Abstract
Studies on the use of and adherence to secondary prevention therapies in patients with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD) are lacking. To evaluate and compare aspirin use, any statin use, high-intensity statin use, and statin adherence among patients with premature or extremely premature ASCVD compared with patients with nonpremature ASCVD. This multicenter cross-sectional study used the clinical and administrative data sets of the US Department of Veterans Affairs (VA) to identify adult patients with at least 1 primary care visit in the VA health care system between October 1, 2014, and September 30, 2015. The study cohort comprised patients with ASCVD (ischemic heart disease, peripheral arterial disease, or ischemic cerebrovascular disease) who were enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. Patients with missing data for date of birth or sex and those with limited life expectancy were excluded. Data were analyzed from November 1, 2019, to January 1, 2020. Premature (the first ASCVD event occurred at age <55 years for men and age <65 years for women) vs nonpremature (the first ASCVD event occurred at age ≥55 years for men or age ≥65 years for women) ASCVD and extremely premature (the first ASCVD event occurred at age <40 years) vs nonpremature ASCVD. The primary outcomes were aspirin use, any statin use, high-intensity statin use, and statin adherence (measured by proportion of days covered [PDC] ≥0.8). Of the 1 248 158 patients identified, 135 703 (10.9%) had premature ASCVD (mean [SD] age, 49.6 [5.8] years; 116 739 men [86.0%]), 1 112 455 (89.1%) had nonpremature ASCVD (mean [SD] age, 69.6 [8.9] years; 1 104 318 men [99.3%]), and 7716 (0.6%) had extremely premature ASCVD (mean [SD] age, 34.2 [4.3] years; 6576 men [85.2%]). Patients with premature ASCVD vs those with nonpremature ASCVD had lower rates of aspirin use (96 468 [71.1%] vs 860 726 [77.4%]; P < .001) and any statin use (98 908 [72.9%] vs 894 931 [80.5%]; P < .001); had a statin PDC of 0.8 or higher (57 306 [57.9%] vs 644 357 [72.0%]; P < .001); and a higher rate of high-intensity statin use (49 354 [36.4%] vs 332 820 [29.9%]; P < .001). Similarly, patients with extremely premature ASCVD were less likely to use aspirin (odds ratio [OR], 0.27; 95% CI, 0.26-0.29), any statin (OR, 0.25; 95% CI, 0.24-0.27), or high-intensity statin (OR, 0.78; 95% CI, 0.74-0.82) and to be statin adherent (OR, 0.44; 95% CI, 0.41-0.47). In this study, patients with premature or extremely premature ASCVD appeared to be less likely to use aspirin or statins and to adhere to statin therapy. This finding warrants further investigation into premature ASCVD and initiatives, including clinician and patient education, to better understand and mitigate the disparities in medication use and adherence.
Highlights
Substantial advancements in prevention of atherosclerotic cardiovascular disease (ASCVD) have led to substantial improvements in adverse cardiovascular events and associated mortality.[1,2,3] Despite the improvements, the incidence of ASCVD has increased in younger patients.[4]
Meaning Results of this study suggest that patients with premature or extremely premature ASCVD have a greater accrued lifetime risk of adverse cardiovascular events, which warrant directed initiatives that can mitigate the disparities in medication use and adherence
A higher proportion of patients with premature ASCVD vs those with nonpremature ASCVD had a body mass index of 30 or higher (75 519 of 135 703 [55.7%] vs 442 891 of 1 112 455 [39.8%]), whereas a lower proportion had a history of diabetes (65 263 [48.1%] vs 565 444 [50.8%]) and hypertension (127 519 [94.0%] vs 1 064 670 [95.7%])
Summary
Substantial advancements in prevention of atherosclerotic cardiovascular disease (ASCVD) have led to substantial improvements in adverse cardiovascular events and associated mortality.[1,2,3] Despite the improvements, the incidence of ASCVD has increased in younger patients.[4]. The use of aspirin and high-intensity statin for secondary prevention of ASCVD is well established and endorsed by multisociety guidelines.[15,16,17,18] A strong association between nonadherence with these secondary prevention measures and increased cardiovascular mortality has been well demonstrated.[19,20] Whether the similarity in rates of cardiovascular mortality between older patients with ASCVD and younger patients with premature ASCVD is attributable to less aggressive implementation of and adherence with secondary prevention strategies among younger adults remains unknown because it has not been studied. A previous investigation evaluated statin use in younger patients, the study was limited to 1 domain of ASCVD (IHD).[21] a thorough assessment of statin use across the entire spectrum of patients with premature ASCVD is unavailable. Data on statin adherence and the use of aspirin in this population are scarce
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