Multifactor Program Reduces CVD Risk Factors Among the Medically Underserved

Charlene Laino

November 10, 2003

Nov. 10, 2003 (Orlando) -- The results of two late-breaking clinical trials presented at the American Heart Association (AHA) Scientific Sessions emphasize the importance of risk factor reduction programs in underserved populations.

The Heart Disease on the Mend study found that a multifactor risk reduction program can reduce cardiovascular disease risk factors among low-income and minority patients.

At one year, retention in the program was more than 90%, despite the fact only one in three participants could understand instructions in English, said chief investigator William L. Haskell, MD, associate professor of medicine in the Division of Cardiology at Oregon Health & Science University in Portland.

There was also a significant improvement in most of the major cardiovascular disease (CVD) risk factors, including systolic and diastolic blood pressure, total cholesterol, and fasting glucose levels, he said.

The findings "run contrary to the belief that this population is so involved in daily activities that a [structured risk reduction program] wouldn't work," Dr. Haskell told a news conference here Sunday.

For the study, funded by the Health Trust of Santa Clara County in California, 149 patients at high risk for CVD were identified at regional clinics that serve low-income patients.

One third of the patients were randomized to "usual care" for one year, while two thirds were randomized to the Heart Disease on the Mend year-long multifactor risk reduction program. The program included 60-minute visits once every two months with a dietician or nurse practitioner in addition to routine healthcare examinations. At each visit, goals were reassessed, new targets were set, and any needed medications were provided free of charge.

Mean age of the patients was 57 years, and 56% were women. More than half (57%) were Hispanic, 10% were Asian, 7% were African American, 16% were white, and 10% were of other ethnicity.

Just 33% of participants were fluent in English. Also, 54% had type 2 diabetes, 67% suffered from dyslipidemia, 70% had hypertension, and 38% were obese.

Despite the obstacles, the program worked. "We were exceedingly pleased with its success," Dr. Haskell said.

At 12 months, 91% of patients completed a follow-up visit.

Among the findings at follow-up:



  • Total cholesterol levels were lower among those who received the specialized care: a mean of 184 mg/dL vs. 199 mg/dL for those who received usual care ( P < .01).

  • Mean low-density lipoprotein (LDL) cholesterol was 104 mg/dL in the intervention arm compared with 116 mg/dL for those who received usual care ( P < .01).

  • The mean total cholesterol to high-density lipoprotein cholesterol ratio was 4.2 in the intervention group vs. 4.8 in the usual care group ( P < .001).

  • Mean fasting glucose was 142 mg/dL on average for those given usual care compared with 129 mg/dL in the group given specialized care ( P < .01).

  • Mean diastolic blood pressure was 81 mm Hg in the usual care group vs. 77 mm Hg in the intervention group ( P < .001).



One key risk factor bucked the positive trend: body weight.

"We did not see a significant reduction in body weight," Dr. Haskell said. "This remains at the top of our list of major challenges."

While the Heart Disease on the Mend program helped the medically underserved population, a second systemic intervention program failed to improve adherence to secondary prevention goals among women hospitalized with coronary heart disease.

Lori Mosca, MD, MPH, PhD, director of preventive cardiology at New York-Presbyterian Hospital in New York City, presented the results of the Secondary Prevention Beyond Walls Intervention Trial in Women (WITTI), which enrolled 304 women with coronary heart disease admitted to three academic medical centers between September 2001 and February 2003.

The women were randomized to receive usual care or structured intervention, which included an educational session prior to discharge about eight AHA prevention goals and strategies, behavioral counseling, and structured follow-up by telephone and in person.

Forty-eight percent of the women were white, 34% were black, and 15% were Hispanic.

At six months, there was no significant difference in the summary score for goals met or in the proportion of individual goals achieved between the intervention and usual care groups, Dr. Mosca reported.

For example, only about 60% of patients in both groups attained the LDL goal of less than 100 mg/dL, while less than 20% of patients in both groups were at ideal weight at six months.

One exception: Minority women in the intervention group were 2.4 times more likely to reach the blood pressure goal of less than 140/90 mm Hg compared with minority women in the usual care group (95% confidence interval, 1.13 - 5.03), she said. A logistic regression analysis showed that interaction between ethnic status and type of care was significant for achieving the blood pressure goal.

One of the most striking observations of the study was the loss of 10% to 15% of women to any follow-up whatsoever, Dr. Mosca said. "This was despite the fact we called them at least three times, called their doctors, sent faxes."

Raymond J. Gibbons, MD, chairman of the AHA Committee on Scientific Sessions Program and Arthur and Gladys D. Gray Professor of Medicine at Mayo Medical School in Rochester, Minnesota, said that the findings "were a bit disappointing."

He added, "They point to the need for continuing research and identification of strategies that will be effective in reducing risk factors among women."

Dr. Mosca agreed. Noting that women with CVD tend to be older than their male counterparts, she said, "Many say they are too tired, too old to go to the doctor. I suspect with women that transportation is a key barrier to effective care."

AHA Scientific Sessions 2003: Plenary Session I, Late-Breaking Clinical Trials. Presented Nov. 9, 2003.

Reviewed by Gary D. Vogin, MD

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