European Journal of Cardiovascular Prevention & Rehabilitation最新文献

Background: Clinical trials generally provide strong evidence of the efficacy of cardiovascular preventive strategies, but poor evidence of their 'real-life' utility, in terms of effectiveness and cost-effectiveness.

Design and methods: The Cardiovascular Disease Prevention Model is presented, which represents a means of extrapolating the results of clinical trials to a broader, more relevant context. The model is configured as a decision-analysis tree, and underpinned by life-course analysis and Markov processes. Uncertainty and sensitivity analyses are undertaken by Monte Carlo simulation.

Results: The results of effectiveness and cost-effectiveness analyses of a hypothetical preventive intervention are presented to demonstrate the outputs of the model. The potential impact and efficiency of the intervention are made obvious.

Conclusions: The Cardiovascular Disease Prevention Model offers a means to translate the results of trials of cardiovascular preventive interventions, in order to inform clinical and public health practice, as well as health policy.

Background: In patients with coronary artery disease, the target intensity-level of exercise training is usually based on a training heart rate that aims to be close to the upper level of metabolic aerobic exercise.

Aim: We intended to evaluate whether a training heart rate calculated with the Karvonen formula after a conventional exercise test is comparable with the heart rate at the anaerobic threshold in patients after myocardial infarction treated with beta-blockers and if not to propose a new formula.

Methods and results: In this multicenter prospective study, 115 consecutive beta-blocked patients recovering from myocardial infarction performed a cardiopulmonary exercise test to determine the anaerobic threshold. The training heart rate determined by the Karvonen formula was compared with the heart rate at the anaerobic threshold in a derivation sample (n=58) and a validation sample (n=57) of patients. The Karvonen training heart rate was significantly lower than the heart rate at the anaerobic threshold (91+/-5 versus 102+/-17 bpm, P<0.0001) in the first sample of patients and this difference was clinically relevant in 40% of patients. Thus, a 'modified Karvonen training heart rate', equal to 0.8xx(maximum heart rate-resting heart rate)+resting heart rate, was calculated by linear regression in the derivation sample and prospectively assessed in the validation sample. The modified Karvonen training heart rate was closer to the heart rate at the anaerobic threshold than the Karvonen training heart rate, and the difference between the modified Karvonen training heart rate and the heart rate at the anaerobic threshold was clinically relevant in only 5% of patients.

Conclusion: The Karvonen formula underestimates the heart rate at the anaerobic threshold in beta-blocked patients, which may lead to undertraining of patients with coronary artery disease; we propose another formula more adapted to these patients.

Optimal use of cardiopulmonary exercise testing (CPET) in clinical practice and chronic heart failure (CHF) requires appropriate data presentation and a flexible interpretative strategy. The greatest potential impact on the decision-making process may rest not on the value of any individual measurement, although some are obviously more important than others, but rather on their integrative use. Such an integrative approach relies on interrelationship, trending phenomena and patterns of key gas exchange variable responses. An multiparametric approach will be discussed in different clinical applications, for exercise prescription and monitoring, functional evaluation of drug therapy or cardiac resynchronisation therapy efficacy, and risk stratification. The role of CPET in the daily clinical decision-making process will be underscored. Future indications of CPET will be addressed, suggesting and promoting an extended candidacy either to all CHF patients, including those at high risk or most vulnerable, such as female, elderly patients, and patients with implantable cardioverter defibrillator or in every clinical setting where objective definition of exercise capacity provides implications for medical, surgical, and social decision making.

Background: Efficient prevention policies need to be informed by knowledge of the cost-effectiveness of preventive treatments. This paper calculates the cost-effectiveness of aspirin, antihypertensive treatments and statins for prevention of cardiovascular disease.

Design: The investigation is a modelling study.

Methods: Ten-year cardiovascular risks and treatment eligibility were determined for each individual in a population of 5603 obtained from the Health Survey of England. Using published costs and evidence of effectiveness the cost-effectiveness of treating each eligible individual was determined over a 10-year time horizon. The marginal cost-effectiveness of additional antihypertensive drugs and increasing doses of statins were determined and a sensitivity analysis was carried out.

Results: Of the 5603 individuals 27.5% (95% confidence interval, 26.3-28.7%) were eligible for at least one treatment: the majority of these were eligible for all three. Cost per cardiovascular disease event prevented is strongly determined by pretreatment cardiovascular disease risk. In three-quarters of patients eligible for all three treatments, the lowest cost per event prevented was with aspirin and in the remainder with two-drug antihypertensive treatment. The marginal costs per event prevented were highest with the addition of a fourth antihypertensive drug and statins. These findings depend on the use of low-cost antihypertensives but are otherwise robust to a wide range of assumptions.

Conclusions: Modelling the cost-effectiveness of treatments to prevent cardiovascular disease is feasible and provides valuable information. Cost-effectiveness analysis argues for more widespread use of aspirin and two-drug antihypertensive treatment and against the use of four-drug antihypertensive treatment or statins.