High Statin Use Research Articles

Use of Dietary Supplements Among People With Atherosclerotic Cardiovascular Disease in the United States: A Population-Based Analysis From NHANES.

Dietary supplement use is prevalent in the general US population, but little is known regarding the driving reasons for their use among those with atherosclerotic cardiovascular disease (ASCVD). Data from the National Health and Nutrition Examination Survey (NHANES) from 2017 to March 2020 were used to identify adults with ASCVD. Supplement use was assessed by interviewers using label review, and surveys captured self-reported reasons for use. Demographic, clinical, medication, and laboratory characteristics were compared between supplement users and nonusers. Among individuals with ASCVD in the National Health and Nutrition Examination Survey (n=965; mean age, 65 years; 56.1% men; 73.7% White individuals), 73.1% reported taking ≥1 dietary supplements, most commonly multivitamins (35.4%), vitamin D (30.8%), and fish oil (19.8%). Of those taking supplements, 47.3% report taking them under the advisement of a health professional. Nearly one fifth (17.9%) reported taking at least 1 supplement for "heart health," most commonly fish oil (11.1%), followed by CoQ10 (4.2%) and resveratrol (1.5%). Supplement users were older (68 versus 62 years; P=0.003), included more women (45.8% versus 37.7%; P=0.17), were less likely to smoke (11.0% versus 36.4%; P<0.001), had higher levels of education (P=0.005) and income (P<0.001), and higher use of statins (69.4% versus 55.8%; P=0.046). Supplement use is common in people with ASCVD. Among the top 3 supplements, a substantial minority were being taken under the direction of health professionals. Supplement users often report taking supplements "for heart health," despite a lack of randomized trial evidence for benefit in ASCVD, indicating a need for more patient and clinician education regarding health benefits of dietary supplements in ASCVD.

P438 DIABETES MELLITUS AND HEART FAILURE: A DANGEROUS ASSOCIATION

Abstract Introduction Diabetes mellitus is a frequent co–morbidity in heart failure patients reaching a prevalence of about 35% and patients with diabetes mellitus are twice as likely as non–diabetics to develop heart failure. The presence of diabetes is associated with higher rates of cardiovascular morbidity and mortality. In recent years, the introduction of remote monitoring systems has allowed for more careful management of them, although there are no large studies demonstrating their effectiveness in terms of improving prognosis. The aim of our study was to evaluate the prognosis of patients with diabetes mellitus and heart failure undergoing remote monitoring. Methods All patients undergoing device implantation for heart failure in our Center were recruited into the study, and the incidence of events (new hospitalizations or hospitalizations) during the period from January 1, 2021 to December 31, 2021 was assessed. Patients were monitored, and direct telephone contact or contact with one of the family members was made for all of them. Data on clinical characteristics and drug therapy were recorded. Results A total of 240 patients (73±11 years, 81% male) of whom 74 were diabetic (73±11 years, 87% male) and 166 were nondiabetic (73±10 years, p=0.82, 80% male, p= 0.198) were enrolled in the study. The two groups had no statistically significant differences in terms of clinical characteristics (such as ejection fraction, NYHA class, presence of anemia, rate of wide QRS, or rate of defibrillator implantation) except for a higher incidence of coronary artery disease in diabetic patients (70%) and multivessel coronary disease (67%) than in non–diabetic patients (57% coronary artery disease p= 0.05, and 46% multivessel disease p= 0.02). There were no significant differences in terms of drugs with the exception of higher use of statins in the group of diabetic patients (84%) compared to non–diabetics (64%, p= 0.002). Diabetic patients had almost 4 times higher mortality rates than non–diabetic patients (22% and 6% respectively, p&amp;lt; 0.0001). Differently, hospitalization rates were not significantly different among diabetic patients (24%) compared with nondiabetic patients (28%, p= 0.58). Conclusions The association of diabetes mellitus and heart failure represents a dangerous combination associated with an increased incidence of death. Therefore, clinical monitoring strategies and intensity of drug therapy should be particularly implemented in diabetic patients.

Prevalence of Statin Use for Primary Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and 10-Year Disease Risk in the US

The burden of atherosclerotic cardiovascular disease (ASCVD) in the US is higher among Black and Hispanic vs White adults. Inclusion of race in guidance for statin indication may lead to decreased disparities in statin use. To evaluate prevalence of primary prevention statin use by race and ethnicity according to 10-year ASCVD risk. This serial, cross-sectional analysis performed in May 2022 used data from the National Health and Nutrition Examination Survey, a nationally representative sample of health status in the US, from 2013 to March 2020 (limited cycle due to the COVID-19 pandemic), to evaluate statin use for primary prevention of ASCVD and to estimate 10-year ASCVD risk. Participants aged 40 to 75 years without ASCVD, diabetes, low-density lipoprotein cholesterol levels 190 mg/dL or greater, and with data on medication use were included. Self-identified race and ethnicity (Asian, Black, Hispanic, and White) and 10-year ASCVD risk category (5%-<7.5%, 7.5%-<20%, ≥20%). Prevalence of statin use, defined as identification of statin use on pill bottle review. A total of 3417 participants representing 39.4 million US adults after applying sampling weights (mean [SD] age, 61.8 [8.0] years; 1289 women [weighted percentage, 37.8%] and 2128 men [weighted percentage, 62.2%]; 329 Asian [weighted percentage, 4.2%], 1032 Black [weighted percentage, 12.7%], 786 Hispanic [weighted percentage, 10.1%], and 1270 White [weighted percentage, 73.0%]) were included. Compared with White participants, statin use was lower in Black and Hispanic participants and comparable among Asian participants in the overall cohort (Asian, 25.5%; Black, 20.0%; Hispanic, 15.4%; White, 27.9%) and within ASCVD risk strata. Within each race and ethnicity group, a graded increase in statin use was observed across increasing ASCVD risk strata. Statin use was low in the highest risk stratum overall with significantly lower rates of use among Black (23.8%; prevalence ratio [PR], 0.90; 95% CI, 0.82-0.98 vs White) and Hispanic participants (23.9%; PR, 0.90; 95% CI, 0.81-0.99 vs White). Among other factors, routine health care access and health insurance were significantly associated with higher statin use in Black, Hispanic, and White adults. Prevalence of statin use did not meaningfully change over time by race and ethnicity or by ASCVD risk stratum. In this study, statin use for primary prevention of ASCVD was low among all race and ethnicity groups regardless of ASCVD risk, with the lowest use occurring among Black and Hispanic adults. Improvements in access to care may promote equitable use of primary prevention statins in Black and Hispanic adults.

Identifying factors explaining practice variation in secondary stroke prevention in primary care: a cohort study based on all patients with ischaemic stroke in the Stockholm region

ObjectivesThe aim of this study was to describe the practice variation in dispensation of secondary stroke preventive drugs among patients at different primary care centres (PCCs) in Stockholm region and...

Fasting Substrate Concentrations Predict Cardiovascular Outcomes in the CANagliflozin cardioVascular Assessment Study (CANVAS).

To examine whether the circulating substrate mix may be related to the incidence of heart failure (HF) and cardiovascular (CV) mortality and how it is altered by canagliflozin treatment. We measured fasting glucose, free fatty acids (FFA), glycerol, β-hydroxybutyrate, acetoacetate, lactate, and pyruvate concentrations in 3,581 samples from the CANagliflozin cardioVascular Assessment Study (CANVAS) trial at baseline and at 1 and 2 years after randomization. Results were analyzed by univariate and multivariate Cox proportional hazards models. Patients in the lowest baseline FFA tertile were more often men with a longer duration of type 2 diabetes (T2D), higher urinary albumin excretion, lower HDL-cholesterol levels, higher history of CV disease (CVD), and higher use of statins and insulin. When all seven metabolites were used as predictors, FFA were inversely associated with incident hospitalized HF (hazard ratio [HR] 0.33 [95% CI 0.21-0.55]), while glycerol was a positive predictor (2.21 [1.45-3.35]). In a model further adjusted for 16 potential confounders, including prior HF and CVD and pharmacologic therapies, FFA remained a significant negative predictor. FFA and glycerol also predicted CV mortality (HR 0.53 [95% CI 0.35-0.81] and 1.81 [1.26-2.58], respectively) and all-cause death (0.50 [0.36-0.70] and 1.64 [1.22-2.18]). When added to these models, background insulin therapy was an independent positive predictor of risk of death. Canagliflozin treatment significantly increased plasma FFA and β-hydroxybutyrate regardless of background antihyperglycemic therapy. A constitutive metabolic setup consisting of higher lipolysis may be beneficial in delaying or preventing hospitalized HF; a further stimulation of lipolysis by canagliflozin may reinforce this influence.

Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data

SummaryBackgroundIn the prevention of cardiovascular disease, a WHO target is that at least 50% of eligible people use statins. Robust evidence is needed to monitor progress towards this target in low-income and middle-income countries (LMICs), where most cardiovascular disease deaths occur. The objectives of this study were to benchmark statin use in LMICs and to investigate country-level and individual-level characteristics associated with statin use.MethodsWe did a cross-sectional analysis of pooled, individual-level data from nationally representative health surveys done in 41 LMICs between 2013 and 2019. Our sample consisted of non-pregnant adults aged 40–69 years. We prioritised WHO Stepwise Approach to Surveillance (STEPS) surveys because these are WHO’s recommended method for population monitoring of non-communicable disease targets. For countries in which no STEPS survey was available, a systematic search was done to identify other surveys. We included surveys that were done in an LMIC as classified by the World Bank in the survey year; were done in 2013 or later; were nationally representative; had individual-level data available; and asked questions on statin use and previous history of cardiovascular disease. Primary outcomes were the proportion of eligible individuals self-reporting use of statins for the primary and secondary prevention of cardiovascular disease. Eligibility for statin therapy for primary prevention was defined among individuals with a history of diagnosed diabetes or a 10-year cardiovascular disease risk of at least 20%. Eligibility for statin therapy for secondary prevention was defined among individuals with a history of self-reported cardiovascular disease. At the country level, we estimated statin use by per-capita health spending, per-capita income, burden of cardiovascular diseases, and commitment to non-communicable disease policy. At the individual level, we used modified Poisson regression models to assess statin use alongside individual-level characteristics of age, sex, education, and rural versus urban residence. Countries were weighted in proportion to their population size in pooled analyses.FindingsThe final pooled sample included 116 449 non-pregnant individuals. 9229 individuals reported a previous history of cardiovascular disease (7.9% [95% CI 7.4–8.3] of the population-weighted sample). Among those without a previous history of cardiovascular disease, 8453 were eligible for a statin for primary prevention of cardiovascular disease (9.7% [95% CI 9.3–10.1] of the population-weighted sample). For primary prevention of cardiovascular disease, statin use was 8.0% (95% CI 6.9–9.3) and for secondary prevention statin use was 21.9% (20.0–24.0). The WHO target that at least 50% of eligible individuals receive statin therapy to prevent cardiovascular disease was achieved by no region or income group. Statin use was less common in countries with lower health spending. At the individual level, there was generally higher statin use among women (primary prevention only, risk ratio [RR] 1.83 [95% CI 1.22–2.76), and individuals who were older (primary prevention, 60–69 years, RR 1.86 [1.04–3.33]; secondary prevention, 50–59 years RR 1.71 [1.35–2.18]; and 60–69 years RR 2.09 [1.65–2.65]), more educated (primary prevention, RR 1.61 [1.09–2.37]; secondary prevention, RR 1.28 [0.97–1.69]), and lived in urban areas (secondary prevention only, RR 0.82 [0.66–1.00]).InterpretationIn a diverse sample of LMICs, statins are used by about one in ten eligible people for the primary prevention of cardiovascular diseases and one in five eligible people for secondary prevention. There is an urgent need to scale up statin use in LMICs to achieve WHO targets. Policies and programmes that facilitate implementation of statins into primary health systems in these settings should be investigated for the future.FundingNational Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy and Innovation, and National Institute of Diabetes and Digestive and Kidney Diseases.

Risk factor management in coronary patients: results from the EUROASPIRE V survey

Abstract Background Previously, there has been a misperception that cardiovascular disease (CVD) mainly affects males. Although lately, there is increasing awareness about the risk of CVD in women, evidence suggests that the management of women with CVD is suboptimal. Purpose The aim of this study is to look at gender differences in treatment and risk factor control after a coronary event across countries with varying income levels. Methods Analyses were based on the ESC-EORP EUROASPIRE V survey, including patient information from 27 European countries. Patients included (18–80 years), were hospitalised for an ischaemic coronary event. Information on medical treatment, risk factors and behavioural changes were obtained during patient interviews (6 months to 2 years after hospitalization). Findings on treatment and risk factor control were compared with the European guidelines on CVD prevention (2016). Country classification by income level (low/medium income vs. high income) was done according to the World Bank Atlas method. Logistic regression analyses adjusted for sex, age, education level, country income, surgical intervention, stroke, heart failure and diabetes were performed. Results Data from 8261 coronary patients, of which 25.8% women, were included in the analyses. Mean (SD) age at the interview was 62.95 (9.72) years for men and 65.36 (9.21) years for women. First, when looking at the evidence based medication intake, no gender differences were seen in the prescription of antiplatelets/aspirin, whereas statins were more often prescribed in men (82.8% vs. 77.7%; p=0.002). A closer look by country income revealed that this difference is entirely due to the higher statin use among men from low/medium income countries (79.6% vs. 72.3%; p=0.004). Second, the risk factor profile differed substantially between genders. Overall, a worse risk factor profile was seen in women. Although, men were more likely to smoke (20.7% vs. 12.8%; p&amp;lt;0.001), women were less physically active (63.2% vs. 72.5%; p&amp;lt;0.001), had more obesity (34.9% vs. 45.7%; p&amp;lt;0.001) and central obesity (51.8% vs. 78.0%; p&amp;lt;0.001), and had a worse lipid control (65.9% vs. 74.3%; p&amp;lt;0.001). Overall, no gender differences were seen in diabetes prevalence and blood pressure control. A closer look at country income level showed that the gender difference in smoking prevalence dissolved in high income countries. In addition, women in low income countries were more likely to suffer from diabetes (26.7% vs. 38.9%; p&amp;lt;0.001). Conclusion These findings suggest a worse risk factor profile in women despite little to no gender differences in medical treatment. Further research is needed to understand the gender-differential in risk factor control. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque

Relation Between Cardiology Follow-Up Visits, Evidence-Based Statin Prescribing, and Statin Adherence (from the Veterans Affairs Health Care System)

Statin use remains suboptimal in patients with atherosclerotic cardiovascular disease (ASCVD). We assessed whether outpatient care with a cardiology provider is associated with evidence-based statin prescription and statin adherence. We identified patients with ASCVD aged ≥18 years receiving primary care in 130 facilities and associated community-based outpatient clinics in the entire Veterans Affairs Health Care System between October 1, 2013 and September 30, 2014. Patients were divided into: (1) patients with at least 1 outpatient cardiology visit and (2) patients with no outpatient cardiology visits in the year before the index primary care visit. We assessed any- and high-intensity statin prescription adjusting for several patient- and facility-level covariates, and statin adherence using proportion of days covered (PDC). We included 1,249,061 patients with ASCVD (mean age: 71.9 years; 98.0% male). After adjusting for covariates, patients who visited a cardiology provider had greater odds of being on a statin (87.4% vs 78.4%; Odds ratio [OR] 1.25, 95% Confidence interval [CI] 1.24 to 1.26), high-intensity statin (34.5% vs 21.2%; OR: 1.21, 95% CI 1.21 to 1.22), and higher statin adherence (mean PDC 0.76 ± 0.29 vs 0.70 ± 0.34, PDC ≥0.8: 62.0% vs 57.3%; OR 1.09, 95% CI 1.09 to 1.11). A dose response relation was seen with a higher number of cardiology visits associated with a higher statin use and statin adherence. In conclusion, compared with outpatient care delivered by primary care providers alone, care delivered by a cardiology provider for patients with ASCVD is associated with a higher likelihood of guideline-based statin use and statin adherence.

Prevalence and Predictors of Cholesterol Screening, Awareness, and Statin Treatment Among US Adults With Familial Hypercholesterolemia or Other Forms of Severe Dyslipidemia (1999-2014).

Familial hypercholesterolemia (FH) and other extreme elevations in low-density lipoprotein cholesterol significantly increase the risk of atherosclerotic cardiovascular disease; however, recent data suggest that prescription rates for statins remain low in these patients. National rates of screening, awareness, and treatment with statins among individuals with FH or severe dyslipidemia are unknown. Data from the 1999 to 2014 National Health and Nutrition Examination Survey were used to estimate prevalence rates of self-reported screening, awareness, and statin therapy among US adults (n=42 471 weighted to represent 212 million US adults) with FH (defined using the Dutch Lipid Clinic criteria) and with severe dyslipidemia (defined as low-density lipoprotein cholesterol levels ≥190 mg/dL). Logistic regression was used to identify sociodemographic and clinical correlates of hypercholesterolemia awareness and statin therapy. The estimated US prevalence of definite/probable FH was 0.47% (standard error, 0.03%) and of severe dyslipidemia was 6.6% (standard error, 0.2%). The frequency of cholesterol screening and awareness was high (>80%) among adults with definite/probable FH or severe dyslipidemia; however, statin use was uniformly low (52.3% [standard error, 8.2%] of adults with definite/probable FH and 37.6% [standard error, 1.2%] of adults with severe dyslipidemia). Only 30.3% of patients with definite/probable FH on statins were taking a high-intensity statin. The prevalence of statin use in adults with severe dyslipidemia increased over time (from 29.4% to 47.7%) but not faster than trends in the general population (from 5.7% to 17.6%). Older age, health insurance status, having a usual source of care, diabetes mellitus, hypertension, and having a personal history of early atherosclerotic cardiovascular disease were associated with higher statin use. Despite the high prevalence of cholesterol screening and awareness, only ≈50% of adults with FH are on statin therapy, with even fewer prescribed a high-intensity statin; young and uninsured patients are at the highest risk for lack of screening and for undertreatment. This study highlights an imperative to improve the frequency of cholesterol screening and statin prescription rates to better identify and treat this high-risk population. Additional studies are needed to better understand how to close these gaps in screening and treatment.

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OBJECTIVES/SPECIFIC AIMS: Cardiac complications are common after hospital admission for sepsis, and elevated troponin has been associated with increased all-cause mortality. However, little is known about clinical or imaging factors that predict these cardiac events. Coronary artery calcification (CAC) is an easily identifiable imaging finding, even on nongated CT scans. The goal of this study is to identify if CAC predicts all cause mortality and acute myocardial infarction. METHODS/STUDY POPULATION: This is a single center, nonconcurrent cohort study including 899 patients who were admitted for sepsis and had a detectable TnI level from January 2013 to December 2013. Patients with a CT scan of the chest or abdomen done for other clinical indications within 6 months of this admission were reviewed for the presence or absence of CAC. Medical records were individually reviewed for mortality and type I acute myocardial infarctions at 1 year. RESULTS/ANTICIPATED RESULTS: In total, 144 patients (mean age 57±14.8 years, 48% female) were included in the analysis. CAC was seen in 59% of these scans. Compared to those without detectable CAC, the CAC group had similar APACHE score (18 vs. 16.6, p=0.259), peak TnI (3.64 vs. 2.11 mg/dL, p=0.363), aspirin (63% vs. 51%, p=0.144), and β blocker use (90% vs. 85%, p=0.357) and had higher statin use (48% vs. 27%, p=0.013). CAC was associated with increased all-cause mortality (59.5% vs. 38.9%, p=0.016) and type I myocardial infarctions (10.6% vs. 1.7%, p=0.039) compared with those without CAC. DISCUSSION/SIGNIFICANCE OF IMPACT: Coronary artery calcification is often seen when patients present with a noncardiac acute illness, such as sepsis, often making a new diagnosis for these patients. Mortality and acute MI after sepsis can be predicted by coronary calcification, and identify patients who should be targeted for therapy and close follow-up.

Functional Testing or Coronary Computed Tomography Angiography in Patients With Stable Coronary Artery Disease

BackgroundThe choice of either anatomical or functional noninvasive testing to evaluate suspected coronary artery disease might affect subsequent clinical management and outcomes. ObjectivesThis study analyzed the association of initial noninvasive cardiac testing in outpatients with stable symptoms, with subsequent use of medications, invasive procedures, and clinical outcomes. MethodsWe studied patients enrolled in a Danish nationwide register who underwent initial noninvasive cardiac testing with either coronary computed tomography angiography (CTA) or functional testing (exercise electrocardiography or nuclear stress testing) from 2009 to 2015. Further use of noninvasive testing, invasive procedures, medications, and medical costs within 120 days were evaluated. Risks of long-term mortality and myocardial infarction (MI) were analyzed using adjusted Cox proportional hazard models. ResultsA total of 86,705 patients underwent either functional testing (n = 53,744, mean age 57.4 years, 49% males) or coronary CTA (n = 32,961, mean age 57.4 years, 45% males), and were followed for a median of 3.6 years. Compared with functional testing, there was significantly higher use of statins (15.9% vs. 9.1%), aspirin (12.7% vs. 8.5%), invasive coronary angiography (14.7% vs. 10.1%), and percutaneous coronary intervention (3.8% vs. 2.1%); all p < 0.001 after coronary CTA. The mean costs of subsequent testing, invasive procedures, and medications were higher after coronary CTA ($995 vs. $718; p < 0.001). Unadjusted rates of mortality (2.1% vs. 4.0%) and MI hospitalization (0.8% vs. 1.5%) were lower after coronary CTA than functional testing (both p < 0.001). After adjustment, coronary CTA was associated with a comparable all-cause mortality (hazard ratio: 0.96; 95% confidence interval: 0.88 to 1.05), and a lower risk of MI (hazard ratio: 0.71; 95% confidence interval: 0.61 to 0.82). ConclusionsIn stable patients undergoing initial evaluation for suspected coronary artery disease, coronary CTA was associated with greater use of statins, aspirin, and invasive procedures, and higher costs than functional testing. Coronary CTA was associated with a lower risk of MI, but a similar risk of all-cause mortality.

Does African American Race Impact Statin Efficacy in Renal Transplant Outcomes?

There is a lack of studies assessing if race impacts the efficacy of 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGCR) inhibitor (“statin”) therapy on renal transplantation (RTx) outcomes. We examined the association between statin therapy and RTx outcomes, while concurrently quantifying the effect modification African American (AA) race has on statin efficacy.This was a retrospective longitudinal cohort study of solitary adult RTx (n = 1176) between June 2005 and May 2013. The Cox proportional hazard model was used to examine the impact of statin therapy on graft loss, death, and acute rejection and determine if significant interactions exist between statin therapy and race. Models were adjusted for demographics, socioeconomic status, cardiovascular history, medication use, and transplant characteristics.AAs (n = 624) and non-African Americans (n = 552) were equally likely to receive statin therapy (P = 0.922). Mean LDL and TGs in AA were 94 mg/dL and 133 mg/dL compared to 90 mg/dL and 163 mg/dL in non-AA, respectively. After adjusting for confounders, high statin users had 52% lower risk of developing graft loss (HR 0.48, 95% CI 0.29–0.80) and a nonstatistically significant reduction in death (HR 0.50, 95% CI 0.23–1.06) compared to low statin users. Acute rejection was not significantly influenced by statin use (HR 0.77 95% CI 0.46–1.27). There was a significant interaction between race and statin therapy for death (P = 0.007), but not for graft loss (P = 0.121) or rejection (P = 0.605). After stratifying by race, high statin use reduced the risk of death in AAs (HR 0.43, 95% CI 0.20–0.94), but not in non-AAs (HR 1.09, 95% CI 0.49–2.44).High statin use reduces the risk of graft loss in RTx, with a mortality benefit in AAs compared to non-AA, despite similar LDL levels. These results suggest a compelling reason to optimize statin therapy in renal transplant recipients (RTR), especially in AAs.

Statin use and risk of gallstone disease: A meta-analysis.

There is emerging evidence from animal and human studies that current statins can decrease the formation of gallbladder cholesterol gallstones and subsequently decrease the risk of gallstone disease, but consistent results have not been reported. We performed a meta-analysis to provide an overview of the relevant studies. Relevant studies published between January 1980 and February 2014 were identified by searching Medline, Embase and the Cochrane Library. Studies were selected using a priori defined criteria. The strength of the relationship between statin use and risk of gallstone disease was assessed by adjusted odds ratio (OR). A total of 622 868 participants from six studies (four case-control studies, one cohort study and one cross-sectional study) were identified in this meta-analysis. The studies provided adjusted overall OR estimates for current statin use versus non-use, leading to a pooled OR of 0.86 (95% confidence interval [CI], 0.77-0.97; P < 0.001). The overall OR of population-based case-control studies and cholecystectomy due to gallstone disease were 0.83 (95% CI, 0.73-0.95; P = 0.0131) and 0.78 (95% CI, 0.74-0.82; P = 0.615), respectively. There is evidence that current statin use lowers the risk of gallstone disease compared with non-use, especially for cholecystectomy due to gallstone disease. Low statin use (1-4 prescriptions) did not decrease the risk of gallstone disease, but moderate and high statin use significantly decreased the risk. Further multicenter and better controlled studies are needed to confirm these findings.

AB0511 Does the Advanced AGE Influence on the Type of Renal Injury and the Prognosis of Lupus Nephritis?

ObjectivesTo analyze if the advanced age influence on the type of renal injury and the prognosis of lupus nephritis (LN).MethodsWe evaluated 243 patients with systemic lupus erythematosus (SLE) followed in...

Genetically guided statin therapy on statin perceptions, adherence, and cholesterol lowering: a pilot implementation study in primary care patients.

Statin adherence is often limited by side effects. The SLCO1B1*5 variant is a risk factor for statin side effects and exhibits statin-specific effects: highest with simvastatin/atorvastatin and lowest with pravastatin/rosuvastatin. The effects of SLCO1B1*5 genotype guided statin therapy (GGST) are unknown. Primary care patients (n = 58) who were nonadherent to statins and their providers received SLCO1B1*5 genotyping and guided recommendations via the electronic medical record (EMR). The primary outcome was the change in Beliefs about Medications Questionnaire, which measured patients’ perceived needs for statins and concerns about adverse effects, measured before and after SLCO1B1*5 results. Concurrent controls (n = 59) were identified through the EMR to compare secondary outcomes: new statin prescriptions, statin utilization, and change in LDL-cholesterol (LDL-c). GGST patients had trends (p = 0.2) towards improved statin necessity and concerns. The largest changes were the “need for statin to prevent sickness” (p < 0.001) and “concern for statin to disrupt life” (p = 0.006). GGST patients had more statin prescriptions (p < 0.001), higher statin use (p < 0.001), and greater decrease in LDL-c (p = 0.059) during follow-up. EMR delivery of SLCO1B1*5 results and recommendations is feasible in the primary care setting. This novel intervention may improve patients’ perceptions of statins and physician behaviors that promote higher statin adherence and lower LDL-c.

The results of Look AHEAD do not row against the implementation of lifestyle changes in patients with type 2 diabetes

The Look AHEAD trial, evaluating the effects of weight loss on cardiovascular (CV) morbidity and mortality in overweight/obese people with type 2 diabetes (T2D), was interrupted after a median 9.5-year follow-up because the incidence of CV events was not different between the Intensive Lifestyle Intervention (ILI) and the control groups, and unlikely to statistically change thereafter. This made health providers and patients wondering about clinical value of diet and physical exercise in diabetic patients. Many factors may have made difficult to ascertain benefits of lifestyle intervention, besides the lower than predicted CV event rates. Among others, LDL-cholesterol was lowered more, with a higher use of statins, in the control group. Anyhow, ILI significantly improved numerous health conditions, including quality of life, CV risk factors and blood glucose control, with more diabetes remissions and less use of insulin.The intervention aimed at weight loss by reducing fat calories, and using meal replacements and, eventually, orlistat, likely underemphasizing dietary composition. There is suggestive evidence, in fact, that qualitative changes in dietary composition aiming at higher consumption of foods rich in fiber and with a high vegetable/animal fat ratio favorably influence CV risk in T2D patients.In conclusion, the Look AHEAD showed substantial health benefits of lifestyle modifications. Prevention of CV events may need higher attention to dietary composition, contributing to stricter control of CV risk factors. As a better health-related quality of life in people with diabetes is an important driver of our clinical decisions, efforts on early implementation of behavioral changes through a multifactorial approach are strongly justified.

Parity and Cardiovascular Disease Risk among Older Women: How Do Pregnancy Complications Mediate the Association?

To determine whether parity is associated with increased risk of cardiovascular disease (CVD) after accounting for perinatal complications. CVD prevalence, number of births, and a history of preeclampsia, term low birth weight, preterm or stillbirth were evaluated among 540 women (mean age, 80 years; 47% black) enrolled in the Pittsburgh, PA site of the Health, Aging and Body Composition Study. Biomarkers were measured and CVD status was determined by self-report and hospital records. Nulliparous women (n = 89) had lower CVD prevalence compared with parous women (18.0% vs. 30.2%). Parous women without perinatal complications of interest (n = 321) had higher statin use compared with nulliparas, a trend accompanied by lower high-density lipoprotein (HDL) and higher triglycerides among women with perinatal complications (n = 130). After adjustment, parous women with no complicated births had a 1.95-fold (95% confidence interval [CI], 1.03-3.7) higher CVD prevalence compared to nulliparas. Among women with one or more pregnancy complications, CVD prevalence was 2.67 times (CI, 1.34-5.33) higher. Women with five or more births had the highest CVD prevalence (odds ratio [OR], 2.60; CI, 1.17-5.76) that was attenuated to 2.27 (1.00-5.15) after adjustment for complications of interest. History of pregnancy complications and higher statin use accounted for some but not all of the excess CVD prevalence among older parous women.

Statins down under

Use of statins in Australia is markedly higher than in Europe [1], although overall expenditure on cardiovascular drugs is less than that of many European countries [2]. A high rate of statin use is consistent with extensive trial evidence suggesting that the statins produce significant health gains. However, in practice, achieving those gains will require doctors to prescribe appropriately, eligible patients to receive treatment and patients to persist with treatment. In order to make international comparisons, we applied the standard international method for estimating drug use across populations, the defined daily dose (DDD), to national data on community statins dispensed, from 1990, when they were first introduced in Australia, to the end of 2004. The DDD is the assumed average maintenance dose for a drug for its main indication [3]. We do not know if Australians enjoy better health outcomes as a result of their high statin use. For example, we lack Australian studies to compare with the work of Unal & colleagues who estimated that statins contributed 6.5% to reduced coronary heart disease mortality in England and Wales from 1981 and 2000 [4]. In 2000, Australia’s use of statins was three times higher than that given by Walley & colleagues [1] for England (79.5 vs. 23.9 DDDs/1000/day). Higher use of statins in Australia might be reflected in a greater contribution of statins to reductions in mortality, although this could be modified by differences in prescribing practices, patients’ persistence with treatment and the effect of dietary and other factors. In 2003, Australian use of statins was 25% greater than the highest rates across EU countries, and in 2000 it was 40% higher [1]. Even before the marked increase in statin utilization rate in 1997/1998, which corresponded to the introduction of atorvastatin to the Australian Pharmaceutical Benefits Scheme, Australia had higher statin utilization than Finland, Italy, Norway and Sweden [5]. From 1991 to 1997, Australian utilization increased from 5.2 to 25.3 DDDs/1000/year representing a mean annual increase of 3.6 DDDs/1000/year. From 1998 to 2004, the increase was from 39.1 to 162.1 DDDs/1000/year, a mean annual increase of 19.5 DDDs/1000/year (Figure 1). Figure 1 Australian community utilization of individual statins and all statins combined, DDDs/1000 population/day, yearly from 1990 to 2004. Source: DUSC database, August 2005 The DDD has not altered since statins were introduced. Thus if, for example, some patients were prescribed twice the DDD, utilization rates would double even though no more people were taking statins. Walley & colleagues observed that apparent variation between countries might in part be explained by the rise in relative use of more potent statins, particularly atorvastatin [1]. Using commercial data sources they calculated that on average two thirds of the DDD increase in statin use, related to increases in prescribed daily dose (PDDs). In Australia there was a trend to greater strength tablets for all statins. Atorvastatin 40 mg experienced a six-fold market share increase (2–12%) from 2001 to 2004, while simvastatin 40 mg almost tripled its market share (5–14%). Over the same period, atorvastatin 10 mg market share fell from 17% to 13%, although the absolute number of prescriptions dispensed remained steady, while simvastatin 10 mg fell fourfold (26% to 6%) although the absolute number of prescriptions fell only twofold. In 2004, atorvastatin 20 mg had the highest market share (18.5%) overtaking simvastatin 20 mg in 2002 (data available on request). An objective assessment of the outcomes from the use of greater strength tablets in the population is overdue, especially in view of the IDEAL trial in which patients randomized post-myocardial infarction to atorvastatin 80 mg day−1 did not achieve a significant reduction in major coronary events compared with those taking simvastatin 20 mg day−1[6]. The Australian health care system provides universal cover for pharmaceuticals listed on the Pharmaceutical Benefits Scheme (PBS), so statins have been widely available. However, we need person-level linked data to explore fully the distribution of statin use and associated cardiovascular outcomes in Australia. These data are collected nationally but studies linking drug use prescription data to health data require ethical clearance before data custodians can release data. It is difficult to study demographic patterns of use as this requires linkage of databases: one utilization study for 7 months of 2002 has been conducted, showing differential statin utilization across age, sex and socioeconomic groups [7]. The marked increase in statin use in Australia over the past decade raises the question: how much higher are they likely to rise? Currently, the PBS listing for all statins restricts doctors to prescribing them according to cholesterol or triglyceride concentrations which differ for different patient categories. If PBS restrictions for statins were expanded to accord with clinical evidence supporting absolute risk as the basis for prescribing [8], further increases in statin utilization could reasonably be expected.

Treatment and secondary prevention of ischemic coronary events in Croatia (TASPIC-CRO study)

The objective of this study is to determine the status of major risk factors for coronary heart disease in patients with established coronary heart disease in Croatia and whether the Joint European Societies' recommendations on coronary heart disease prevention are being followed in Croatia and whether secondary prevention practices have improved between 1998 and 2003. Five surveys were undertaken in 35 centres covering the geographical area of the whole of Croatia between 1 June, 1998 and 31 March, 2003. Consecutive patients of both sexes were identified after coronary-bypass grafting or a percutaneous transluminal coronary angioplasty or a hospital admission with acute myocardial infarction or ischaemia. Data collection was based on a review of medical records and the methodology used was similar to the one used in the EUROASPIRE study. Fifteen thousand, five hundred and twenty patients were enrolled (64.6% men); 35% of patients smoked cigarettes, 66% had raised blood pressure, 69% elevated serum total cholesterol, 69% elevated serum low-density lipoprotein (LDL) cholesterol, 42% low high-density lipoprotein (HDL) cholesterol, 37% elevated triglycerides, 30% diabetes and 34% family history of coronary heart disease. More men were smokers and had low HDL cholesterol, but more women had elevated total and LDL cholesterol, hypertension and diabetes. More men had Q wave acute myocardial infarction, but more women had angina. Over 5 years, the prevalence of hypercholesterolemia decreased substantially from 82.7 to 65%. Eighty-three percent of patients received aspirin and this percentage did not change during the study. The use of diuretics, calcium antagonists and nitrates did not change either. The reported use of statins, angiotensin-converting enzyme inhibitors and beta-blockers increased significantly. This survey shows a high prevalence of modifiable risk factors in Croatian patients with coronary heart disease. Although the higher use of statins, angiotensin-converting enzyme inhibitors and beta-blockers is encouraging, the fact that most coronary heart disease patients are still not achieving the recommended goals remains a concern. There is real potential to reduce the very high coronary heart disease morbidity and mortality in Croatia.

Statin use after acute myocardial infarction: a nationwide study in Denmark.

To study outpatient statin use after first acute myocardial infarction (AMI) in Denmark between 1995 and 2002 and to determine the predictors of statin use. This is a nationwide population-based study using administrative registries. Patients with first AMI between 1995 and 2002 older than 30 years of age and alive 6 months after discharge (n = 45 219) were identified through the National Patient Registry. The statins purchased by these patients within 6 months after discharge were determined using the Registry of Medicinal Product Statistics, a nationwide prescription database. Statin use following AMI increased from 13% in 1995 to 61% in 2002. In 2002, 81% of patients aged 30-64 years used statins. Older patients used fewer statins, but use increased more among patients aged 75-84 years: from 1.3% to 43%. Use in elderly patients did not differ according to gender in 2000-02, but young men used more than younger women. In 2000-02, patients with diabetes (odds ratio (OR): 0.84; 95% confidence interval (CI): 0.74-0.95) and with heart failure (OR: 0.70; 95% CI: 0.64-0.76) were undertreated; this trend was present throughout the period. In this nationwide study, younger patients after AMI had high statin use in 2002, but high-risk patients such as those with diabetes and heart failure were still being undertreated.