Abstract
BackgroundHigh-potency statin therapy is recommended in the secondary prevention of cardiovascular disease but discontinuation, dose reduction, statin switching, and/or nonadherence occur in practice.ObjectivesTo determine the prevalence and predictors of deviation from high-potency statin use early after a non-ST elevation acute coronary syndrome (NSTE-ACS) and its association with subsequent major adverse cardiovascular events (MACE) and all-cause mortality (ACM).MethodsA total of 1005 patients from a UK-based prospective NSTE-ACS cohort study discharged on high-potency statin therapy (atorvastatin 80 mg, rosuvastatin 20 mg, or 40 mg daily) were included. At 1 month, patients were divided into constant high-potency statin users, and suboptimal users incorporating statin discontinuation, dose reduction, switching statin to a lower equivalent potency, and/or statin nonadherence. Follow-up was a median of 16 months.ResultsThere were 156 suboptimal (∼15.5%) and 849 constant statin users. Factors associated in multivariable analysis with suboptimal statin occurrence included female sex (odds ratio 1.75, 95% confidence interval [CI] 1.14–2.68) and muscular symptoms (odds ratio 4.28, 95% CI 1.30–14.08). Suboptimal statin use was associated with increased adjusted risks of time to MACE (hazard ratio 2.10, 95% CI 1.25–3.53, P = .005) and ACM (hazard ratio 2.46, 95% CI 1.38–4.39, P = .003). Subgroup analysis confirmed that the increased MACE/ACM risks were principally attributable to statin discontinuation or nonadherence.ConclusionsConversion to suboptimal statin use is common early after NSTE-ACS and is partly related to muscular symptoms. Statin discontinuation or non-adherence carries an adverse prognosis. Interventions that preserve and enhance statin utilization could improve post NSTE-ACS outcomes.
Highlights
Cardiovascular disease (CVD) is the leading cause of mortality worldwide.[1,2] In the United States and the United Kingdom, CVD accounts for the largest and second largest proportions of healthcare expenditure of any disease category, respectively.[3,4,5] an acute coronary syndrome (ACS) is a sudden event, most of the morbidity and mortality accrues later, after hospital discharge
Factors associated in multivariable analysis with suboptimal statin occurrence included female sex and muscular symptoms
Suboptimal statin use was associated with increased adjusted risks of time to major adverse cardiovascular events (MACE) and all-cause mortality (ACM)
Summary
Cardiovascular disease (CVD) is the leading cause of mortality worldwide.[1,2] In the United States and the United Kingdom, CVD accounts for the largest and second largest proportions of healthcare expenditure of any disease category, respectively.[3,4,5] an acute coronary syndrome (ACS) is a sudden event, most of the morbidity and mortality accrues later, after hospital discharge. After an ACS, high-potency statin therapy, prescribed as atorvastatin 80 mg daily, is indicated because it has been demonstrated in randomized controlled trials (RCTs) to be highly effective and superior to both placebo and moderate statin therapy for reducing cardiovascular events.[6,7,8] the effectiveness of drugs in RCTs can be undermined in clinical practice by several factors including poor adherence, discontinuation, and switching prescriptions to a lower equivalent potency. Poor statin adherence has been reported in up to 50% of patients,[9] statin discontinuation rates vary from 15%10 to 60% to 75%11,12 and changing to lower potency statin therapy has been noted in w1%13 to 42%14 of patients. High-potency statin therapy is recommended in the secondary prevention of cardiovascular disease but discontinuation, dose reduction, statin switching, and/or nonadherence occur in practice
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