting to attend’ (19.3%), ‘referred to another hospital service’ (10.6%), and ‘work related commitments’ (7.3%). Conclusion: Considering the reported benefits of attending cardiac rehabilitation, the number of people who decline to attend has important implications for their health and related health system costs related to ongoing disease.

Background: Diabetes education is believed to bring about sustained benefits in diabetes mellitus (DM) patient outcomes. These benefits have not been widely studied in an inpatient hospital setting, and as such the aim was to determine whether a hospital diabetes in-service, and specifically diabetes education, results in reduced blood glucose and HbA1c levels after hospital discharge. Methods and materials: A cohort review was performed at a large teaching hospital, in Canberra, Australia. Sixty seven patients comprising 35 males and 32 females who were referred upon discharge to the Diabetes Services as having a history of uncontrolled DM from February 1st, 2015 until January 31st, 2016 were evaluated. The retrospective discharge blood glucose level (BGL) was compared to prospective BGL 3 months after hospital discharge. HbA1c was prospectively taken before and 3 months after Diabetes Service education. A between subjects t-Test was used to compare patients' glucose and HbA1c averages. Results: The average discharge BGL result was 13.3 mmol/L, compared to the post-discharge result of 11.2 mmol/L, indicating a significant decrease (p = < 0.01). The average pre-HbA1c result was 10.45%, and decreased to the post-HbA1c result of 8.96%, which was significant (p = <0.05). Conclusion: This study is the first to measure the direct glucose adherence benefits associated DM education within Australia and provides evidence on the effectiveness of a Diabetes Service in reducing patient BGLs. Utilisation of Diabetes Services to control glycaemia encourages ongoing efforts and translates to reduced micro and macro cardiovascular risk factors associated with DM.

Aims: To determine the extent to which targets for blood pressure (BP) (<140.90 mmHg) and random blood glucose level (BGL) (<7.7 mmol/L) control in patients with chronic kidney disease (CKD) are achieved; and the extent clinical inertia affects BP and glucose control in CKD and diabetes mellitus (DM). Methods: Data was collected from the 1st January 2015 until 31st December 2015 on key patient pathology, admission reason, final discharge diagnosis, and information concerning clinical guideline adherence. Results: Eighty-seven (n = 87) CKD patients were included. The average hospital BP for all CKD patients was 134.3/73.4 mmHg, adhering to recommendations of <140/90 mmHg. The average CKD patient pre-admission BP was 134.8/72.2 mmHg compared to the discharge BP of 129.8/72.2 mmHg. At admission, 63.3% and 93.1% of patients adhered to systolic and diastolic BP recommendations, which significantly (p = < .05) increased at discharge to a systolic and diastolic BP adherence of 83.9% and 98.8%, respectively. The average random hospital BGL was 7.7 mmol/L, indicating good control, whereas the pre-hospital HbA1c average was 7.58%, indicating poor control (>7.0% >53 mmol/mol). There were 21 cases of clinical inertia, affecting 18 out of 87 patients (20.7%), with significant adverse hospital discharge differences (p = <.05) between clinical inertia and non- clinical inertia patient systolic BP (144.2 vs. 132.8 mmHg), deranged BGL (66.7% vs. 35.3%), and reduction in kidney function (83.3% vs. 30.9%). Conclusion: Adherence appears to be related to inpatient clinical inertia and outpatient patient health literacy and empowerment.

Objective The prediabetes and cardiovascular complications studies proposes to develop a screening protocol for diabetes cardiovascular risk, and strategies for holistic management amongst others. Over 500 participants were recruited in the first 2 years of rural community research screening. Specific for this report, various published findings were reviewed. The objective is to summarize research outcomes and itemize limitations as they constitute basis of future directions. ResultsAffordability and availability are major confounding behavioural change wheel factors in the rural community. 4.9% prevalence of prediabetes, which may be lower or non-significantly different in urban areas. Hyperglycaemia co-morbidity with dyslipidaemia (5.0%), obesity (3.1%) and hypertension (1.8%) were observed. Limitation of the study includes participants being mostly over 60 years old, which has created impetus for the Global Alliance on Chronic Diseases agenda on vulnerability of older adults to diabetes being a new direction of the collaboration. Other directions in Australia and Nepal focus on patients with chronic kidney disease with or without cardiovascular complications. This report highlights the need to translational research.

There is a large number of patients with chronic kidney disease (CKD), diabetes mellitus (DM), and hypertension (HT) but whether the targets on blood pressure (BP) control in patients with DM and/or CKD are met is not clear. This narrative review therefore investigated evidence on services aimed at achieving desirable clinical results in patients with CKD and DM, and HT in Australia. Literature pertaining to pathology diagnosis and management of these patients as well as the complexities in management were considered. This involved evidence from PubMed-listed articles published between 1993 and 2016 including original research studies, focusing on randomised controlled trials and prospective studies where possible, systematic and other review articles, meta- analyses, expert consensus documents and specialist society guidelines, such as those from the National Heart Foundation of Australia, American Diabetes Association, the Department of Health, The Royal College of Pathologists of Australasia, and The Australasian College of Emergency Medicine. Based on the literature reviewed, it is yet unknown as to how effective programs, such as diabetes inpatient services, endocrine out-patient services, and cardiac rehabilitation services, are at achieving guideline recommendations. It is also not clear how or whether clinicians are encumbered by complexities in their efforts of adhering to DM, HT, and glucose control recommendations, and the potential reasons for clinical inertia. Future studies are needed to ascertain the extent to which required BP and glucose control in patients is achieved, and whether clinical inertia is a barrier.

Aims: To review the epidemiology and the clinical evidence regarding achieving blood pressure (BP) and blood glucose control in patients with chronic kidney disease (CKD) and diabetes mellitus (DM), with emphasis on adherence and barriers within the context of Australian clinical guidelines. This article then considers Australian services aimed at BP, DM, and CKD, guideline adherence and control. Methods: Evidence from PubMed-listed articles published between 1994 and 2016 is considered, including original research, focusing on randomised controlled trials and prospective studies, review articles, meta- analyses, expert and professional bodies' guidelines as well as our experience. Results: There have been no Australian studies that consider adherence to BP control in DM and CKD patients. This is a major limitation in preventing DM and renal disease progression. It is possible that Australian clinicians are not adhering to DM, hypertension (HT), and glucose recommendations, thus resulting in reduced patient outcomes. Conclusions: It is hoped that future studies ascertain the extent to which the required BP and glucose control in patients is achieved, and the potential barriers to adherence. The significance of this is immense since the impact of failure to control blood glucose levels and BP leads to renal damage.

Objective: To determine if the Cardiac rehabilitation (CR) program had positive effects on the patient medically as well as effects on pathological risk factors, functional capacity, and mental health; and the extent to which targets for blood pressure (BP) control in patients with hypertension (HT) and diabetes mellitus (DM) are achieved. Methodology: CR participant data was collected from 1st June 2014 until 31st December 2015 (19 months), which included: demographics, medical history, social history, medications, lipid profiles and anthropometric measurements. Additional data was collected on The Patient Health Questionnaire (PHQ-9) factors, and on the participants 6 minute walk test (6MWT). Study participants were eligible to participate in the study if they attended 10 or more CR program sessions out of 12 at the Calvary Public Hospital Canberra. Results: Seventy nine (79) participants participated in the study. Significant reductions in BP (n=79) (p =<0.05), blood LDL cholesterol levels (n=26) (p =<0.05), and improvements in participants PHQ-9 scores (n=79) (p =<0.001), and their 6MWT (n=78) (p =<0.001) were noted. Participants were also able to better manage their medication (p =<0.05). Importantly, results indicated that significant improvements (p=<0.05) were made in DM patients (n=18) diastolic BP, physical ability and depression and anxiety. Conclusion: A CR program can reduce risk factors associated with CVD, and improves mental health and physical fitness of participants. Results indicated that the CR program reduces DM patient risk factors through improved physical fitness and reductions in depression and anxiety, leading to reduced risk of future cardiovascular and renal disease. Key words: Cardiovascular Diseases; Rehabilitation; Acute Coronary Syndrome; Outpatients; Diabetes Mellitus

Objective: To determine the patients’ perceived benefits or barriers in participating in a cardiac rehabilitation program and the various reasons for declining the program. Method: Data collected included patients’ responses to the self-administrated ‘Outpatient Cardiac Rehabilitation Program Evaluation’ form, after attending a cardiac rehabilitation program. The evaluation involved analysis of 9- binary and open ended questions. A retrospective study was completed on data collected from January 2010 to December 2015 (6 years) and included 643 adult cases comprising 500 men and 143 women. Results: Two hundred and seventy nine (43.4%) of the 643 patients participated in the cardiac rehabilitation program, while 364 (56.6%) declined. The sex distribution of those that participated was 234 (83.8%) males and 45 (16.2%) females while those that declined was 266 (73.1%) males and 98 (23.9%) females. Of those who participated, 96.1% indicated they received benefits from attending the cardiac rehabilitation program, with 96.8% identifying significant changes to their lifestyle (p < 0.01) and sense of well-being improvement (p < 0.001) as key benefits, in addition to perceived quicker recovery. According to participants, these positive outcomes resulted from a healthier diet, exercise, better stress management, and support from other patients with similar conditions. The major reasons for declining participation was ‘not wanting to attend’ (19.3%), ‘referred to another hospital service’ (10.6%), and ‘work related commitments’ (7.3%). Conclusion: This study reports a large percentage of patients declining cardiac rehabilitation, which is worrying, and needs further investigation, considering the benefits of such a program as cited by the patients that took part in cardiac rehabilitation.

Objective: To determine if the Cardiac rehabilitation (CR) program had positive effects on the patient medically as well as effects on pathological risk factors, functional capacity, and mental health; and the extent to which targets for blood pressure (BP) control in patients with hypertension (HT) and diabetes mellitus (DM) are achieved. Methodology: CR participant data was collected from 1st June 2014 until 31st December 2015 (19 months), which included: demographics, medical history, social history, medications, lipid profiles and anthropometric measurements. Additional data was collected on The Patient Health Questionnaire (PHQ-9) factors, and on the participants 6min walk test (6MWT). Study participants were eligible to participate in the study if they attended 10 or more CR program sessions out of 12 at the Calvary Public Hospital Canberra. Results: Seventy nine (79) participants participated in the study. Significant reductions in BP (n=79) (p=<0.05), blood LDL cholesterol levels (n=26) (p=<0.05), and improvements in participants PHQ-9 scores (n=79) (p=<0.001), and their 6MWT (n=78) (p=<0.001) were noted. Participants were also able to better manage their medication (p=<0.05). Importantly, results indicated that significant improvements (p=<0.05) were made in DM patients (n=18) diastolic BP, physical ability and depression and anxiety. Conclusion: A CR program can reduce risk factors associated with CVD, and improves mental health and physical fitness of participants. Results: Indicated that the CR program reduces DM patient risk factors through improved physical fitness and reductions in depression and anxiety, leading to reduced risk of future cardiovascular and renal disease.

This Grand Rounds presentation aimed to discuss the pathophysiologic mechanisms in the development of hypertension in diabetes mellitus patients, and its subsequent link to chronic kidney disease and cardiovascular disease. Furthermore this presentation aimed to communicate conference research results concerning the Hospital's Cardiac Rehabilitation Program, including patient perceived and pathological benefits of cardiac rehabilitation attendance.

Aims: To determine the prevalence and severity of cardiac arrhythmias in a rural Australian population using ECG assessment. Study Design: This is a University-based research project. Comparative design with random samples used. Place and Duration of Study: School of Community Health, Charles Sturt University, Albury, NSW, Australia. Methodology: Five hundred and eight participants with or without a known history of cardiovascular disease were recruited via public media announcements indicating a health screening opportunity carried out at the local university. Their medical history was obtained and a 12-lead electrocardiography (ECG) was recorded. ECG recordings were classified into severity and prevalence determined in each category. The number of participants that had to be referred and had follow-up by the general practitioner was determined. Results: Moderate to severe ECG anomalies, which included atrial fibrillation or left bundle branch block were identified in 58 (11.4%) of the participants. Forty (7.9%) individuals with ECG anomalies were referred to the general practitioner for further evaluation. Eight participants did not seek further advice. Twenty-two (68.8%) participants that made an appointment to see their general practitioner were either commenced on treatment, had their treatment changed or received surgery. A further 85 (16.7%) of individuals required regular follow-up in line with their ECG characteristics and other health information, presenting with non-clinical ECG changes that had the potential for adverse health outcomes in the future including long QT interval, right bundle branch block or left ventricular hypertrophy for instance. Conclusion: Our study has demonstrated that a substantial number of patients in this rural community have both ECG abnormalities and or cardiac arrhythmias that required regular review or commencement of treatment by their doctor. - See more at: http://www.sciencedomain.org/abstract.php?iid=372&id=12&aid=2771#.Ur8HtCiQm5c

Peripheral arterial disease (PAD) is asymptomatic in 50–75% of cases and tends to be underdiagnosed due to the inherent difficulties in screening. Accurate peripheral vascular testing is particularly important for those at highest risk of PAD, including older people and people with diabetes, renal disease or a history of smoking. Unfortunately, commonly used tests for PAD have limited sensitivity in these most at-risk populations. This article provides guidance to support early detection of PAD using evidence-based clinical tests. It also contains a flowchart as a clinical guide and a set of recommendations concerning the measurement of toe pressures. More targeted screening can reduce morbidity and mortality rates in people with PAD who are at high risk of cardiovascular events and who often remain undiagnosed.

The objective of own study was to investigate the quality of hypertension management in a rural Chinese population. A prospective cross-sectional study was conducted in 922 hypertensive patients in a regional community in southern China. The average systolic (SBP) and diastolic blood pressure (DBP) was 167.8 +/- 22.5 mmHg and 94.3 +/- 14.2 mmHg respectively. A total of 823 patients (89.3%) patients had a SBP of greater than or equal to 140 mmHg, and 596 (64.6%) had a DBP of greater than or equal to 90 mmHg. Fully 568 patients (69.7%) were treated with one or two antihypertensive drugs, mostly with calcium channel blockers. In patients treated with antihypertensive drugs, the average SBP and DBP were 170.3 +/- 23.1 mmHg and 96.2 +/- 14.8 mmHg, respectively. Blood pressure was poorly controlled in these hypertensive patients. Further studies are required to identify the barriers to the effective management of uncontrolled hypertension in a rural setting.

Digoxin has been used to treat congestive heart failure (CHF) for more than two centuries. It's clinical efficacy, however, has been under question in recent years because recent clinical trials showed that digoxin therapy in CHF patients was associated with no beneficial effects in mortality, but only a modest reduction in clinical symptoms and the frequency of heart failure related hospitalisation. Digoxin's effect on mortality seems closely related to its serum concentrations; high serum concentrations (e.g. >or=1.2 ng/ml) have been found to increase the risk of all-cause mortality in heart failure patients. Digoxin-associated risk in mortality may be due to an increases in myocardial oxygen consumption and arrhythmogenesis at higher serum concentrations. We hypothesized that the serum concentration of digoxin is a major determinant factor of its efficacy on mortality rates in patients with congestive heart failure. The maintenance of digoxin's serum concentration at the lower end of the reference range, i.e., between 0.5 and 0.8 ng/ml, may reduce mortality rates as well as improve clinical symptoms.

Abstract:Congestive heart failure (CHF) is a leading cause of morbidity and mortality worldwide . Many CHF patients have intraventricular conduction delays such as right or left bundle branch block or non-specific QRS widening on the body surface ECG .Intraventricular conduction delays cause dyssynchrony of the ventricles ,leading to regional movement abnormalities and worsening of cardiac function .Recent clinical trials have indicated that cardiac resynchronization therapy improves cardiac function class,exercise tolerance, maximum oxygen consumption and quality of life in patients with moderate to severe heart failure .It is also associated with a significant reduction in mortality and hospital admissions for heart failure . [Life Science Journal . 2006; 3(1) : 1 - 4] (ISSN: 1097 - 8135) . Keywords: heart failure; cardiac resynchronization therapy; cardiac electrophysiology

Cardiovascular diseases have become the leading cause of morbidity and mortality in Asia. In China, cardiovascular disease accounted for 37.8% of all deaths in 2010. Hypertension, hyperlipidaemia, smoking, obesity and dietary deficiencies have been the major contributing factors for the cardiovascular disease in the region. The awareness and control rates of hypertension in most Asian countries are lower than their western counterparts. The reasons for the suboptimal control of hypertension and possible solutions to overcome the barriers to hypertension management are summarized.