Guidelines Recommend Statin Therapy Research Articles

Sex-based utilization of guideline recommended statin therapy and cardiovascular disease outcomes: Data from a multisite healthcare network primary prevention cohort

BackgroundIn the US, women have similar cardiovascular death rates as men. However, less is known about sex differences in statin use for primary prevention and associated atherosclerotic cardiovascular disease (ASCVD) outcomes. MethodsStatin prescriptions using electronic health records were examined in patients without ASCVD (myocardial infarction (MI), revascularization or ischemic stroke) between 2013 and 2019. Guideline-directed statin intensity (GDSI) at index (at least moderate intensity, defined per pooled-cohort equation) and follow-up visits were compared between sexes across ASCVD risk groups, defined by the pooled-cohort equation. Cox regression hazard ratios were calculated for statin use and outcomes (myocardial infarction, stroke/transient ischemic attack (TIA), and all-cause mortality) stratified by sex. Interaction terms (statin and sex) were applied. ResultsAmong 282,298 patients, (mean age ∼ 50 years) 17.1 % women and 19.5 % men were prescribed any statin at index visit. Time to GDSI was similar between sexes, but the proportion of high-risk women on GDSI at follow-up were lower compared to high-risk men (2-years: 27.7 vs 32.0 %, and 5-years: 47.2 vs 55.2 %, p < 0.05). When compared to GDSI, no statin use was associated with higher risk of MI and ischemic stroke/TIA among both sexes. High-risk women on GDSI had a lower risk of mortality (HR=1.39 [1.22–1.59]) vs. men (HR=1.67 [1.50–1.86]) of similar risk (p value interaction=0.004). ConclusionIn a large contemporary healthcare system, there was underutilization of statins across both sexes in primary prevention. High-risk women were less likely to remain on GDSI compared to high-risk men. GDSI significantly improved the survival in both sexes regardless of ASCVD risk group. Future strategies to ensure continued use of GDSI, specifically among women, should be explored.

Lipid-lowering therapy and LDL-C control for primary prevention in persons with diabetes across 90 health systems in the United States

ObjectiveNational guidelines recommend statin therapy for patients with type 2 diabetes. We assessed the extent of moderate- to high-intensity statin therapy utilization in community practice. MethodsWe evaluated lipid-lowering therapy (LLT) and low-density lipoprotein cholesterol (LDL-C) levels at baseline and 1-year follow-up in patients aged 40–75 years with type 2 diabetes but without atherosclerotic cardiovascular disease (ASCVD), across 90 health systems in the United States participating in an electronic health record–derived dataset, Cerner Real-World Data. Multivariable logistic regression was used to evaluate factors associated with utilization of moderate- to high-intensity statin. ResultsWe identified 241,232 patients with type 2 diabetes (58.1 % on moderate- to high-intensity statin, 7.0 % on low-intensity statin, and 34.9 % on no statin). Predictors of moderate- to high-intensity statin therapy included retinopathy (adjusted odds ratio [aOR], 1.26; 95 % confidence interval [CI], 1.15–1.38), hypertension (aOR, 1.52; 95 % CI, 1.43–1.61), and stage 3 chronic kidney disease (aOR, 1.14; 95 % CI, 1.07–1.21). Women (aOR, 0.85; 95 % CI, 0.82–0.87), and those with rheumatoid arthritis (aOR, 0.79; 95 % CI, 0.71–0.87), psoriasis (aOR, 0.85; 95 % CI, 0.75–0.96), and hepatitis C (aOR, 0.40; 95 % CI, 0.39–0.46), had reduced odds of moderate- to high-intensity statin treatment. Utilization of ezetimibe was rare (2.0 %). LDL-C control was suboptimal at baseline (37.0 % and 27.9 % had LDL-C ≥100 mg/dL and <70 mg/dL, respectively). At 1-year follow-up, the rate of moderate- to high-intensity statin therapy utilization was 65.3 %. ConclusionIncreased efforts are needed to improve LDL-C control and LLT use for primary prevention of ASCVD in adults with type 2 diabetes, in particular among women and those with risk-enhancing inflammatory conditions.

Guideline adherence to statin therapy and association with major adverse cardiac events in high-risk patients following major noncardiac surgery

Abstract Introduction Statins are widely used for the prevention of coronary artery disease (CAD) and associated secondary cardiovascular complications. Despite established evidence in acute and chronic cardiovascular disease, the optimal perioperative use of statins remains uncertain. We aimed to evaluate adherence to current guideline recommendations regarding statin therapy in high-risk patients undergoing major noncardiac surgery and its association with major adverse cardiac event (MACE). Methods Class I indications for statin therapy according to current ESC clinical practice guidelines were assessed among consecutive high-risk patients undergoing major noncardiac surgery enrolled in a prospective multicentre cohort study. The primary endpoint MACE, a composite of cardiovascular death and spontaneous acute myocardial infarction, was recorded during 120-day follow up and centrally adjudicated by cardiologists blinded to statin therapy. As a co-primary endpoint, perioperative myocardial infarction/injury (PMI) due to a type 1 MI (T1MI) or likely type 2 MI (lT2MI) within the first three postoperative days was used. After multivariable adjustment with inverse probability of treatment weighting (IPTW) to account for differences between statin and non-statin users, we performed a Cox proportional hazard model with MACE and a logistic regression model with PMI due to T1MI or lT2MI as endpoints. Results Between October 2014 and February 2018, we included 8116 high-risk patients undergoing major noncardiac surgery. 4227 of 8116 patients (52.1%) had at least one class I indication for statin therapy. The most common indication for statin use was CAD in 2235 patients (52.9%) followed by diabetes with comorbidities in 1676 patients (39.6%) and peripheral artery disease in 1514 patients (35.8%). From all patients with a class I indication for statin use, only 2440 (57.7%) were on statins preoperatively. Usage was highest in patients with prior myocardial infarction (828/1110 [74.6%]) and lowest in patients with chronic kidney disease stage 3-5 (494/996 [49.6%]). During the follow up of 120 days, 192 MACE occurred (4.6%) including 116 cardiovascular deaths. After multivariable adjustment, preoperative use of statins was associated with a reduced risk of MACE (weighted hazard ratio 0.59, 95% confidence interval [CI] 0.41-0.86; p = 0.006). PMI due to T1MI or lT2MI occurred in 508 of 4170 (12.2%) patients. After IPTW, the weighted odds ratio for PMI in patients receiving preoperative statin therapy was 1.15 (95%CI 1.01-1.31; p = 0.036). Conclusion Current adherence to guideline-recommended statin therapy in the noncardiac surgery population is suboptimal. The use of statins was associated with reduced rates of adverse cardiac events within 120 days, but not with cardiac PMI.Percentage of patients receiving statinsMACE within 120 days

Abstract 12292: Lipid-Lowering Therapy and LDL-C Control for Primary Prevention in Persons With Diabetes Across 90 Health Systems in the United States

Background: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in persons with type 2 diabetes, and national guidelines recommend statin therapy for primary prevention of ASCVD in persons with type 2 diabetes (T2DM). Aim: To evaluate the degree of utilization of appropriate intensity statin therapy for primary prevention in patients with T2DM in community practice. Methods: We evaluated lipid-lowering therapy (LLT) and LDL-cholesterol (LDL-C) levels in patients aged 40–75 years with T2DM but without atherosclerotic cardiovascular disease (ASCVD), across 90 health systems in the United States participating in an EHR-derived dataset, Cerner Real World Data at baseline and one year follow-up. Multivariable logistic regression was used to evaluate factors associated with guideline-recommended (moderate- to high-intensity) statin therapy use. Results: We identified 241,232 patients with T2DM (58.1% on appropriate statin, 7.0% on low-intensity statin, and 34.9% on no statin. Predictors of appropriate statin therapy included retinopathy (adjusted odds ratio [aOR], 1.26; 95% CI, 1.15–1.38), hypertension [aOR 1.52 (1.43-1.61)], and stage 3 chronic kidney disease [CKD; aOR 1.14(1.07–1.21]. Women (aOR, 0.85, 95% CI, 0.82-0.87), and those with rheumatoid arthritis [aOR, 0.79 (0.71–0.87)], psoriasis [aOR, 0.85 (0.75–0.96)], and hepatitis C [aOR, 0.4 (0.39–0.46)] had reduced odds of appropriate statin treatment. Utilization of ezetimibe was rare (2.0%). LDL-C control was suboptimal (36.9% and 27.9% had LDL-cholesterol ≥100 mg/dL and &lt;70 mg/dL, respectively). Therapy uptitration was infrequent; at one-year only 65.3% of patients were on appropriate statin intensity (Figure). Conclusions: Increased efforts are needed to improve primary prevention of ASCVD in adults with T2DM, particularly among women and those with risk-enhancing inflammatory conditions.

Prioritising cardiovascular disease risk assessment to high risk individuals based on primary care records.

To provide quantitative evidence for systematically prioritising individuals for full formal cardiovascular disease (CVD) risk assessment using primary care records with a novel tool (eHEART) with age- and sex- specific risk thresholds. eHEART was derived using landmark Cox models for incident CVD with repeated measures of conventional CVD risk predictors in 1,642,498 individuals from the Clinical Practice Research Datalink. Using 119,137 individuals from UK Biobank, we modelled the implications of initiating guideline-recommended statin therapy using eHEART with age- and sex-specific prioritisation thresholds corresponding to 5% false negative rates to prioritise adults aged 40-69 years in a population in England for invitation to a formal CVD risk assessment. Formal CVD risk assessment on all adults would identify 76% and 49% of future CVD events amongst men and women respectively, and 93 (95% CI: 90, 95) men and 279 (95% CI: 259, 297) women would need to be screened (NNS) to prevent one CVD event. In contrast, if eHEART was first used to prioritise individuals for formal CVD risk assessment, we would identify 73% and 47% of future events amongst men and women respectively, and a NNS of 75 (95% CI: 72, 77) men and 162 (95% CI: 150, 172) women. Replacing the age- and sex-specific prioritisation thresholds with a 10% threshold identify around 10% less events. The use of prioritisation tools with age- and sex-specific thresholds could lead to more efficient CVD assessment programmes with only small reductions in effectiveness at preventing new CVD events.

Guideline adherence to statin therapy and association with short-term and long-term cardiac complications following noncardiac surgery: A cohort study.

Peri-operative complications are common and associated with high morbidity and mortality. Optimising the use of statins might be of important benefit in peri-operative care and reduce morbidity and mortality. To evaluate adherence to current guideline recommendations regarding statin therapy and its association with peri-operative and long-term cardiac complications. Prospective cohort study. Multicentre study with enrolment from October 2014 to February 2018. Eight thousand one hundred and sixteen high-risk inpatients undergoing major noncardiac surgery who were eligible for the institutional peri-operative myocardial injury/infarction (PMI) active surveillance and response program. Class I indications for statin therapy were derived from the current ESC Clinical Practice Guidelines during the time of enrolment. PMI was prospectively defined as an absolute increase in cTn concentration of the 99th percentile in healthy individuals above the preoperative concentration within the first three postoperative days. Long-term cardiac complications included cardiovascular death and spontaneous myocardial infarction (MI) within 120 days. The mean age was 73.7 years; 45.2% were women. Four thousand two hundred and twenty-seven of 8116 patients (52.1%) had a class I indication for statin therapy. Of these, 2440 of 4227 patients (57.7%) were on statins preoperatively. Adherence to statins was lower in women than in men (46.9 versus 63.9%, P < 0.001). PMI due to type 1 myocardial infarction/injury (T1MI; n = 42), or likely type 2 MI (lT2MI; n = 466) occurred in 508 of 4170 (12.2%) patients. The weighted odds ratio in patients on statin therapy was 1.15 [95% confidence interval (CI) 1.01 to 1.31, P = 0.036]. During the 120-day follow-up, 192 patients (4.6%) suffered cardiovascular death and spontaneous MI. After multivariable adjustment, preoperative use of statins was associated with reduced risk; weighted hazard ratio 0.59 (95% CI 0.41 to 0.86, P = 0.006). Adherence to guideline-recommended statin therapy was suboptimal, particularly in women. Statin use was associated with an increased risk of PMI due to T1MI and lT2MI but reduced risk of cardiovascular death and spontaneous MI within 120 days. Clinicaltrials.gov identifier NCT02573532.

Gaps in Guideline-Based Lipid-Lowering Therapy for Secondary Prevention in the United States: A Retrospective Cohort Study of 322 153 Patients.

Many patients with atherosclerotic cardiovascular disease (ASCVD) are not on guideline-recommended statin therapy. We evaluated utilization of statins and other lipid-lowering therapy (LLT), and changes in low-density lipoprotein cholesterol (LDL-C), among patients with ASCVD over a 1-year period. LLT and LDL-C levels at the first outpatient visit (January 1, 2017-December 31, 2018) and 1-year follow-up were evaluated using data from Cerner Real-World Data, an electronic health record-derived data set from 92 US health systems. Logistic regression was used to evaluate factors associated with high-intensity statin use. We identified 322 153 patients with ASCVD (median age 69 years, 58.8% men, 81.8% White). Overall, 76.1% of patients were on statins, with only 39.4% on high-intensity statins. Men were more likely to receive high-intensity statins than women (multivariable-adjusted odds ratio, 1.34 [95% CI, 1.30-1.38]). Increasing age was associated with lower odds of statin use (odds ratio, 0.79 per 5-year increase at 60 years [95% CI, 0.78-0.81]). Patients with peripheral artery disease (odds ratio, 0.40 [95% CI, 0.37-0.42]) and cerebrovascular disease (odds ratio, 0.75 [95% CI, 0.70-0.80]) had lower odds of using high-intensity statins than those with coronary artery disease. At baseline, most patients (61.3%) had elevated LDL-C (≥70 mg/dL), including 59.8% of those on low/moderate-intensity statins and 76.1% on no statin; only 45.3% achieved an LDL-C <70 mg/dL at 1 year. Nonstatin LLT use was low (ezetimibe, 4.4%; proprotein convertase subtilisin/kexin type 9 inhibitors, 0.7%). Among patients on no statin or low/moderate-intensity statin at baseline, 14.8% and 13.4%, respectively, were on high-intensity statins at 1 year. Among patients with ASCVD in routine care, high-intensity statins are underutilized, and uptitration and use of nonstatin therapy are uncommon. Women, older adults, and individuals with noncardiac ASCVD are particularly undertreated. Concerted efforts are needed to address therapeutic inertia for lipid management in patients with ASCVD.

Using Polygenic Risk Scores for Prioritizing Individuals at Greatest Need of a Cardiovascular Disease Risk Assessment.

Background The aim of this study was to provide quantitative evidence of the use of polygenic risk scores for systematically identifying individuals for invitation for full formal cardiovascular disease (CVD) risk assessment. Methods and Results A total of 108 685 participants aged 40 to 69 years, with measured biomarkers, linked primary care records, and genetic data in UK Biobank were used for model derivation and population health modeling. Prioritization tools using age, polygenic risk scores for coronary artery disease and stroke, and conventional risk factors for CVD available within longitudinal primary care records were derived using sex-specific Cox models. We modeled the implications of initiating guideline-recommended statin therapy after prioritizing individuals for invitation to a formal CVD risk assessment. If primary care records were used to prioritize individuals for formal risk assessment using age- and sex-specific thresholds corresponding to 5% false-negative rates, then the numbers of men and women needed to be screened to prevent 1 CVD event are 149 and 280, respectively. In contrast, adding polygenic risk scores to both prioritization and formal assessments, and selecting thresholds to capture the same number of events, resulted in a number needed to screen of 116 for men and 180 for women. Conclusions Using both polygenic risk scores and primary care records to prioritize individuals at highest risk of a CVD event for a formal CVD risk assessment can efficiently prioritize those who need interventions the most than using primary care records alone. This could lead to better allocation of resources by reducing the number of risk assessments in primary care while still preventing the same number of CVD events.

Approach to risk stratification of atherosclerotic cardiovascular disease: Use of biomarkers and imaging in a Canadian context.

To outline the 2021 Canadian Cardiovascular Society (CCS) dyslipidemia guidelines and to present the current approaches to cardiovascular risk stratification, including the incorporation of biomarkers and imaging tests. Current guidelines were reviewed and an Ovid MEDLINE literature search was performed. Cardiovascular disease (CVD) is the leading cause of global mortality, with ischemic heart disease contributing to nearly half of these deaths. Risk stratification is undertaken to identify patients who would benefit from primary prevention for atherosclerotic CVD (ASCVD), but commonly used methods for risk stratification are imperfect. The CCS guidelines endorse that the presence of risk modifiers (family history of premature ASCVD, high-sensitivity C-reactive protein level ≥2.0 mg/L, lipoprotein[a] level ≥500 mg/L [≥50 mg/dL], or coronary artery calcium >0) supports the use of statin therapy in those at intermediate risk (Framingham risk score 10% to 19.9%) who do not otherwise meet the recommendations for statin use. The CCS guidelines recommend statin therapy in patients at intermediate risk when cholesterol levels are elevated (low-density lipoprotein cholesterol level ≥3.5 mmol/L, non-high-density lipoprotein cholesterol level ≥4.2 mmol/L, or apolipoprotein B level ≥1.05 g/L). In addition, statin therapy should be considered for patients at low risk (Framingham risk score 5% to 9.9%) with elevated cholesterol levels, especially if risk modifiers are present. When cholesterol levels are not elevated, evidence still favours the use of statins in intermediate-risk patients when risk modifiers are present and in men 50 years and older and women 60 years and older with 1 additional risk factor. Biomarkers and imaging tests have the potential to improve ASCVD risk stratification by reclassifying any patient whose risk has been inaccurately estimated by traditional methods. Recently published guidelines by the CCS suggest the use of biomarkers and imaging in certain patient groups.

Adherence to Clinical Guidelines on STATIN Prescribing Among Diabetic Patients Aged 40-75 Years Old in a Primary Care Setting: A Cross-Sectional Study.

BackgroundDiabetes mellitus (D.M.) is a chronic metabolic disease caused by decreased insulin secretion, which increases the risk of cardiovascular diseases. Evidence has shown that statins reduce cardiovascular risk in patients with diabetes; moreover, most clinical guidelines recommend statins.ObjectiveThis study aimed to assess the level and status of adherence to guidelines on statin prescription in patients with diabetes mellitus in a primary care setting in Palestine.MethodsA retrospective cross-sectional descriptive study was conducted at an ambulatory center in Palestine. Data were collected by auditing prescription records and reviewing medical charts of patients with diabetes who visited the clinic from February 15 to March 17, 2021. The collected data included patient characteristics, comorbidities, lipid profiles, and statin prescription. A chi-square test was used to evaluate the appropriateness of the prescribed statins with different demographic and clinical variables. Statistical significance was set at p < 0.05. Statistical Package for Social Sciences (SPSS) version 22 was used to analyze the data.ResultsOut Of 262 diabetic patients included in the analysis, 74% were prescribed appropriate statin therapy according to the American Diabetes Association (ADA) guidelines, and 24% of patients had inappropriate statin therapy or needed statins. Furthermore, 82.8% were on high-intensity statins, while 11% were not taking any statins. More than 60% of patients had uncontrolled diabetes and hypertension.ConclusionMost guidelines recommend statin therapy in diabetic patients owing to its benefits in preventing cardiovascular complications. In this study, most patients were on appropriate STATIN therapy; however, 50% of diabetic patients had LDL of more than 100 mg/dl, and 25% were not prescribed statins, increasing their risk of ASCVD. Therefore, we recommend strict adherence to the established guidelines on statins prescribed to patients with diabetes to prevent cardiovascular complications, save lives, and reduce healthcare costs.

Lipid-Lowering Therapy for Primary Prevention of Cardiovascular Disease: A Nationwide Analysis of 440,721 Patients

Lead Author's Financial Disclosures AAK was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number T32HL12547. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health. Study Funding Esperion Therapeutics, Inc. Background/Synopsis Statins are indicated for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) in adults with diabetes mellitus (DM), elevated 10-year risk, and those with LDL-C ≥190 mg/dL. Contemporary treatment patterns in community practice are not well described. Objective/Purpose To explore the use and dosing of statin therapy and use of several classes of non-statin lipid lowering therapies (LLT) in adults recommended for statins in primary prevention. Methods We identified adults recommended for primary prevention statin therapy who received outpatient care in 90 US health systems between 2017 and 2018 using a de-identified, electronic health record dataset; Cerner Real World Data. Primary prevention populations included: DM and age 40-75, calculated 10-year ASCVD risk ≥7.5% and age 40-75, and those with LDL-C ≥190 mg/dL or familial hypercholesterolemia based on diagnosis code. Medication data, including self-reported use of supplements, were examined. Based on the 2013 ACC/AHA Cholesterol Guideline (what was active at the time), patients were classified as: on appropriate- intensity statin, on under-dosed statin, or not on a statin. Results We identified 440,721 patients recommended for statins (median age 63 years, 50.1% male, and 75.5% white race), including (by mutually exclusive, hierarchical order) 308,620 (70%) patients with DM, 125,411 (28.5%) with a 10-year risk ≥7.5%, and 6,690 (1.5%) with LDL-C ≥190 mg/dL. Overall, 211,295 (47.9%) were on appropriate statin therapy, 29,039 (6.6%) were on lower-than-recommended statin intensity, and 200,387 (45.5%) were not on any statin (Figure). People with DM had the relative highest percent utilization of appropriate-dose statin (53.8%), while only 35.4% of those recommended for 10-year risk were on appropriate- dose statin, and only 12% of those with LDL-C ≥190 mg/dL were treated appropriately (Figure). Utilization of non-statin LLT was low overall across all three groups (15.8%). However, nearly one in ten (9.4%) of those recommended for primary prevention reported taking non-prescription Omega-3/fish oil supplements (Figure). Conclusions Over half of primary prevention patients at high risk for ASCVD in the US are not on appropriate-dose, guideline-recommended statin therapy. Of these, the majority were not on any statin. Non-statin LDL-C lowering medication use was also low. Despite no data for cardiovascular benefit, a substantial number of adults were taking non-prescription fish oil. There remains a strong national need to improve overall utilization and evaluate barriers to prescription/uptake of evidence based LLT in all patients eligible for primary prevention. AAK was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number T32HL12547. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health.

497 Coronary Artery Calcification On CT Pulmonary Angiograms; Prevalence, Frequency Of Reporting And Impact On Clinical Management - A Single Center Tertiary Hospital Experience

Introduction: Coronary artery calcification (CAC) is a strong independent predictor of major adverse cardiovascular outcomes. Society guidelines recommend statin therapy for patients with a CAC score ≥ 100 Agatston units on a dedicated coronary CT scan. The purpose of this study was to investigate the prevalence of CAC on CT pulmonary angiogram (CTPA) scans, the frequency of CAC reporting in CTPA reports, and its impact on therapeutic management among patients undergoing CTPA.

Detecting and Managing ASCVD in Women: A Focus on Statins.

At the end of the activity, participants will be able to:Summarize important findings and trends involving women and atherosclerotic cardiovascular disease (ASCVD). Characterize the multiple cardiometabolic changes that occur during menopause and the associated ASCVD risk. Discuss the challenges of assessing ASCVD risk and dyslipidemia management in women. Identify women with elevated ASCVD risk and implement guideline-recommended statin therapy.

Statin Use Is Associated with Excess Risk for Diabetes Progression

Guidelines recommend statin therapy in middle-aged people (age range, 40–75) with type 2 diabetes for preventing cardiovascular disease (Diabetes Care

Polygenic risk scores in cardiovascular risk prediction: A cohort study and modelling analyses

Polygenic risk scores (PRSs) can stratify populations into cardiovascular disease (CVD) risk groups. We aimed to quantify the potential advantage of adding information on PRSs to conventional risk factors in the primary prevention of CVD. Using data from UK Biobank on 306,654 individuals without a history of CVD and not on lipid-lowering treatments (mean age [SD]: 56.0 [8.0] years; females: 57%; median follow-up: 8.1 years), we calculated measures of risk discrimination and reclassification upon addition of PRSs to risk factors in a conventional risk prediction model (i.e., age, sex, systolic blood pressure, smoking status, history of diabetes, and total and high-density lipoprotein cholesterol). We then modelled the implications of initiating guideline-recommended statin therapy in a primary care setting using incidence rates from 2.1 million individuals from the Clinical Practice Research Datalink. The C-index, a measure of risk discrimination, was 0.710 (95% CI 0.703-0.717) for a CVD prediction model containing conventional risk predictors alone. Addition of information on PRSs increased the C-index by 0.012 (95% CI 0.009-0.015), and resulted in continuous net reclassification improvements of about 10% and 12% in cases and non-cases, respectively. If a PRS were assessed in the entire UK primary care population aged 40-75 years, assuming that statin therapy would be initiated in accordance with the UK National Institute for Health and Care Excellence guidelines (i.e., for persons with a predicted risk of ≥10% and for those with certain other risk factors, such as diabetes, irrespective of their 10-year predicted risk), then it could help prevent 1 additional CVD event for approximately every 5,750 individuals screened. By contrast, targeted assessment only among people at intermediate (i.e., 5% to <10%) 10-year CVD risk could help prevent 1 additional CVD event for approximately every 340 individuals screened. Such a targeted strategy could help prevent 7% more CVD events than conventional risk prediction alone. Potential gains afforded by assessment of PRSs on top of conventional risk factors would be about 1.5-fold greater than those provided by assessment of C-reactive protein, a plasma biomarker included in some risk prediction guidelines. Potential limitations of this study include its restriction to European ancestry participants and a lack of health economic evaluation. Our results suggest that addition of PRSs to conventional risk factors can modestly enhance prediction of first-onset CVD and could translate into population health benefits if used at scale.

Abstract 16657: Guideline Recommended Statin Therapy and Sex Based Cardiovascular Disease Outcomes: Data From a Multi-site Healthcare Network Primary Prevention Cohort

Introduction: Statin therapy has been shown to reduce ASCVD morbidity and mortality. Evidence on statin utilization per the ACC/AHA cholesterol guidelines and outcomes are limited in primary prevention cohorts of women. We investigated statin use outcomes per 10-year ASCVD risk in a large healthcare system stratified by sex. Methods: Statin prescription in patients without CAD (MI or revascularization) or ischemic stroke were evaluated (2013-2019). Risk categories per the ASCVD risk were defined as: Borderline (5%-7.4%), Intermediate (7.5%-19.9%) or High (≥20%). Guideline-directed statin intensity (GDSI), at time of first event, was defined as: “at least moderate” for Intermediate and high -risk groups. Cox regression hazard ratios (HR) [95% CI] were calculated for statin use and outcomes (MI, stroke and composite ASCVD events) stratified by gender. Interaction terms (age ≥75y and sex) were applied. Results: Among 159,100 women (out of 282,298 patients; mean age ~51y), 15,153 (9.5%), 26,697 (16.8%) and 10,583 (6.7%) were categorized as borderline, intermediate and high risk, respectively. Only 9,277 (35%) intermediate and 4,893 (46%) of high-risk women received any intensity of statin. High risk women (vs men) on GDSI, had lower association with CAD events (HR 0.8 [0.7-0.9]) and increased stroke risk (HR 1.2 [1.1-1.4]) ( Table). Intermediate and high-risk women (on &lt;GD statin or no statin) had higher stroke risk than those on GD statin (p for interaction &lt;0.001 ). Older women (≥75y) on “no statin” (vs GD statin) had independently increased risk of CAD (HR 1.30[1.1-1.6]) (p interaction &lt;0.001) . Conclusions: In a real-world primary prevention cohort, women on statin therapy had significantly improved ASCVD outcomes and lower mortality. However, approximately one-fourth of statin-eligible women were not prescribed any statin therapy. Further research can develop healthcare system strategies to optimize under-treatment of women for ASCVD prevention.

Abstract 17321: Guideline Recommended Statin Therapy Implementation and Cardiovascular Outcomes: Insights From a Multi-Site Healthcare Primary Prevention Cohort

Background: The 2013 and 2018 ACC/AHA cholesterol guidelines recommend using the 10-year ASCVD risk to guide statin therapy for primary prevention. Evidence of real-world consequences of non-adherence to these guidelines in primary prevention cohorts is limited. We investigated outcomes based on statin use in a large healthcare system, stratified by 10y ASCVD risk. Methods: Statin prescription practices in patients without CAD or ischemic stroke were evaluated ( 2013-2019). Patient categories constructed per the ASCVD risk were; Borderline (5%-7.4%), Intermediate (7.5%-19.9%) or High (≥20%). Guideline-directed statin intensity (GDSI) , at time of first event, was defined as; “none or any intensity” for borderline , “at least moderate” for Intermediate and high -risk groups. Mean (±SD) time to start/change to GD therapy from first interaction in healthcare, ASCVD incident rates [IR] and mortality were calculated across risk categories stratified by statin utilization. Results: Among 282,298 patients (mean age ~50y), 29,134 (10.3%), 63,299 (22.4%) and 26,687 (9.5%) were borderline, intermediate and high risk, respectively. Within intermediate-risk, 27,358 (43%) and 8,300 (31%) of high-risk never received any statin. Only 17,519 (65.6%) high-risk subjects who were prescribed statin, received GDSI [mean time ~1.8y]. A graded increase in ASCVD and mortality IRs was seen in all risk categories comparing statin versus no statin use (Table). Conclusions: In a multi-site healthcare network, over one-third of statin-eligible patients were not prescribed statin therapy. In eligible patients, who ultimately received statins, mean time to GDSI was ~2yrs. The consequences of non-adherence to guidelines is illustrated with greater incident ASCVD events and mortality among those patients not treated with statin therapy. Further research can define identify barriers and develop healthcare system strategies to optimize preventive therapies.

Impact of clinical pharmacist-led diabetes management clinic on health outcomes at an academic hospital in Riyadh, Saudi Arabia: A prospective cohort study

BackgroundDiabetes prevalence is estimated to reach 20.6% by 2030. Studies have illustrated main reasons for uncontrolled patients and concluded: low level of awareness, limited access to healthcare providers, and lack of cooperation between different disciplines. The role of pharmacists has been proven to improve patient-related outcomes, including an improvement in HgA1C readings between 0.54% and 1.6%. ObjectivesThis study was conducted to evaluate diabetes-related health outcomes in a pharmacist-led diabetes clinic in terms of HgbA1C level, guideline-recommended routine screenings, medication adherence, and biomarkers of other comorbidities. MethodA prospective cohort study conducted from August 2017 until July 2018 at an academic hospital. The pharmacist-led diabetes clinic was providing the service for a half-day per week. The study included all adult diabetic patients referred to the pharmacist-led clinic and had -at least- three 3-month apart follow-up visits with no exclusions. The baseline assessments for patients receiving routine diabetic care was performed using HgbA1C level, blood pressure, lipid and thyroid panel, eye and foot examinations, preventive measures, and adherence. The baseline results were compared to the follow-up results thereafter. A descriptive analysis was used to report the differences between intervals. Main outcome measure: (a) Reduction in HgbA1c levels, (b) intervention made by clinical pharmacists in an outpatient setting. ResultThe study included thirty-five patients. The mean ± SD age was 56 ± 10 years old. At baseline, mean HgbA1C was 9.5% ± 1.3%. HgbA1C was ≥10% for 13 patients. Albuminuria was never previously assessed for 14 patients. Twenty percent were receiving incorrect dose compared to the guideline-recommended statin therapy. By the end of study, mean HgbA1C had significantly improved to be 8.3% ± 1.4% (p = 0.0004). Nine patients achieved their HgbA1C goal of <7%. All patients were assessed for albuminuria, and managed accordingly. Thirty-two patients were eligible to receive statin therapy, and prescribed appropriate doses. Additionally, peripheral neuropathy was assessed for all cohort, and seven patients received recommended vaccinations. ConclusionInvolving clinical pharmacists in diabetes management clinic can provide valuable services, help patients to adhere to the therapeutic plans, and assist physicians to achieve better treatment outcomes.

Patient-Reported Reasons for Not Using Primary Prevention Statin Therapy.

Almost half of patients who meet American College of Cardiology/American Heart Association (ACC/AHA) criteria for statin therapy are untreated. We aimed to evaluate patient-reported reasons for not using guideline-recommended statin therapy in a public healthcare system. Achieving this goal is key to addressing gaps in care and reducing preventable cardiovascular morbidity. We surveyed patients who met 2013 ACC/AHA guidelines for statin therapy but were not using statins. The survey probed domains of patient knowledge regarding cardiovascular health and benefits of statins, barriers to use, physician trust, and interest in cardiovascular care. Among 71 patients eligible for guideline-recommended statin therapy but not currently taking statins, 49 (69%) had a high school education or lower, 41 (58%) reported that they were unaware they should be prescribed a statin and 49 (69%) were unaware of the benefits of statins. Almost all patients, 70 (99%), reported caring about their cardiovascular health, 61 (86%) reported that they had a high level of trust in their physician, and 51 (72%) reported a willingness to follow their physician’s advice. Despite interest in cardiovascular health, awareness of benefits of statin therapy was low and knowledge of recommended statin therapy was low. Increasing patients’ awareness of their eligibility through systematic testing and linkage to statin therapy, along with education, may increase statin use among patients recommended for therapy.

Estimation of Atherosclerotic Cardiovascular Disease Risk Among Patients in the Veterans Affairs Health Care System

Current guidelines recommend statin therapy for millions of US residents for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). It is unclear whether traditional prediction models that do not account for current widespread statin use are sufficient for risk assessment. To examine the performance of the Pooled Cohort Equations (PCE) for 5-year ASCVD risk estimation in a contemporary cohort and to test the hypothesis that inclusion of statin therapy improves model performance. This cohort study included adult patients in the Veterans Affairs health care system without baseline ASCVD. Using national electronic health record data, 3 Cox proportional hazards models were developed to estimate 5-year ASCVD risk, as follows: the variables and published β coefficients from the PCE (model 1), the PCE variables with cohort-derived β coefficients (model 2), and model 2 plus baseline statin use (model 3). Data were collected from January 2002 to December 2012 and analyzed from June 2016 to March 2020. Traditional ASCVD risk factors from the PCE plus baseline statin use. Incident ASCVD and ASCVD mortality. Of 1 672 336 patients in the cohort (mean [SD] baseline age 58.0 [13.8] years, 1 575 163 [94.2%] men, 1 383 993 [82.8%] white), 312 155 (18.7%) were receiving statin therapy at baseline. During 5 years of follow-up, 66 605 (4.0%) experienced an ASCVD event, and 31 878 (1.9%) experienced ASCVD death. Compared with the original PCE, the cohort-derived model did not improve model discrimination in any of the 4 age-sex strata but did improve model calibration. The PCE overestimated ASCVD risk compared with the cohort-derived model; 211 237 of 1 136 161 white men (18.6%), 29 634 of 218 463 black men (13.6%), 1741 of 44 399 white women (3.9%), and 836 of 16 034 black women (5.2%) would be potentially eligible for statin therapy under the PCE but not the cohort-derived model. When added to the cohort-derived model, baseline statin therapy was associated with a 7% (95% CI, 5%-9%) lower relative risk of ASCVD and a 25% (95% CI, 23%-28%) lower relative risk for ASCVD death. In this study, lower than expected rates of incident ASCVD events in a contemporary national cohort were observed. The PCE overestimated ASCVD risk, and more than 15% of patients would be potentially eligible for statin therapy based on the PCE but not on a cohort-derived model. In the statin era, health care professionals and systems should base ASCVD risk assessment on models calibrated to their patient populations.