Diagnosis Of Atherosclerotic Cardiovascular Disease Research Articles

Assessment and management of cardiovascular risk factors among U.S. Veterans with newly diagnosed prostate cancer.

5510 Background: Cardiovascular disease (CVD) is a leading cause of death in men with prostate cancer (PC). Androgen deprivation therapy (ADT) is associated with increased CVD risk, and American Heart Association guidelines recommend CVD risk factor assessment and management in PC patients starting ADT. We characterized rates of guideline-concordant assessment and management of CVD risk factors for US Veterans with newly diagnosed PC, according to ADT use and prior atherosclerotic CVD diagnosis. Methods: We used cross-sectional data from VA Corporate Data Warehouse to identify Veterans with an incident diagnosis of PC from 2001-2017. Primary outcomes were guideline-concordant baseline CVD risk factor assessment (defined as ≥1 blood pressure, cholesterol, and HbA1c or fasting glucose measurement within 1 year prior to 6 months after ADT start or PC diagnosis), CVD risk factor control, and CVD risk-reducing medication use. Risk difference multivariable regression analyses adjusting for age, race, poverty, PC risk category, and year were used to evaluate the effect of ADT on study outcomes. Results: Of 191,829 Veterans with newly diagnosed PC, 27% (n = 51,419) were treated with ADT within 1 year of diagnosis, and 18% (n = 34,110) had a pre-existing diagnosis of atherosclerotic CVD. From 2001-2017, annual rates of guideline-concordant CVD risk factor assessment increased from 26% to 77%. In adjusted analyses, pre-existing atherosclerotic CVD diagnosis was associated with higher CVD risk factor assessment rate (64% vs 53%), better control of baseline LDL (94 vs 108 mg/dL), and higher rates of anti-hypertensive (90% vs 66%), lipid-lowering (83% vs 49%), and glucose-lowering (32% vs 20%) medication use. Treatment with ADT was associated with similar to minimally higher rates of CVD risk factor assessment (58% vs 54%), LDL control (104 vs 105 mg/dL), and anti-hypertensive (73% vs 69%), lipid-lowering (55% vs 55%), and glucose-lowering (25% vs 21%) medication use. Sixty percent of men starting ADT had at least one sub-optimally controlled CVD risk factor, and 1 in 4 of these men were not receiving a corresponding risk-reducing medication. One third of men starting ADT had BMI > 30 kg/m2. Conclusions: CVD risk factor assessment in Veterans with PC has increased over time. However, ADT does not appear to meaningfully impact CVD assessment or management, despite its known association with CVD risk. Over half of patients initiating ADT had elevated CVD risk factor(s). Multi-disciplinary efforts to improve CVD risk mitigation are needed among men initiating ADT.

Abstract 291: Changes In Prescribing Patterns Before And After Price Reduction In Pcsk9 Inhibitors

Introduction: Atherosclerotic cardiovascular disease (ASCVD) is one of the leading causes of morbidity and mortality worldwide. There have been many advances in the lipid management of these patients from statin therapy to the more recent PCSK9 inhibitors. PCSK9 inhibitors (PCSK9i) have been shown to reduce cardiovascular events in patients with ASCVD. Despite their efficacy, there have been challenges to physicians adopting widespread use of PCSK9i, particularly cost. Our goal is to evaluate PCSK9i utilization in a real world setting before and after reduction in costs of PCSK9i. Methods: We retrospectively reviewed a large metropolitan outpatient cardiology practice EMR database to evaluate the demographics of their patient population as well as individual prescriber habits to determine their utilization of PCSK-9i before and after the price reduction in March 2016. All data were compared using χ 2 and student t-test via IBM SPSS version 25. Results: Patients were included if they had a diagnosis of ASCVD and had been seen once between January and December 2019. Among eligible patients, despite reduction in cost, only 4.1% (1059 of 25749) were prescribed a PCSK9i. Compliance with PSCK9i from 2015 to 2019 improved from 20% (9 of 45) to 68% (215 of 316). The percentage of patients with insurance approval for a PCSK9i via commercial carriers increased by over 10% after the 2016 price decrease (31.0% [155 of 500] to 41.3% [231 of 559], P<0.001). Data can be seen in Table 1. Conclusions: In a large metropolitan cardiology practice, of over 25,000 patients eligible for a PCSK9i, only 4.1% were actively prescribed. Although compliance increased over threefold over the study period, there are still clear barriers to prescribing and compliance with PCSK9i. Despite the cost reduction, women and older patients were less likely to be treated with a PCSK9i. Additional barriers exist for prescribing for eligible patients, particularly in older women.

Gender differences in major adverse cardiovascular outcomes among aged over 60 year-old patients with atherosclerotic cardiovascular disease: A population-based longitudinal study in Taiwan.

Atherosclerotic cardiovascular disease (ASCVD) including cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial disease (PAD), contributes to the major causes of death in the world. Although several studies have evaluated the association between gender and major adverse cardiovascular outcomes in old ASCVD patients, the result is not consistent. Hence, we need a large-scale study to address this issue.This retrospective cohort study included aged over 60 year-old patients with a diagnosis of ASCVD, including CVD, CAD, or PAD, from the database contained in the Taiwan National Health Insurance Bureau during 2001 to 2004. The matched cohort was matched by age, comorbidities, and medical therapies at a 1:1 ratio. A total of 9696 patients were enrolled in this study, that is, there were 4848 and 4848 patients in the matched male and female groups, respectively. The study endpoints included acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, in-hospital mortality, and so on. In multivariate Cox regression analysis in matched cohort, the adjusted hazard ratios (HRs) for female group in predicting acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality were 0.67 (P < .001), 0.73 (P = .0015), 0.78 (P < .001), 0.59 (P < .001), and 0.77 (P = .0007), respectively.In this population-based propensity matched cohort study, age over 60 year-old female patients with ASCVD were associated with lower rates of acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality than male patients. Further prospective studies may be investigated in Taiwan.

Predictors of Statin Intolerance in Patients With a New Diagnosis of Atherosclerotic Cardiovascular Disease Within a Large Integrated Health Care Institution: The IMPRES Study.

Statins are among the most prescribed medications because of the well-documented benefits of safely lowering low-density lipoprotein cholesterol. However, many patients are unable or unwilling to continue statin therapy because of real or perceived adverse effects. This study sought to increase understanding about which patients are unlikely to tolerate statin therapy. The Intermountain Healthcare's electronic data repository was queried from January 1, 1999, to December 31, 2013, to identify all adults who survived their first encounter of coronary artery disease (CAD), cerebral vascular disease, or peripheral artery disease and received statin therapy during follow-up. Statin intolerance (SI) was identified by the documentation of clinician-noted intolerance or allergy or by the use of pitavastatin. Patients were followed up for ≥3 years or until death. Of the 48,997 patients evaluated, 3049 (6.2%) were documented with SI. Of those with SI, 9.8% were prescribed a low-intensity, 73.4% a moderate-intensity, and 16.8% a high-intensity statin dose. After adjustment for covariables, significant predictors of SI were female sex [odds ratio (OR) = 1.47, P < 0.0001], age (65-74 vs. <65: OR = 1.15, P = 0.002; ≥75 vs. <65: OR = 0.90, P = 0.03), hypertension (OR = 1.11, P = 0.01), hyperlipidemia (OR = 1.31, P < 0.0001), smoking (OR = 0.88, P = 0.001), renal failure (OR = 1.20, P = 0.009), heart failure (OR = 1.26, P < 0.0001), sleep apnea (OR = 1.22, P < 0.0001), prior malignancy (OR = 1.18, P = 0.007), depression (OR = 1.13, P = 0.04), and index atherosclerotic cardiovascular disease diagnosis (CAD vs. cerebral vascular disease: OR = 1.71, P < 0.0001; CAD vs. peripheral artery disease: OR = 1.23, P = 0.02). In this study, the strongest identified clinical predictor of future SI was female sex. Many standard cardiovascular risk factors were also associated with SI, suggesting that patients with multiple comorbidities are more likely to be vulnerable.

Abstract P249: Association Between Cardiovascular Event Type And Smoking Cessation Rates Among Outpatients With Atherosclerotic Cardiovascular Disease: Insights From The Ncdr Pinnacle Registry

Introduction: Understanding the factors that drive cessation may help inform patient counseling and improve quit rates. We aimed to determine if the type of atherosclerotic cardiovascular disease (ASCVD) event impacts the patient’s likelihood of quitting, independent of patient factors. Hypothesis: We assessed the hypothesis that more impactful ASCVD events would be associated with a greater likelihood of smoking cessation (e.g., more likely to quit after CABG vs PCI). Methods: Using 2013-2016 data from the NCDR PINNACLE outpatient cardiac registry, we identified patients who were current smokers and had an eventual diagnosis of ASCVD. Self-reported smoking status was assessed at each consecutive visit and rates of smoking cessation after each interim ASCVD event (MI, PCI, CABG, stroke/TIA, and PAD diagnosis) were examined. We then constructed separate Cox models with non-proportional hazards for interim ASCVD events (time-dependent covariates), adjusting for age, sex, race, dyslipidemia, diabetes, hypertension, and heart failure; and compared models using AIC. Results: Across 358 cardiology practices, 378478 patients were smokers who eventually had ASCVD (mean age 65.8±11.9, male 63.6%). Cessation rates after each ASCVD event were: MI 30.5%, PCI 30.7%, CABG 28.5%, stroke/TIA 24.7%, and PAD 24.6% (Table). After multivariable adjustment, patients were more likely to quit smoking after a stroke/TIA (HR 2.46, 95% CI 2.40-2.52) followed by CABG (HR 2.45, 95% CI 2.37-2.53), PCI (HR 1.85, 95% CI 1.79-1.91), MI (HR 1.79, 95% CI 1.72-1.86), and a new diagnosis of PAD (HR 1.47, 95% CI 1.42-1.51); p&lt;0.0001 for all events. Conclusion: In a large US registry, we found that only ~25-30% of patients reported quitting smoking after an ASCVD event, but the type of ASCVD event significantly impacts the likelihood of smoking cessation. Using these data to inform patient counseling—targeting cessation efforts to those most likely to quit—may help improve outcomes.

Contemporary use of lipid-lowering therapy for secondary prevention in Korean patients with atherosclerotic cardiovascular diseases.

Background/AimsWe evaluated the contemporary use of lipid-lowering therapy (LLT) in Korean patients with atherosclerotic cardiovascular disease (ASCVD), and identified factors associated with statin non-prescription.MethodsUsing the Korean Health Insurance Review and Assessment data, we identified LLT-naïve subjects newly diagnosed with ASCVD between 2011 and 2012, and followed up until 2015. LLT-naïve status was defined as no LLT prescription for 1 year before ASCVD diagnosis. ASCVD was defined as first hospitalization or emergency room visit for coronary artery disease (CAD), acute cerebrovascular disease (CVD), or peripheral artery disease (PAD). Statin intensity was defined per the 2013 American College of Cardiology/American Heart Association guideline for cholesterol treatment.ResultsThe study enrolled 80,884 subjects newly diagnosed with ASCVD, of whom only 48,725 (60.2%) received LLT during the follow-up period. Statin, combination of statin and non-statin, and non-statin LLT were administered in 50.5%, 9.7%, and 0.1% of all subjects, respectively. Statins were prescribed to 80.4% of CAD patients but only to 50.2% and 46.8% of CVD and PAD patients. Statin-based LLT usually had moderate- (77.2%) or high-intensity (18.5%). Subjects not prescribed statins were younger or older (< 40 or ≥ 70 years), more commonly female, and more likely to have comorbidities. Statins were prescribed at the time of ASCVD diagnosis in 45.5% of all subjects, and in 53.0% within 90 days of diagnosis.ConclusionsOnly 60% of LLT-naïve Korean patients newly diagnosed with ASCVD received statins. Statins were often prescribed in subjects with CAD but less commonly in those with CVD or PAD. Moderate-intensity statins were most frequently used.

Association of Depression Risk with Patient Experience, Healthcare Expenditure, and Health Resource Utilization Among Adults with Atherosclerotic Cardiovascular Disease.

Approximately 20% of patients with atherosclerotic cardiovascular disease (ASCVD) suffer from depression. To compare healthcare expenditures and utilization, healthcare-related quality of life, and patient-centered outcomes among ASCVD patients, based on their risk for depression (among those without depression), and those with depression (vs. risk-stratified non-depressed). The 2004-2015 Medical Expenditure Panel Survey (MEPS) was used for this study. Adults ≥ 18years with a diagnosis of ASCVD, ascertained by ICD-9 codes and/or self-reported data. Individuals with a diagnosis of depression were identified by ICD-9 code 311. Participants were stratified by depression risk, based on the Patient Health Questionnaire-2. A total of 19,840 participants were included, translating into 18.3 million US adults, of which 8.6% (≈ 1.3 million US adults) had a high risk for depression and 18% had a clinical diagnosis of depression. Among ASCVD patients without depression, those with a high risk (compared with low risk) had increased overall and out-of-pocket expenditures (marginal differences of $2880 and $287, respectively, both p < 0.001), higher odds for resource utilization, and worse patient experience and healthcare quality of life (HQoL). Furthermore, compared with individuals who had depression, participants at high risk also reported worse HQoL and had higher odds of poor perception of their health status (OR 1.83, 95% CI [1.50, 2.23]) and poor patient-provider communication (OR 1.29 [1.18, 1.42]). The sample population includes self-reported diagnosis of ASCVD; therefore, the risk of underestimation of the cohort size cannot be ruled out. Almost 1 in 10 individuals with ASCVD without diagnosis of depression is at high risk for it and has worse health outcomes compared with those who already have a diagnosis of depression. Early recognition and treatment of depression may increase healthcare efficiency, positive patient experience, and HQoL among this vulnerable population.

VEGFR2 and OPG genes modify the risk of subclinical coronary atherosclerosis in patients with familial hypercholesterolemia

Background and aimsHeterozygous familial hypercholesterolemia (FH) is a genetic disorder characterized by high levels of low-density lipoprotein cholesterol (LDL-C). The magnitude of atherosclerotic cardiovascular disease (ASCVD) risk in FH patients is highly variable, and this can result from genetic factors. The aim of our study was to characterize whether polymorphisms in VEGFR2 and OPG genes could influence the expression of ASCVD in FH patients. MethodsWe studied 318 FH patients from the SAFEHEART registry, without clinical diagnosis of ASCVD. A coronary tomographic angiography (CTA) was performed to determine and evaluate the presence of coronary stenosis and coronary artery calcium, as measured by coronary calcium score (CCS). Genotyping of OPG rs2073618 and VEGFR2 rs2071559 polymorphisms was performed using TaqMan 5′-exonuclease allelic discrimination assays. ResultsHomozygous GG genotype and G allele of VEGFR2 rs2071559 polymorphism were associated with decreased risk of developing coronary artery stenosis. In the analysis of OPG rs2073618 and VEGFR2 rs2071559 polymorphisms, according to the presence of coronary artery calcium, we found significant differences in both polymorphisms. Homozygous GG genotype and G allele of VEGFR2 rs2071559 polymorphism were associated with decreased risk of accumulation of coronary artery calcium measured by CCS in CTA. Moreover, being a carrier of the GG genotype and G allele of the OPG rs2073618 polymorphism increased the risk of the presence of coronary artery calcium measured by CCS in CTA. ConclusionsPolymorphisms in VEGFR2 and OPG genes modify the risk of ASCVD in FH patients.

Guidelines impact cholesterol management

Previous research demonstrates increased utilization of high-intensity statins, but unchanged low-density lipoprotein cholesterol (LDL-C) levels, immediately after the 2013 American College of Cardiology (ACC) and the American Heart Association (AHA) guideline release. The objective of this study was to determine achievement of statin therapy goals in patients with atherosclerotic cardiovascular disease (ASCVD) before and up to 4years after the 2013 ACC/AHA guideline release compared with LDL-C goals of <70mg/dL and <100mg/dL previously recommended by other professional societies. The single-system cohort study used medical records, laboratory results, and claims data (November 2012-October 2017) of adults with ≥1 claim for a statin, ≥1 ASCVD diagnosis in propensity score-matched analyses. Among 1938 patients (mean age 70 ± 11, 48% female) with ASCVD, the percentage on high-intensity statin therapy significantly increased over time: 24% in 2013, 34% 2014, 42% 2015, and 49% 2016 (P<.0001). The increase in high-intensity statin use was 13 to 22% higher among patients managed by subspecialists (cardiologist and endocrinologists) compared with those managed by primary care providers. Mean LDL-C level was slightly, but not significantly, lower in 2013 (80mg/dL) than in other years: 85mg/dL in 2014, 83mg/dL in 2015, and 82mg/dL in 2016. The proportion of patients reaching LDL-C goals ranged from 51% to 56% for the <70mg/dL target and 77% to 85% for the <100mg/dL target over time. High-intensity statin use among secondary prevention patients increased significantly immediately after the 2013 ACC/AHA guidelines release, primarily in those managed by subspecialists. However, the mean LDL-C and the proportion of patients reaching LDL-C < 70mg/dL and < 100mg/dL remain unchanged across comparison cohorts.

Impact of an integrated clinical and specialty pharmacy service model on access to PCSK9 inhibitor therapy

Background: Despite the proven benefits of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in dramatically lowering low-density lipoprotein cholesterol (LDL-C) levels, access to these costly medications remains challenging. A recent nationwide report of over 51,000 patients prescribed a PCSK9 inhibitor found that only 47% of patients gained insurance approval, with an average time to approval of 29 days. Vanderbilt Specialty Pharmacy (VSP) developed a model to streamline insurance approval and increase patient access to evolocumab and alirocumab.Objectives: To evaluate the time to PCSK9 inhibitor approval and factors that impact time to approval in an integrated specialty pharmacy model.Methods: A single-center, retrospective cohort study of patients prescribed a PCSK9 inhibitor by a Vanderbilt University Medical Center provider between 1 September 2015 and 1 December 2016 was conducted. The primary endpoint was days to treatment approval from first provider treatment request. Secondary endpoints were patient, prescriber, and clinical factors related to treatment approval. Descriptive statistics, univariate, and multivariable Cox regression analyses were performed to evaluate the impact of specified factors on the time to treatment approval.Results: VSP gained access to PCSK9 inhibitor treatment through insurers in 264 patients during the study period. The majority were male (52%) with a mean age of 62 (SD ±11) and mean baseline LDL-C of 162mg/dL (SD ±57). The median time to medication approval was 7 days, ranging of 0–266. Mean time to medication approval was 17 days (SD ±25). On univariate analysis, older patients (≥65) were significantly more likely to achieve approval earlier compared to those <65 years (p = .031) as were patients prescribed PCSK9 therapy for atherosclerotic cardiovascular disease (ASCVD) (p < .001). The time to medication approval was longer when a prior authorization (PA) was required (HR 0.17, SD ±0.5; p < .001) or a first level appeal was required (HR 0.28, SD ±0.04; p < .001). On multivariable analysis, older age, the requirement of a PA, and the requirement of a first level appeal remained significant predictors to the time to medication approval (p < .001).Conclusions: The VSP model of an integrated clinical pharmacist and pharmacy technician expedited the time to PCSK9 inhibitor access and initiation. As expected, the need for a prior authorization or appeal increased the time to approval. However, age and diagnosis of ASCVD positively impacted time to approval.

Abstract 240: Association of Depression Risk With Patient Experience, Healthcare Expenditure and Health Resource Utilization Among Adults With Atherosclerotic Cardiovascular Disease

Background: Approximately 20% of patients with atherosclerotic cardiovascular disease (ASCVD) suffer from depression. Currently, these two conditions are the most common causes of disability in high-income countries and projected to become so for all countries by 2030. Depression is a risk marker for ASCVD and associated with worse health outcomes. In a nationally representative US adult population, we evaluate patient experience, healthcare expenditure and resource utilization among non-depressed ASCVD patients based on their risk for depression. Methods: The 2004-2015 Medical Expenditure Panel Survey (MEPS), a nationally representative sample was the basis for our study. We included adults ≥18 years with a diagnosis of ASCVD, ascertained by ICD9 codes and/or self-reported data and excluded those with a diagnosis of Depression, identified by ICD9 code 311. Individuals were stratified by depression risk (based on the Patient Health Questionnaire-2): Two-part econometric model was used to study cost data, and regression models for all other associations, adjusted for ASCVD risk factors. Results: The study sample consisted of 16,136 ASCVD patients without the diagnosis of depression (aged 67 ± 10 years, 55% male), translating into 179.2 million US adults, of which 8.6% (15.5 million US adults) had a high risk for depression. Individuals with high vs. low risk for depression had higher overall and out-of-pocket healthcare expenditures ($1,200 &amp; $353, respectively; both p &lt; 0.001). Additionally, those with high risk had higher odds for hospitalizations [OR 1.75 (1.75, 2.32)], poor self-perceived health status [OR 4.83 (3.28, 7.12)], poor patient-provider communication scores [OR 2.44 (1.93, 3.09)], poor patient satisfaction [OR 3.33 (1.64, 6.77)], and significantly worse healthcare-related quality of life measures than those with low risk for depression (Table). Conclusion: Among ASCVD patients without a diagnosis of depression, individuals with a greater risk for depression were more likely to report worse healthcare experience, increased resource utilization and higher healthcare spending. To enhance health outcomes and increase healthcare efficiency, more aggressive screening for depression risk to promote improved recognition and intervention are needed among this vulnerable population.

Patient-reported adherence to statin therapy, barriers to adherence, and perceptions of cardiovascular risk.

BackgroundPatient reports of their adherence behaviors, concerns about statins, and perceptions of atherosclerotic cardiovascular disease (ASCVD) risk could inform approaches for improving adherence to statin therapy. We examined these factors and their associations with adherence.MethodsWe conducted telephone interviews among a stratified random sample of adults receiving statins within an integrated delivery system (N = 730, 81% response rate) in 2010. We sampled equal numbers of individuals in three clinical risk categories: those with 1) coronary artery disease; 2) diabetes or other ASCVD diagnosis; and 3) no diabetes or ASCVD diagnoses. We assessed 15 potential concerns about and barriers to taking statins, and perceived risk of having a heart attack in the next 10 years (0–10 scale). We calculated the proportion of days covered (PDC) by statins in the last 12 months using dispensing data and used multivariate logistic regression to examine the characteristics associated with non-adherence (PDC<80%). Analyses were weighted for sampling proportions.ResultsSixty-one percent of patients with PDC<50% reported not filling a new prescription, splitting or skipping statins, or stopping refilling statins in the last 12 months vs. 15% of those with PDC≥80% (p<0.05). The most commonly reported concerns about statins were preferring to lower cholesterol with lifestyle changes (66%), disliking medications in general (59%), and liver or kidney problems (31%); having trouble remembering to take statins (9%) was the most common reason for taking less than prescribed. In multivariate analyses, clinical risk categories were not significantly associated with odds of non-adherence; however, those with higher perceived risk of heart attack were less likely to be non-adherent.ConclusionsPatient-reported medication-taking behaviors were correlated with statin PDC and those with lower perceived cardiovascular risk were less likely to be adherent. These findings highlight the importance of eliciting from and educating patients on their adherence behaviors and ASCVD risks.

Clinical characteristics, patterns of lipid-lowering medication use, and health care resource utilization and costs among patients with atherosclerotic cardiovascular disease.

PurposeThe aim of this study was to investigate real-world patient characteristics, medication use, and health care resource utilization (HCRU) and costs among patients with clinical atherosclerotic cardiovascular disease (ASCVD) as defined by 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, to examine burden of disease and unmet needs, such as potential undertreatment.Patients and methodsThis retrospective cohort study utilized a nationally representative managed care database to identify newly diagnosed ASCVD patients between January 1, 2007, and November 30, 2012 (index = first ASCVD diagnosis date) in the USA. Patients had ≥12-month pre-index (baseline) and ≥12-month post-index (follow-up) health plan enrollment and no baseline lipid-lowering medication (LLM). Patient characteristics, LLM utilization patterns, HCRU, and costs were examined for all patients and by subgroups based on LLM use pattern and/or follow-up low-density lipoprotein cholesterol (LDL-C) levels.ResultsA total of 128,017 ASCVD patients were identified with a mean (SD) age of 59 (13) years, 43.1% female, and 48.8% with ≥36-month follow-up. Within 12-month follow-up, 10.6% had high-intensity statins and 56.9% had no LLM fills. Baseline mean (SD) all-cause costs were $8,852 ($25,608). At 12-month follow-up, mean (SD) all-cause and ASCVD-related costs were $31,443 ($54,040) and $20,289 ($45,159), respectively. The 36-month analyses showed similar distributions. Multivariable analyses showed that age, gender, region, health insurance type, baseline comorbidities, baseline use of specific medications, baseline lipid profiles, and index ASCVD type were significantly associated with all-cause and ASCVD-related health care costs.ConclusionPatients have nonoptimal treatment for ASCVD and substantial HCRU and costs associated with residual risk. Unmet needs and cost burdens of ASCVD patients merit additional investigation.

Paleogenetic study on the 17th century Korean mummy with atherosclerotic cardiovascular disease.

While atherosclerotic cardiovascular disease (ASCVD) is known to be common among modern people exposed to various risk factors, recent paleopathological studies have shown that it affected ancient populations much more frequently than expected. In 2010, we investigated a 17th century Korean female mummy with presumptive ASCVD signs. Although the resulting report was a rare and invaluable conjecture on the disease status of an ancient East Asian population, the diagnosis had been based only on anatomical and radiological techniques, and so could not confirm the existence of ASCVD in the mummy. In the present study, we thus performed a paleogenetic analysis to supplement the previous conventional diagnosis of ASCVD. In aDNA extracted from the same Korean mummy, we identified the risk alleles of seven different SNPs (rs5351, rs10757274, rs2383206, rs2383207, rs10757278, rs4380028 and rs1333049) that had already been revealed to be the major risk loci of ASCVD in East Asian populations. The reliability of this study could be enhanced by cross-validation using two different analyses: Sanger and SNaPshot techniques. We were able to establish that the 17th century Korean female had a strong genetic predisposition to increased risk of ASCVD. The current paleogenetic diagnosis, the first of its kind outside Europe, re-confirms its utility as an adjunct modality for confirmatory diagnosis of ancient ASCVD.

Trends in prescribing rate of statins at discharge and modifiable factors in patients with atherosclerotic cardiovascular disease.

Tremendous effort has been invested in reducing the prevalence of atherosclerotic cardiovascular disease (ASCVD) in China. Meanwhile, accumulating evidence has emerged to show the benefits of statins in the prevention of cardiovascular disease. The present study investigated the change trends of statins prescription at discharge among patients with ASCVD in recent years, differences across subtypes of ASCVD, and associated factors. The study included 51,972 patients with a discharge diagnosis of ASCVD who were hospitalized in West China Hospital from 2008 to 2014. Trends of statins prescription rates between subtypes of ASCVD were compared and potential influential factors were explored. The overall statins prescription rate in patients with ASCVD was 58.8%. Adjusted odds ratios (ORs) of increase in prescription rate per year were 1.15 (95% CI 1.13-1.17, p<0.001), 1.14 (95% CI 1.10-1.17, p<0.001), 1.19 (95% CI 1.16-1.23; p<0.001), 1.14 (95% CI 1.09-1.19; p<0.001), and 1.13 (95% CI 1.09-1.17; p<0.001) for ASCVD, coronary artery disease, cerebrovascular disease, peripheral arterial disease (PAD), and polyvascular disease, respectively; no significant differences in trends were detected among ASCVD subtypes. However, statins prescription rates were persistently lower in cerebrovascular disease and PAD than the other two subtypes. Discharge departments, together with other physician-related and patient-related characteristics were associated with statins utilization. In conclusion, between 2008 and 2014, statins prescription rate in patients with ASCVD was not optimal. The increasing trends in statins prescription among patients with ASCVD subtypes were similar but the differences did not decrease. Consciousness of integrated and successive medical care should be strengthened in China.

Predicting Cardiovascular Events in Familial Hypercholesterolemia: The SAFEHEART Registry (Spanish Familial Hypercholesterolemia Cohort Study).

Although risk factors for atherosclerotic cardiovascular disease (ASCVD) in familial hypercholesterolemia (FH) have been described, models for predicting incident ASCVD have not been reported. Our aim was to use the SAFEHEART registry (Spanish Familial Hypercholesterolemia Cohort Study) to define key risk factors for predicting incident ASCVD in patients with FH. SAFEHEART is a multicenter, nationwide, long-term prospective cohort study of a molecularly defined population with FH with or without previous ASCVD. Analyses to define risk factors and to build a risk prediction equation were developed, and the risk prediction equation was tested for its ability to discriminate patients who experience incident ASCVD from those who did not over time. We recruited 2404 adult patients with FH who were followed up for a mean of 5.5 years (SD, 3.2 years), during which 12 (0.5%) and 122 (5.1%) suffered fatal and nonfatal incident ASCVD, respectively. Age, male sex, history of previous ASCVD, high blood pressure, increased body mass index, active smoking, and low-density lipoprotein cholesterol and lipoprotein(a) levels were independent predictors of incident ASCVD from which a risk equation with a Harrell C index of 0.85 was derived. The bootstrap resampling (100 randomized samples) of the original set for internal validation showed a degree of overoptimism of 0.003. Individual risk was estimated for each person without an established diagnosis of ASCVD before enrollment in the registry by use of the SAFEHEART risk equation, the modified Framingham risk equation, and the American College of Cardiology/American Heart Association ASCVD Pooled Cohort Risk Equations. The Harrell C index for these models was 0.81, 0.78, and 0.8, respectively, and differences between the SAFEHEART risk equation and the other 2 were significant (P=0.023 and P=0.045). The risk of incident ASCVD may be estimated in patients with FH with simple clinical predictors. This finding may improve risk stratification and could be used to guide therapy in patients with FH. URL: http://clinicaltrials.gov. Unique identifier: NCT02693548.

Abstract 112: Statin Utilization in the Outpatient Clinic of a University Based Residency Training Program

Background: Current guidelines released in 2013 recommend statins for five specific patient groups including persons with clinical atherosclerotic cardiovascular disease (ASCVD) and diabetes. National estimates of statin utilization in 2012 report statin use in persons with ASCVD at 58.8% and 63.5% among persons with diabetes. A recent review also showed suboptimal statin prescription rates prior to 2013, with only 23% being prescribed a statin at goal dose. Our goal was to assess statin prescriptions in a large resident run outpatient clinic and identify factors affecting statin prescriptions as potential targets for intervention to improve compliance with the guidelines. Methods: We obtained data from the medical record data warehouse of a primary care outpatient clinic within a large safety-net hospital from Jan–Dec 2015. The clinic is predominantly run by internal medicine residents and supervised by general internal medicine attending physicians. Patients with a diagnosis of ASCVD and diabetes were identified and electronic medical records abstraction was done to identify persons who were prescribed a statin (regardless of dose). Bivariate analyses were conducted to identify potential factors affecting statin prescriptions. Results: Our patient population was predominantly African American, representing more than 70% of our clinic patients. We found 87% of persons with ASCVD and 70% of persons with diabetes were on statin. We found no differences in statin prescriptions by demographic characteristics among persons with ASCVD. Among patients with diabetes, younger age (p&lt;0.01), female sex (p&lt;0.05), non-black race (p&lt;0.05) and private insurance/lack of insurance (p&lt;0.01) were associated with a lower likelihood of being prescribed a statin. Conclusion: Statin prescriptions among patients with ASCVD and diabetes appear to be higher in our patient population compared to prior national estimates, however statin prevalence remains suboptimal. Our next steps are to begin a targeted educational intervention for residents in the continuity clinic and ultimately demonstrate that resident driven intervention is an effective way to increase compliance with the guidelines.

Missed Opportunities for Primary Prevention of Cardiovascular Disease in an HIV Clinic

Background Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of death among people living with HIV (PLWH). PLWH have a high prevalence of ASCVD risk factors, including hypertension (HTN), dyslipidemia, diabetes mellitus (DM), elevated BMI, smoking, physical inactivity, and poor diet.Methods Setting—Urban Ryan White funded clinic in Columbia, SC providing care to about 2200 PLWH. A retrospective chart review was performed on a sample of patients ≥40 years old. Patients were eligible if they did not have a known diagnosis of ASCVD, had ≥ 3 visits in the last 3 years, and at least 1 visit in the past 12 months. Data regarding demographics, comorbidities, lab values, medications, and recent blood pressures were abstracted. Data were collected on assessment and intervention for smoking, weight loss, diet, and exercise. Objectives of this study were to: (1) determine the prevalence of ASCVD risk factors among patients without known ASCVD; (2) estimate the proportion of patients who received appropriate pharmacologic and lifestyle interventions. ResultsCharts were reviewed in random order until 100 charts had the required variables to calculate the 10-year ASCVD risk (Figure 1). These complete charts were similar in demographic characteristics to the clinic population. Of the complete charts, 66% met BMI criteria for being obese or overweight; but < 30% of these patients had documentation of the diagnosis, or received appropriate intervention for diet, exercise, or weight loss. HTN was diagnosed in 42% of patients, and 52% of these were adequately controlled. An additional 9% met criteria for HTN but did not carry the diagnosis. Documented diagnosis of DM was surprisingly low at <5%. Nurses assessed smoking in 100% of patients, and the majority of smokers received an intervention. Based on current guidelines, less than 25% of eligible patients were prescribed a statin (Figure 2). To our concern, none of the patients with LDL ≥190 mg/dL or DM had evidence of statin therapy.Conclusion Although > 85% of clinic patients have an undetectable HIV viral load, there were multiple missed opportunities for primary prevention of cardiovascular disease, including interventions for smoking cessation, diet and exercise, and guideline based anti-HTN and statin therapy.Figure 1:Disclosures A. Jones, Proctor & Gamble: Stock, Dividend. CVS Health Corp: Stock, Dividend. Johnson & Johnson: Stock, Dividend. Baxter Inc.: Stock, Dividend. Becton-Dickinson: Stock, Dividend. United Health Group: Stock, Dividend

Antihyperlipidemic Medication Treatment Patterns and Statin Adherence Among Patients with ASCVD in a Managed Care Plan After Release of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol.

The American College of Cardiology (ACC) and American Heart Association (AHA) released a new blood cholesterol treatment guideline in November 2013. It is unknown how the new recommendations have affected cholesterol medication use and adherence in a commercial health plan. To evaluate the effect of the 2013 guideline release on antihyperlipidemic treatment patterns and statin adherence in patients with atherosclerotic cardiovascular disease (ASCVD) compared with a historical control group. This study was a historical cohort analysis of adult patients (aged 21-75 years) with clinical ASCVD enrolled in a SelectHealth commercial health plan. Patients were included in the guideline implementation cohort if they had a medical claim with an ICD-9-CM diagnosis of ASCVD in the year before the November 2013 ACC/AHA guideline release. The index date was defined as the first outpatient medical claim with an ICD-9-CM for ASCVD in the first 6 months after the guideline was released. Patients were required to have continuous enrollment for ≥ 1 year before and after the index date. These same criteria were applied to patients exactly 4 years earlier to identify a historical control group. Patients meeting these criteria formed the antihyperlipidemic treatment patterns cohort. Of these, patients who also had ≥1 pharmacy claim for a statin in the 1-year pre- and post-index periods were included in the statin adherence cohort. Antihyperlipidemic treatment patterns were assessed using pharmacy claims for antihyperlipidemic medications in the 1-year pre- and post-index periods. Antihyperlipidemic medication claims were classified as a nonstatin cholesterol medication, low-intensity statin, moderate-intensity statin, or high-intensity statin. To address differences in pre-index antihyperlipidemic medications between the guideline implementation and historical control groups, patients were randomly matched 1:1 based on pre-index classification in a post hoc analysis. Post-index antihyperlipidemic classifications were compared between groups using a Stuart-Maxwell test. The change in mean statin adherence (proportion of days covered [PDC]) was compared within and between groups using paired and independent t-tests, respectively. The proportion of adherent patients (PDC ≥ 0.80) in the pre- and post-index periods was compared between groups using a chi-square test. A multivariable logistic regression was used to compare the likelihood of being adherent in the post-index period while controlling for pre-index adherence and other potential confounders. A total of 7,818 adult members with ASCVD in the index period and 1 year before the index period were identified. Of those, 1,841 patients met the criteria to be included in the analysis, and 1,526 patients were matched on antihyperlipidemic classification and included in the antihyperlipidemic treatment patterns analysis. Baseline characteristics were similar, although the guideline implementation group was younger (58.3 vs. 60.5 years, P < 0.001), and more were male (74.8% vs. 71.3%, P = 0.106) than the historical control group. In the matched cohort, there was a significant difference in the post-index antihyperlipidemic classification (P < 0.001), which appeared to be a result of the difference in nonstatin cholesterol medications (guideline 6.9% vs. historical 13.0%) and high-intensity statins (guideline 23.7% vs. historical 16.3%). Of the 1,841 patients in the antihyperlipidemic treatment patterns cohort, 919 patients met inclusion criteria for the statin adherence analysis. Although PDC decreased over time in both groups, significantly more patients in the guideline implementation group were adherent in the post-index period than the historical control group (66.5% vs. 57.3%, respectively; P = 0.005). Additionally, patients in the guideline implementation group were more likely than the historical control to be adherent in the post-index period when adjusting for potential confounders (OR = 1.49, 95% CI = 1.10-2.03; P = 0.011). Since the release of the updated ACC/AHA treatment guideline, more commercial health plan patients with ASCVD used high-intensity statins and fewer used nonstatin cholesterol medications than historical controls. Additionally, since the guideline release, more patients are adherent to statin therapy than historical controls. This study provides managed care organizations with valuable information regarding the effect of the 2013 ACC/AHA guideline. No outside funding or services were received for this work. Outside of the current study, Bellows has received research funding from Biogen Idec, Regeneron Pharmaceuticals, Myriad Genetic Laboratories, Shire Development, and Bristol-Myers Squibb and an honorariam from Avanir Pharmaceuticals. Voelker received summer intern support from Pfizer and the AMCP Foundation during the time of this study. The remaining authors have nothing to disclose. All authors contributed to study concept and design and to the revision of the manuscript. Bellows, Olsen, and Voelker collected the data, assisted by Wander; data interpretation was performed primarily by Bellows, along with Olsen and Voelker and assisted by Wander. The manuscript was primarily written by Bellows, along with the other authors.

Potential Clinical Impact of Abdominal Aortic Calcification on Bone Density Lateral Spine Images

Abdominal aortic calcification (AAC) predicts incident atherosclerotic cardiovascular disease (ASCVD) events and can be accurately identified on densitometric lateral spine images obtained at the time of bone densitometry. Our objective was to estimate the proportion of patients referred for bone densitometry who have a high level of AAC and are not already known to have ASCVD or to be at high risk for ASCVD. AAC was scored on densitometric lateral spine images of 2168 individuals blinded to clinical diagnoses or risk factors using the 24-point Framingham scale. We ascertained preexisting ASCVD diagnoses and risk factors using electronic health record data. We used the risk calculator of the American Heart Association (AHA) and the American College of Cardiology (ACC) to estimate the 10-yr risk of hard ASCVD outcomes (myocardial infarction, death caused by coronary heart disease, or nonfatal or fatal stroke). A high level of AAC (AAC score ≥5) was present in 41 (6.1%, 95% confidence interval [CI]: 4.4%–8.2%) of those aged less than 65 yr, in 253 (23.1%, 95% CI: 20.7%–25.7%) of those aged 65–74 yr, and in 153 (37.8%, 95% CI: 33.0%–42.7%) of those aged 75–80 yr. Among those aged 65–74 yr, 16.9% (95% CI: 14.7%–19.3%) had a high level of AAC and no prior clinical diagnosis of ASCVD, but only 2.4% had a high level of AAC and a predicted 10-yr risk of hard ASCVD outcomes <7.5%. AAC is common among those aged 65 yr and older who were referred for bone densitometry and had no known ASCVD, although these individuals can also be recognized as being at intermediate to high risk using the AHA-ACC ASCVD risk calculator. Further studies regarding the impact of identification of AAC on provider and patient cardiovascular disease risk management choices are warranted.