Drugs For Cardiovascular Prevention Research Articles

Prescription patterns of antidiabetic and cardiovascular preventive medications in community-dwelling older adults with type 2 diabetes mellitus: a cross-sectional study.

To describe trends in antidiabetics drug prescription patterns in community-dwelling older adults with type 2 diabetes mellitus (T2DM) and to evaluate the use of cardiovascular preventive medications among those diagnosed with atherosclerotic cardiovascular disease (ASCVD). This cross-sectional, face-to-face interview study that comprised community-dwelling older adults (≥ 65 years) diagnosed with T2DM. The study questionnaire included the patients' demographics, clinical data, and current medication use. Patients with established ASCVD were further classified into low (i.e., not receiving evidence-based therapy or only one) and high (i.e., receiving at least two evidence-based therapies) composite score groups. Bivariate analysis followed by multivariable logistic regression analysis were performed to evaluate the demographic/clinical characteristics associated with the use of antidiabetic monotherapy/polytherapy and evidence-based pharmacotherapy. A total of 500 older adults were enrolled. The mean age of included participants was 73 ± 7 years, 310 participants (62%) were males, and 385 participants (77.0%) had established ASCVD. Antidiabetic monotherapy was reported in 251 participants (50.2%), with metformin followed by sulfonylureas being the most commonly prescribed drugs as monotherapy. The results of the multivariable analysis showed that age [odds ratio (OR) = 0.89, 95% CI: 0.85-0.94, P < 0.001], obesity (OR = 4.18, 95% CI: 1.63-10.36, P = 0.003), hypertension (OR = 4.2, 95% CI: 1.22-7.66, P = 0.04), and dyslipidemia (OR = 4.1, 95% CI: 1.28-8.30, P = 0.01), were significantly associated with the prescription of cardiovascular preventive medications. Only one in twenty-one participant with T2DM and ASCVD collectively received three guideline-recommended therapies, indicating a deficiency of utilization of cardiovascular preventive drugs.

Statins under-treatment and mortality in patients with atrial fibrillation. Insights from the nationwide START registry

Abstract Background Statins are mainstream drugs for cardiovascular (CV) prevention, but under-prescription is an important clinical challenge. Data on the use of single statins as the rate of under-prescription in atrial fibrillation (AF) are lacking. To evaluate the association of statin underuse with mortality risk in a large AF cohort. Methods 5,477 patients from the nationwide START registry were included. The prevalence of different statins was reported and the association with all-cause and CV mortality investigated. Mortality risk of patients with an indication to but not taking statins was also analysed. Results Mean age was 80.2 years, 46.4% were women. Among 2,899 patients with a clinical indication to statin, only 1,578 (54.4%) were on treatment. In a mean follow-up of 22.5±17.1 months, 491 (4.7%/year) deaths occurred (106 CV deaths, 1.0%/year). Atorvastatin and Simvastatin inversely associated with all-cause (HR 0.692, 95%CI 0.519-0.923, p=0.012 and HR 0.598, 95%CI 0.428-0.836, p=0.003, respectively). and CV death (HR 0.372, 95%CI 0.178-0.776, p=0.008 and HR 0.306, 95%CI 0.123-0.758, p=0.010, respectively). The 1,321 untreated patients were older, more frequently women and with a higher prevalence of diabetes, previous cerebrovascular disease, peripheral artery disease compared to those on treatment. Statin undertreatment was associated with higher risk of all-cause (HR 1.565, 95%CI 1.235-1.983, p&amp;lt;0.001) and CV death (HR 2.057, 95%CI 1.188-3.561, p=0.010). Conclusions AF patients with an indication to statins but left untreated disclose a high risk of all-cause and CV mortality. Implementation of statin prescription in the AF population can help reducing the residual CV risk.

Statins under-treatment and mortality in patients with atrial fibrillation. Insights from the nationwide START registry

Background and aimsStatins are mainstream drugs for cardiovascular (CV) prevention, but under-prescription is an important clinical challenge. Data on the use of single statins and on the rate of under-prescription in atrial fibrillation (AF) are lacking. We evaluated the association of statin underuse with mortality risk in a large AF cohort. Methods and resultsAs many as 5477 patients from the Italian nationwide START registry were included. The prevalence of different statins was reported and the association of under prescription with all-cause and CV mortality investigated.Mean age was 80.2 years, and 46.4% were women. Among 2899 patients with a clinical indication to statin, only 1578 (54.4%) were on treatment. In a mean follow-up of 22.5 ± 17.1 months, 491 (4.7%/year) deaths occurred (106 CV deaths, 1.0%/year). Atorvastatin and Simvastatin were inversely associated with all-cause (HR 0.692, 95% CI 0.519–0.923, p = 0.012 and HR 0.598, 95% CI 0.428–0.836, p = 0.003, respectively) and CV death (HR 0.372, 95% CI 0.178–0.776, p = 0.008 and HR 0.306, 95% CI 0.123–0.758, p = 0.010, respectively).The 1321 untreated patients were older, more frequently women and with a higher prevalence of diabetes, previous cerebrovascular disease, peripheral artery disease compared to those on treatment. Statin undertreatment was associated with higher risk of all-cause (HR 1.400, 95% CI 1.078–1.819, p = 0.012) and CV death (HR 2.057, 95% CI 1.188–3.561, p = 0.010). ConclusionsAF patients with an indication to statins but left untreated show a high risk of all-cause and CV mortality. Implementation of statin prescription in the AF population can help reducing the residual mortality risk.

Established and Emerging Lipid-Lowering Drugs for Primary and Secondary Cardiovascular Prevention.

Despite treatment with statins, patients with elevated low-density lipoprotein cholesterol (LDL-C) and triglycerides remain at increased risk for adverse cardiovascular events. Consequently, novel pharmaceutical drugs have been developed to control and modify the composition of blood lipids to ultimately prevent fatal cardiovascular events in patients with dyslipidaemia. This article reviews established and emerging lipid-lowering drugs regarding their mechanism of action, development stage, ongoing clinical trials, side effects, effect on blood lipids and reduction in cardiovascular morbidity and mortality. We conducted a keyword search to identify studies on established and emerging lipid modifying drugs. Results were summarized in a narrative overview. Established pharmaceutical treatment options include the Niemann-Pick-C1 like-1 protein (NPC1L1) inhibitor ezetimibe, the protein convertase subtilisin-kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab, fibrates as peroxisome proliferator receptor alpha (PPAR-α) activators, and the omega-3 fatty acid icosapent ethyl. Statins are recommended as the first-line therapy for primary and secondary cardiovascular prevention in patients with hypercholesterinaemia and hypertriglyceridemia. For secondary prevention in hypercholesterinaemia, second-line options such as statin add-on or statin-intolerant treatments are ezetimibe, alirocumab and evolocumab. For secondary prevention in hypertriglyceridemia, second-line options such as statin add-on or statin-intolerant treatments are icosapent ethyl and fenofibrate. Robust data for these add-on therapeutics in primary cardiovascular prevention remains scarce. Recent biotechnological advances have led to the development of innovative small molecules (bempedoic acid, lomitapide, pemafibrate, docosapentaenoic and eicosapentaenoic acid), antibodies (evinacumab), antisense oligonucleotides (mipomersen, volanesorsen, pelcarsen, olezarsen), small interfering RNA (inclisiran, olpasiran), and gene therapies for patients with dyslipidemia. These molecules specifically target new cellular pathways, such as the adenosine triphosphate-citrate lyase (bempedoic acid), PCSK9 (inclisiran), angiopoietin-like 3 (ANGPTL3: evinacumab), microsomal triglyceride transfer protein (MTP: lomitapide), apolipoprotein B-100 (ApoB-100: mipomersen), apolipoprotein C-III (ApoC-III: volanesorsen, olezarsen), and lipoprotein (a) (Lp(a): pelcarsen, olpasiran). The authors are hopeful that the development of new treatment modalities alongside new therapeutic targets will further reduce patients' risk of adverse cardiovascular events. Apart from statins, data on new drugs' use in primary cardiovascular prevention remain scarce. For their swift adoption into clinical routine, these treatments must demonstrate safety and efficacy as well as cost-effectiveness in randomized cardiovascular outcome trials.

#4494 DRUG UTILIZATION FOLLOWING INCIDENT CHRONIC KIDNEY DISEASE: AN OBSERVATIONAL STUDY IN THE UNITED STATES AND JAPAN

Abstract Background and Aims Chronic kidney disease (CKD) affects &amp;gt;840 million individuals worldwide and is a leading cause of morbidity and mortality. Complications include cardiorenal outcomes (e.g. end stage kidney disease and heart failure (HF)) and premature death, which may be preventable with early identification and appropriate treatment of CKD. Treatment of CKD with renin-angiotensin-system inhibitors (RASi) has been the main recommendation of guidelines in the past 20 years, but prescribing rates remain low and discontinuation rates remain high, particularly after adverse events like hyperkalaemia episodes. This study aims to describe RASi utilization following incident CKD. Method Adult patients with incident CKD in the United States (US; OPTUM Market Clarity until 31 March 2022) and Japan (Medical Data Vision until 28 February 2022) from 1 January 2016 onwards were included. CKD was defined as any of the following: a UACR measure of ≥30 mg/g, two estimated glomerular filtration rate (eGFR) ≥90 days apart of which the second was ≤75 ml/min/1.73 m2, or a CKD diagnosis code. Patients were included if they had an eGFR ≤60 ml/min/1.73 m2. Patients with ongoing RASi treatment at index, a history of diabetes, heart failure or dialysis were excluded. Results A total of 66,375 incident CKD patients were identified in the US (n = 32,158) and Japan (n = 34,217). Mean age was 66 and 78 years in the US and Japan, respectively, and about half of the patients were female. Mean eGFR was 48 and 40 ml/min/1.73 m2 in the US and Japan, respectively. Approximately 30% of patients had cardiovascular disease, but only 13% (US) and less than 5% (Japan) were prescribed cardiovascular preventive drugs (e.g. statins and low dose aspirin). During a 1-year follow-up after the incident CKD index date, only 15% and 5% had been initiated on RASi in the US and Japan, respectively (Figure 1). Time to RASi initiation was shorter among those with a CKD diagnosis vs those without a diagnosis (US: 15 vs 19 months, Japan: 6 vs 11 months). Of those who initiated treatment, approximately 50% discontinued within one year (Figure 1). Results for initiation and discontinuation were similar across CKD stages in both countries. Conclusion In the US and Japan, initiation of RASi was remarkably low among newly identified CKD patients, and discontinuation of initiated treatment was substantial. Given that most patients with CKD benefit from multi-drug therapy (RASi + SGLT2i) for slowing CKD progression and reduction of adverse events, efforts to increase prescribing and adherence are needed.

Transfer or tailor? Implementing a technology‐supported intervention for noncommunicable diseases across contexts

Transfer or tailor? Implementing a technology‐supported intervention for noncommunicable diseases across contexts

Management Of Therapy of Anticoagulants and Antiplatelets in Acute Gastrointestinal Bleeding and In the Periendoscopic Period

Management of anticoagulant and antiplatelet therapy is a common clinical problem in case of urgent or elective gastrointestinal endoscopic procedures. Anticoagulants and antiplatelet agents are widely used drugs for cardiovascular prevention and reducing the risk of thromboembolic events. Gastrointestinal bleeding represents a serious complication of their use. It’s recommended temporary interruption of anticoagulants in clinically significant gastrointestinal bleeding. For the antiplatelet therapy the decision is when to stop and restart the therapy, depending on whether it’s for primary or secondary cardiovascular prevention. Treatment with antithrombotic drugs in the periprocedural endoscopic period is based on balancing the bleeding risk against the thromboembolic risk. It’s recommended temporary discontinuation of antithrombotic treatment in high-risk endoscopic procedures with high risk for bleeding and to consider the use of “bridging” therapy with LWMH for patients on vitamin K antagonists who are at high thrombotic risk. Antithrombotic agents in endoscopic procedures with lower bleeding risk are not needed to be withheld. Evaluating cardiovascular risk and management of antithrombotic therapy could be a challenge for gastrointestinal endoscopists, therefore collaboration with a cardiologist is of great importance, at least for some patients.

Cost-effectiveness of cholesterol-lowering drugs for secondary cardiovascular prevention in the UK: ezetimibe, evolocumab, and alirocumab

Abstract Background Despite statin treatment, patients with elevated low-density lipoprotein cholesterol (LDL-C) levels remain at high risk for acute cardiovascular events. Ezetimibe, evolocumab, and alirocumab were consequently developed to reduce the risk of recurrent ischemic events in patients with established cardiovascular diseases by 6%, 15%, and 15%, respectively. However, these novel treatments must demonstrate both clinical efficacy and cost-effectiveness to promote long-term adoption by patients, physicians, and insurers. Objective To assess the cost-effectiveness of statins in combination with ezetimibe, evolocumab, and alirocumab for secondary cardiovascular prevention from the perspective of England's National Health Service (NHS). Methods The incidence of major adverse cardiovascular events, including, myocardial infarction, stroke, angina, and coronary revascularization, was simulated with a Markov cohort model. The model was populated with transition probabilities and hazard ratios derived from cardiovascular outcome trials for statin combinations with ezetimibe (IMPROVE-IT), evolocumab (FOURIER), and alirocumab (ODYSSEY). Costs and utilities were retrieved from previous literature. Principle outcomes of interest were the incremental cost-effectiveness ratios (ICER) per quality-adjusted life year (QALY) gained in 2021 Great Britain Pounds (£). Univariate, scenario, willingness-to-pay, and probabilistic sensitivity analyses were conducted to assess the robustness of results. Results For secondary cardiovascular prevention, ezetimibe in combination with statins increased QALYs gained by 0.60 at cost reductions of −£2,529 (ICER: −4,231 £/QALY) per patients compared to statin monotherapy. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors provided incremental QALYs of 0.53 and 0.86 at costs of £45,279 and £46,375 for evolocumab (ICER: 75,283 £/QALY) and alirocumab (ICER: 40,708 £/QALY), respectively. At the NHS' willingness-to-pay threshold of 30,000 £/QALY, there is 100% probability for ezetimibe and 0% probability for PCSK9 inhibitors to be cost-effective in secondary prevention. Results remained robust under univariate, scenario, and probabilistic sensitivity analyses. Conclusions Ezetimibe is cost-effective for secondary cardiovascular prevention at an annual price of £346 in the UK. For PCSK9 inhibitors, discounts of −37% to −53% on alirocumab's (£4,412) and evolocumab's (£4,467) prices are necessary to achieve cost-effectiveness. Funding Acknowledgement Type of funding sources: None.

Drug prescribing changes in the last year of life among homebound older adults: national retrospective cohort study

ObjectivesThis study aimed to evaluate the prescription patterns of drugs during the last year of life in homebound older adults who received home medical care.MethodsWe used a nationwide claims database...

Anticoagulant and Antiplatelet Therapy in Periprocedural Period of Elective Gastrointestinal Endoscopy

Anticoagulants and antiplatelet agents are widely used drugs for cardiovascular prevention and reducing the risk of thromboembolic events. Gastrointestinal bleeding represents a serious complication of their use. Gastrointestinal endoscopy is related to bleeding risk – there is bleeding risk stratification according to endoscopic procedures (high- and low-risk ones). Treatment with antithrombotic drugs in the periprocedural endoscopic period is based on balancing the bleeding risk against the thromboembolic risk. Antithrombotic agents in endoscopic procedures with lower bleeding risk are not needed to be withheld. It is recommended temporary discontinuation of antithrombotic treatment in high-risk endoscopic procedures and to consider the use of “bridging” therapy with LWMH for patients on Vitamin K antagonists who are at high thrombotic risk. Evaluating cardiovascular risk and management of antithrombotic therapy could be a challenge for gastrointestinal endoscopists, therefore, collaboration with a cardiologist is of great importance, at least for some patients.

Prevalence of the Use of Aspirin and Statins for Preventing Cardiovascular Events in the Colombian Population with Type 2 Diabetes Mellitus: Comparison of 2008 and 2018.

BackgroundType 2 diabetes mellitus (T2DM) greatly increases cardiovascular risk. Primary and secondary cardiovascular prevention lead to lower cardiovascular events, improved quality of life and lower costs related to complications.ObjectiveTo estimate the proportion of patients with T2DM undergoing drug therapy for cardiovascular prevention (aspirin and statins) in Colombia and to describe the change in patterns of use between 2008 and 2018.MethodsThis was a cross-sectional study comparing prescriptions for aspirin and statins in 2008 and in 2018 in outpatients diagnosed with T2DM. Records were obtained from a national drug claim database. The proportion of use of cardiovascular prevention drugs and antidiabetic drugs, medications for comorbidities and sociodemographic variables were analyzed for both periods.ResultsIn total, 26 742 patients in 2008 and 188 321 in 2018 with a diagnosis of T2DM treated with antidiabetic drugs were identified, among whom 57.5% and 44.2% received aspirin and 44.9% and 60.2% received statins, respectively. The use of high-intensity statins increased from 1.1% in 2008 to 95.2% in 2018. The probabilities of receiving drugs in 2008 and in 2018 were higher for men (OR: 1.12, 95% CI: 1.06-1.17 and OR: 1.26, 95% CI: 1.23-1.28, respectively), for those persons over 75 years of age (OR: 6.5, 95% CI: 5.3-7.9 and OR: 5.8, 95% CI: 5.4-6.2) and for those who also received clopidogrel (OR: 5.8, 95% CI: 4.4-7.6 and OR: 2.2, 95% CI: 2.1-2.4).ConclusionsThe use of high-intensity statins in patients with T2DM has increased significantly in the last decade, which should reduce cardiovascular events, morbidity and mortality.

Targets for blood glucose: What have the trials told us.

The challenges of diabetes treatment are to prevent or delay microangiopathic complications and macrovascular disease. Early, effective and sustained glycaemic control is advocated by all diabetes guidelines to mitigate the risks of prolonged hyperglycaemia. The post-hoc analyses of the large randomised glucose intervention trials and the long-term results of these trials have shown clearly that intensive glycaemic control may have more favourable cardiovascular effects when initiated earlier in the course of diabetes, particularly among in patients without cardiovascular disease. Based on the intervention trials a haemoglobin A1c level of less than 7.0% (<53 mmol/mol) is a generally accepted target to reduce microvascular disease and should be initiated early in the course of the diabetes. However, haemoglobin A1c targets should be individualised. Achieving a good glycaemic control without detrimental effect and preferably with benefit to the cardiovascular system and to renal function is an important challenge. When targeting a tight glycaemic control, avoidance of hypoglycaemia is crucial particularly in patients with coronary artery disease and in patients with heart failure. The cardiovascular outcomes trials performed to test the cardiovascular safety of the new glucose-lowering therapies offer compelling evidence in favour of the role of these drugs for cardiovascular prevention. Thus, both the glycaemic target and the choice of therapies should now be defined on an individual basis.

Underuse of beta‐blockers by patients with COPD and co‐morbid acute coronary syndrome: A nationwide follow‐up study in New Zealand

Clinical guidelines recommend the use of beta-blockers and other cardiovascular prevention drugs in patients with acute coronary syndrome (ACS). Studies in several countries have found that beta-blockers are underused in patients with chronic obstructive pulmonary disease (COPD) and co-morbid heart disease, although most have only examined use in subgroups of patients. We undertook a nationwide follow-up study in New Zealand to describe the use of beta-blockers and other cardiovascular prevention drugs in patients with COPD and ACS. National health and pharmaceutical dispensing data were used to derive the study cohort, identify patients who were admitted to hospital with ACS and/or heart failure before cohort entry and during follow-up, and ascertain drug use. The study cohort included 83 435 patients aged ≥45 years, with 290 400 person-years of follow-up. Among 2637 patients with ≥1 ACS admission during follow-up, only 56.6% received a beta-blocker in the 6 months following the first admission, while 87.7% and 81%, respectively, received aspirin and a statin. Patients with higher COPD severity were less likely to receive a beta-blocker than those with lower severity, as were those with no history of previous ACS and/or heart failure. Use of beta-blockers following an ACS admission was much lower than expected based on the findings of general audits of ACS management in New Zealand. Along with the higher proportions using aspirin and statins, and the differences in beta-blocker dispensing by COPD severity, this suggests a particular reluctance to prescribe beta-blockers to patients with COPD.

Valor terapéutico potencial de las estrategias dirigidas contra la interleucina 1β en la enfermedad cardiovascular ateroesclerótica

Clinical trials have unequivocally shown that cholesterol-lowering drugs decrease the risk of atherosclerotic cardiovascular disease in an exceptionally wide range of individuals. Yet, even when treated optimally according to current standards, many individuals still experience life-threatening ischemic events. Emerging experimental and clinical evidence strongly suggests that persistent inflammation is a major driver of this residual risk, which has opened the door to the application of anti-inflammatory drugs for cardiovascular disease prevention. Here, we review our current knowledge of the biology of interleukin-1β, a key regulator of inflammation in atherosclerotic plaque and the target of the first clinical trial to demonstrate that an anti-inflammatory drug can effectively reduce cardiovascular risk. We discuss the challenges faced by interleukin-1β inhibitors and other anti-inflammatory compounds in their translation to the clinical scenario, and identify other potential targets within this signaling pathway that hold promise in the cardiovascular setting.

Potential Therapeutic Value of Interleukin 1b-targeted Strategies in Atherosclerotic Cardiovascular Disease.

Clinical trials have unequivocally shown that cholesterol-lowering drugs decrease the risk of atherosclerotic cardiovascular disease in an exceptionally wide range of individuals. Yet, even when treated optimally according to current standards, many individuals still experience life-threatening ischemic events. Emerging experimental and clinical evidence strongly suggests that persistent inflammation is a major driver of this residual risk, which has opened the door to the application of anti-inflammatory drugs for cardiovascular disease prevention. Here, we review our current knowledge of the biology of interleukin-1β, a key regulator of inflammation in atherosclerotic plaque and the target of the first clinical trial to demonstrate that an anti-inflammatory drug can effectively reduce cardiovascular risk. We discuss the challenges faced by interleukin-1β inhibitors and other anti-inflammatory compounds in their translation to the clinical scenario, and identify other potential targets within this signaling pathway that hold promise in the cardiovascular setting.

Are gliflozins the new statins for diabetes?

Since the first demonstration by the 4S (Scandinavian Simvastatin Survival Study) trial that treatment of dyslipidemia significantly decreased by 55% the risk of major cardiovascular events (MACE) in patients with type 2 diabetes (T2D) [1], statins have been consecrated as vital drugs for cardiovascular (CV) prevention. Twenty-five year later the original publication of the 4S trial, the American Diabetes Association (ADA) claims that for patients of all ages with diabetes and atherosclerotic cardiovascular disease (ASCVD) or 10-year ASCVD risk >20%, high-intensity statin therapy should be added to lifestyle therapy [2].

Patients’ and health professionals’ attitudes and perceptions towards the initiation of preventive drugs for primary prevention of cardiovascular disease: protocol for a systematic review of qualitative studies

IntroductionLipid-lowering drugs and antihypertensive agents can be prescribed for the primary prevention of cardiovascular disease. In some cases, patients eligible for primary prevention of cardiovascular disease according to the European...

Bladder cancer risk in users of selected drugs for cardiovascular disease prevention.

The aim of this study was to investigate the relation between bladder cancer risk and the use of selected drugs for cardiovascular disease (CVD) prevention, such as aspirin, statins, and calcium channel blockers (CCBs). We analyzed data from a multicentric case-control study carried out in Italy between 2003 and 2014, including 690 bladder cancer cases and 665 hospital controls. Odds ratios (ORs) of bladder cancer and corresponding 95% confidence intervals (CIs) were estimated using unconditional multiple logistic regression models. The ORs for bladder cancer were 1.21 (95% CI: 0.87-1.68) for regular use of aspirin, 0.72 (95% CI: 0.54-0.97) for use of any CCBs, and 1.32 (95% CI: 0.87-1.99) for use of any statins. A slight inverse association was found with duration of use of CCBs, whereas no consistent association was found with duration of use, age at first use, and frequency for aspirin and statin use, or with indication of use for aspirin (as an analgesic or, for CVD prevention). No significant association was found for various combinations of drugs or for all drugs combined (OR=1.23, 95% CI: 0.31-4.85). Our data indicate the lack of a relevant association between the use of selected drugs for CVD prevention and bladder cancer risk, although suggest a potential favorable role for CCBs.

Patient participation in decision-making about cardiovascular preventive drugs – resistance as agency

Objective: The aim of the study was to describe and explore patient agency through resistance in decision-making about cardiovascular preventive drugs in primary care.Design: Six general practitioners from the southeast of Sweden audiorecorded 80 consultations. From these, 28 consultations with proposals from GPs for cardiovascular preventive drug treatments were chosen for theme-oriented discourse analysis.Results: The study shows how patients participate in decision-making about cardiovascular preventive drug treatments through resistance in response to treatment proposals. Passive modes of resistance were withheld responses and minimal unmarked acknowledgements. Active modes were to ask questions, contest the address of an inclusive we, present an identity as a non-drugtaker, disclose non-adherence to drug treatments, and to present counterproposals. The active forms were also found in anticipation to treatment proposals from the GPs. Patients and GPs sometimes displayed mutual renouncement of responsibility for decision-making. The decision-making process appeared to expand both beyond a particular phase in the consultations and beyond the single consultation.Conclusions: The recognition of active and passive resistance from patients as one way of exerting agency may prove valuable when working for patient participation in clinical practice, education and research about patient–doctor communication about cardiovascular preventive medication. We propose particular attentiveness to patient agency through anticipatory resistance, patients’ disclosures of non-adherence and presentations of themselves as non-drugtakers. The expansion of the decision-making process beyond single encounters points to the importance of continuity of care.KEY POINTSGuidelines recommend shared decision-making about cardiovascular preventive treatment. We need an understanding of how this is accomplished in actual consultations.This paper describes how patient agency in decision-making is displayed through different forms of resistance to treatment proposals.•The decision-making process expands beyond particular phases in consultations and beyond single encounters, implying the importance of continuity of care.•Attentiveness to patient participation through resistance in treatment negotiations is warranted in clinical practice, research and education about prescribing communication.

Cholesterol- and blood-pressure-lowering drug use for secondary cardiovascular prevention in 2004-2013 Europe.

Background Suboptimal use of cardiovascular prevention medications has been reported. We report recent trends in secondary cardiovascular disease prevention drug use in Europe. Design We used the 2004-2013 data from the Survey of Health, Ageing and Retirement in Europe (SHARE), a large longitudinal cohort study in middle-aged and elderly Europeans. Methods Cross-sectional and panel data logistic regression models were used to study trends in cholesterol- and blood pressure-lowering drug use and effects of participant characteristics on the likelihood of drug use among participants with histoty of cardiovascular disease in SHARE. Results In SHARE 21,388 participants reported history of cardiovascular disease and provided data on cholesterol- and blood pressure-lowering drug use. At initial report, 40% and 60% of them used cholesterol- or blood pressure-lowering drugs, respectively. Increasing cross-sectional time trends were observed for both medication classes (odds ratios of use in 2013 vs. 2004, 1.6 (95% confidence interval 1.4-1.7) and 1.5 (1.4-1.6), respectively). However, among participants with multiple observations, the use of both classes declined over time (2013 vs. 2004 odds ratio 0.63 (0.51-0.77) and 0.68 (0.55-0.84), respectively; both trend p < 0.001), and with increasing duration since last cardiovascular event (odds ratio 0.74 (0.60-0.91), trend p = 0.01 and odds ratio 0.82 (0.66-1.03), trend p = 0.06, respectively for durations of nine years or more versus less than one year). Among people with history of cardiovascular disease, those obese, retired or with hypercholesterolaemia, hypertension, worse self-perceived health, and, in the case of lipid-lowering medication, with diabetes, were more likely to use these medications. Conclusions Despite moderately increasing cross-sectional time trends, the use of secondary cardiovascular disease prevention drugs remains low in Europe with substantial discontinuation over time and with increasing duration from an acute cardiovascular event.