Indication For Statin Therapy Research Articles

Coronary Calcium Is Elevated in Patients with Myocardial Infarction without Standard Modifiable Risk Factors.

Objectives: Recent reports have highlighted myocardial infarction (MI) patients without standard modifiable risk factors (SMRF), noting them to be surprisingly common and to have a substantial risk of adverse outcomes. The objective of this study was to address the challenge of identifying at-risk patients without SMRF and providing preventive therapy. Methods: Patients presenting between 2001 and 2021 to Intermountain Health catheterization laboratories with a diagnosis of MI were included if they also had a coronary artery calcium (CAC) scan by computed tomography within 2 years. SMRF were defined as a clinical diagnosis or treatment of hypertension, hyperlipidemia, diabetes, or smoking. The co-primary endpoints in SMRF-less patients were: (1) proportion of patients with an elevated (>50%ile) CAC score, and (2) an indication for statin therapy (i.e., CAC ≥ 100 AU or ≥75%ile). The 60-day and long-term major adverse cardiovascular events were determined. A comparison set included MI patients with SMRF. Results: We identified 429 MI patients with a concurrent CAC scan, of which 60 had no SMRF. SMRF status did not distinguish most risk factors or interventions. No-SMRF patients had a high CAC prevalence and percentile (82% ≥ 50%ile; median, 80%ile), and 77% met criteria for preventive therapy. As expected, patients with SMRF had high CAC scores and percentiles. Outcomes were more favorable for No-SMRF status and for lower CAC scores. Conclusions: Patients without SMRF presenting with an MI have a high prevalence and percentile of CAC. Wider application of CAC scans, including in those without SMRF, is promising as a method to identify an additional at-risk population for MI and to provide primary preventive therapy.

Two Randomized Controlled Trials of Nudges to Encourage Referrals to Centralized Pharmacy Services for Evidence-Based Statin Initiation in High-Risk Patients: Rationale and Design of the SUPER LIPID Program

In patients with or at risk for atherosclerotic vascular disease, statins reduce the incidence of major adverse cardiovascular events, but the majority of U.S. adults with an indication for statin therapy are not prescribed statins at guideline-recommended intensity. Clinicians' limited time to address preventative care issues is cited as one factor contributing to gaps in statin prescribing. Centralized pharmacy services can fulfill a strategic role for population health management through outreach, education, and statin prescribing for patients at elevated ASCVD risk, but best practices for optimizing referrals of appropriate patients are unknown. SUPER LIPID (NCT05537064) is a program consisting of two pragmatic clinical trials testing the effect of nudges in increasing referrals of appropriate patients to a centralized pharmacy service for lipid management, conducted within 11 primary care practices in a large community health system. In both trials, patients were eligible for inclusion if they had an assigned primary care provider (PCP) in a participating practice and were not prescribed a high- or moderate-intensity statin despite an indication, identified via an electronic health record (EHR) algorithm. Trial #1 was a stepped wedge trial, conducted at a single practice with randomization at the PCP level, of an interruptive EHR message that appeared during eligible patients' visits and facilitated referral to the pharmacy service. For the first 3 months, no PCPs received the message; for the second 3 months, half were randomly selected to receive the message; and for the last 3 months, all PCPs received the message. Trial #2 was a cluster-randomized trial conducted at 10 practices, with randomization at the practice level. Practices were randomized to usual care or to have eligible patients automatically referred to centralized pharmacy services via a referral order placed in PCPs EHR inboxes for co-signature. In both trials, when a patient was referred to centralized pharmacy services, a pharmacist reviewed the patient's chart, contacted the patient, and initiated statin therapy if the patient agreed. The primary endpoint of both trials was the proportion of patients prescribed a statin; secondary endpoints include the proportion of patients prescribed a statin at guideline-recommended intensity, the proportion of patients filling a statin prescription, and serum low-density lipoprotein level. SUPER LIPID is a pair of pragmatic clinical trials assessing the effectiveness of two strategies to encourage referral of appropriate patients to a centralized pharmacy service for lipid management. The trial results will develop the evidence base for simple, scalable, EHR-based strategies to integrate clinical pharmacists into population health management and increase appropriate statin prescribing. clinicaltrials.gov; NCT05537064.

Recommended and observed statin use among US adults with and without cancer.

Patients with cancer are at increased cardiovascular risk. We aimed to compare the recommended and observed statin use among individuals with and without cancer. Using three 2-year cycles from the National Health and Nutrition Examination Survey [NHANES] (2013-2018), we analyzed data from 17,050 USA adults. We compared the prevalence of class 1 statin recommendations and use between individuals with and without cancer, overall and among different demographic groups. Individuals with a history of cancer were older and had a higher burden of co-morbidities. Stratified by age groups, they were more likely to have a secondary prevention indication compared to individuals without cancer, but not a primary prevention indication for statin. Among individuals with an indication for statin therapy, the prevalence of statin use was higher in the cancer group compared to those without cancer (60.8% vs 47.8%, p < 0.001), regardless of sex, type of indication (primary vs secondary prevention), and education level. However, the higher prevalence of statin use in the cancer group was noted among younger individuals, ethnic minorities, and those with lower family income. Our finding highlights the importance of optimization of cardiovascular health in patients with cancer, as Individuals with cancer were more likely to have a class 1 indication for statin treatment when compared to individuals without cancer. Important differences in statin use among cohorts based on sex, age, ethnicity, and SES were identified, which may provide a framework through which cardiovascular risk factor control can be targeted in this population.

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

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.

Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage.

Survivors of spontaneous intracerebral hemorrhage (ICH) may have indications for statin therapy. The effect of statins on the risk of subsequent hemorrhagic and ischemic stroke (IS) in this setting is uncertain. We sought to determine the risk of any stroke (ischemic stroke, IS or recurrent-ICH), IS and recurrent-ICH associated with statin use among ICH-survivors. Using the Danish Stroke Registry, we identified all patients admitted to a hospital in Denmark (population 5.8 million) with a first-ever ICH between January 2003-to-December 2021 who were age ≥50-years and survived >30-days. Patients were followed until August 2022. Within this cohort, we conducted three nested case-control analyses for any stroke, IS, and recurrent-ICH. We matched controls for age, sex, time since first-ever ICH, and history of prior IS. The primary exposure was statin use before or on the date of subsequent stroke or the equivalent date in matched controls. Using conditional logistic regression, we calculated adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) for any stroke, IS, and recurrent-ICH associated with statin exposure. We identified 1,959 patients with any stroke (women 45.3%; mean [SD] age, 72.6 [9.7] years) who were matched to 7,400 controls; 1,073 patients with IS (women 42.0%; mean [SD] age, 72.4 [10.0] years) who were matched to 4,035 controls, and 984 patients with recurrent-ICH (women 48.7%; mean [SD] age, 72.7 [9.2] years) who were matched to 3,755 controls. Statin exposure was associated with a lower risk of both any stroke (cases 38.6%, controls 41.1%; (aOR 0.88; 95%CI, 0.78-0.99) and IS (cases 39.8%, controls 41.8%, aOR 0.79; 95%CI, 0.67-0.92), but was not associated with recurrent-ICH risk (cases 39.1%, controls 40.8%, aOR 1.05; 95%CI, 0.88-1.24). Exposure to statins was not associated with an increased risk of recurrent-ICH but was associated with lower risk of any stroke, largely due to a lower risk of IS. Confirmation of these findings in randomized trials is needed. This study provides class III evidence that statin use in ICH patients is associated with a lower risk of any stroke and IS and not with increased risk of recurrent-ICH.

Statin prescribing patterns in patient-centered medical home patients with NAFLD.

Cardiovascular disease is the leading cause of mortality in patients with nonalcoholic fatty liver disease (NAFLD), and statins play a pivotal role in the primary prevention of cardiovascular events. This study investigates statin prescribing in primary care patients with NAFLD to identify opportunities to address cardiovascular disease risk in this cohort. Retrospective cohort study of primary care electronic health record data from 2012-2018. This cohort included 652 patients with radiographic evidence of hepatic steatosis and no evidence of competing chronic liver disease. A statin prescription identified at any time during the study period was the primary outcome. Univariate and multivariable analyses were performed to evaluate the association of clinical signals and comorbidities with statin prescribing. Of the 652 patients in the NAFLD cohort, 56% received a statin prescription during the study period. Elevations in aminotransferases were not associated with statin prescribing (adjusted odds ratio [AOR], 1.17; 95% CI, 0.78-1.76), whereas older patients (AOR, 1.06; 95% CI, 1.05-1.08) and those with diabetes (AOR, 2.61; 95% CI, 1.73-3.92), hypertension (AOR, 2.76; 95% CI, 1.70-4.48), and a BMI greater than or equal to 30 kg/m2 (AOR, 1.49; 95% CI, 1.01-2.22) had higher odds of having a statin prescribed. Of the 288 patients without a statin prescription, 49% had an indication for statin therapy by atherosclerotic cardiovascular disease risk. In total, 16% of included patients did not have lipid panel results during the study period. This study showed no association between NAFLD and statin prescribing, and the findings highlight opportunities to improve primary prevention of cardiovascular disease in these at-risk patients.

Chronic liver disease is not associated with statin prescription in a primary care cohort.

Statins have historically been underutilized in patients with chronic liver disease (CLD). We sought to investigate the association between CLD and statin prescription in a primary care setting. Our retrospective cohort study identified primary care patients with a low-density lipoprotein value and more than one office visit from 2012 through 2018. Indication for statin therapy was determined using the Third Adult Treatment Panel criteria prior to November 2016 and the American College of Cardiology and American Heart Association guidelines thereafter. Indication for statin prescription and statin therapy by year was determined. Patients with CLD were identified using ICD-9/10 diagnosis codes. In total, 2119 individuals with an indication for statin therapy were identified. Of these individuals, 354 (16.7%) had CLD. Alcoholic and nonalcoholic fatty liver disease comprised 44.9% and 28.5% of the CLD population, respectively; 27.7% had cirrhosis. There was no difference in the prevalence of statin prescriptions when comparing patients with a CLD diagnosis to those without one (57.9 vs 59.9%, p = 0.48). A diagnosis of CLD was also not significantly associated with statin prescription when adjusting for other covariates (odds ratio (OR) 1.02; 95% confidence interval (CI) 0.78-1.33). An alanine aminotransferase level greater than 45 U/L significantly reduced the odds of a statin prescription (OR 0.62; 95% CI 0.44-0.87). Overall, the presence of a CLD diagnosis was not associated with attenuated statin utilization compared to those without a CLD diagnosis. Nevertheless, adherence to guideline indicated statin therapy remains suboptimal and efforts to increase statin utilization in this high-risk population remain prudent.

Association between statin therapy dose intensity and radiation cardiotoxicity in non-small cell lung cancer: Results from the NI-HEART study

IntroductionRadiation cardiotoxicity is a dose-limiting toxicity and major survivorship issue for patients with non-small cell lung cancer (NSCLC) completing curative-intent radiotherapy, however patients’ cardiovascular baseline is not routinely optimised prior to treatment. In this study we examined the impact of statin therapy on overall survival and post-radiotherapy cardiac events. MethodsPatients treated between 2015–2020 at a regional center were identified. Clinical notes were interrogated for baseline patient, tumor and cardiac details, and both follow-up cancer control and cardiac events. Three cardiologists verified cardiac events. Radiotherapy planning scans were retrieved for application of validated deep learning-based autosegmentation. Pre-specified Cox regression analyses were generated with varying degrees of adjustment for overall survival. Fine and Gray regression for the risk of cardiac events, accounting for the competing risk of death and cardiac covariables was undertaken. ResultsStatin therapy was prescribed to 59% of the 478 included patients. The majority (88%) of patients not prescribed a statin had at least one indication for statin therapy according to cardiovascular guidelines. In total, 340 patients (71%) died and 79 patients (17%) experienced a cardiac event. High-intensity (HR 0.68, 95%CI 0.50–0.91, p = 0.012) and medium-intensity (HR 0.70, 95%CI 0.51–0.97, p = 0.033) statin therapy were associated with improved overall survival after adjustment for patient, cancer, treatment, response and cardiovascular clinical factors. There were no consistent differences in the rate or grade of cardiac events according to statin intensity. ConclusionsStatin therapy is associated with improved overall survival in patients receiving curative-intent radiotherapy for NSCLC, and there is evidence of a dose–response relationship. This study highlights the importance of a pre-treatment cardiovascular risk assessment in this cohort. Further studies are needed to examine if statin therapy is cardioprotective in patients undergoing treatment for NSCLC with considerable incidental cardiac radiation dose and a low baseline cardiac risk.

Statin Use for Primary Cardiovascular Disease Prevention Is Low in Inflammatory Arthritis.

Patients with inflammatory arthritis (IA) are at high risk for atherosclerotic cardiovascular disease (ASCVD), yet management of dyslipidemia is infrequently prioritized. We applied Canadian dyslipidemia guidelines to determine how many patients with IA would be eligible for primary prevention with statins. We conducted a cross-sectional study of patients with IA in a cardio-rheumatology clinic, with no known CVD and without statin therapy at cohort entry. We stratified patients by Framingham Risk Score (FRS) and summarized the proportion meeting guideline statin-indicated criteria. Multivariable logistic regression analyses determined the association of variables with statin indication after adjustment for age, sex, traditional ASCVD risk factors, and arthritis characteristics. Among 302 patients, most had rheumatoid arthritis (59%). Mean age was 58 years, and 71% were female. Overall, 50% of the cohort was eligible for statin therapy. The majority was low FRS risk category (68%), and the most frequent qualifier for statins was elevated apolipoprotein B (ApoB) levels or low-density lipoprotein cholesterol (LDL-c) levels. In the intermediate FRS group, 91% met criteria for statin therapy based on the presence of a coronary artery calcification (CAC) score > 0 or an elevated high-sensitivity C-reactive protein. Male sex, hypertension, elevated ApoB, and a CAC score > 0 were the factors most strongly associated with indication for statin therapy. Statin therapy is suboptimal in IA despite a significant number of patients meeting indication based on lipoprotein thresholds or CAC scores. Understanding the barriers and potential facilitators of implementing and interpreting these CVD screening tools in IA is needed.

Relation of coronary calcium scoring with cardiovascular events in patients with diabetes: The CLARIFY Registry

IntroductionCoronary artery calcium (CAC) scoring is not routinely performed in patients with diabetes based on an existing class I indication for statin therapy in these patients. However, CAC scoring may improve risk classification and prediction of atherosclerotic cardiovascular disease (ASCVD) events beyond risk scores in asymptomatic individuals with prediabetes and diabetes, warranting CAC assessment in this population. The routine availability through provision of no-charge CAC as an alternative to routine probabilistic risk scores may improve utilization of preventive therapies especially in traditionally underserved populations. MethodsProspective observational study in a large health system offering no-charge CAC scoring for primary prevention risk prediction with available glycosylated hemoglobin (HbA1c) measurements between June 2015 and March 2019 were divided according to no diabetes (HbA1c <5.7 %), prediabetes (HbA1c 5.7 %–6.4 %), or diabetes (HbA1c ≥ 6.5 % or charted history) and followed for major adverse cardiovascular events [myocardial infarction, stroke, death (MACE) or coronary revascularization]. Patient characteristics, health history, laboratory data, and statin prescription rates were measured at baseline and at one year after CAC scoring. ResultsA total of 12,194 subjects with available HbA1c underwent CAC scoring during the study period (6462 diabetes, 2062 prediabetes, and 3670 without diabetes). At a median follow-up of 1.2 years, there were 458 MACE events (71 patients without diabetes, 66 patients with prediabetes, and 321 patients with diabetes). Among patients with diabetes or prediabetes, increased CAC was associated with MACE (HR 1.38 [1.26–1.51], p < 0.001) and MACE or revascularization (HR 1.70 [1.57–1.85], p < 0.001). In patients with diabetes, CAC category was associated with greater statin initiation (89.6 % for CAC≥400 vs 60.1 % for CAC = 0, p < 0.001) and high intensity statin initiation (42.2 % for CAC≥400 vs 16.8 % for CAC = 0, p < 0.001) at one year post CAC scoring. Patients with diabetes had greater reductions in systolic blood pressure, LDL-C, total cholesterol, and triglycerides from baseline with a CAC ≥400 compared to a lower CAC category (p = 0.007). ConclusionsCAC burden is associated with ASCVD risk in patients with diabetes. CAC scoring increases statin prescriptions and reduces ASCVD risk in patients with diabetes, potentially warranting routine CAC assessment in this population.

Cardiovascular Risk Stratification and Appropriate Use of Statins in Patients with Chronic Kidney Disease According to Different Strategies.

Different strategies were proposed to stratify cardiovascular risk and assess the appropriate use of statins in patients with chronic kidney disease (CKD). (1) To apply two strategies on the management of lipids in patients with CKD, analyzing what proportion of patients received lipid-lowering treatment and how many patients without statin therapy would be candidates for receiving them; (2) to identify how many patients achieve the lipid goals. A cross-sectional study was performed. Patients aged between 18 to 70 years and CKD with an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2 (without hemodialysis) were included. The indications for statin therapy according to 2019 ESC/EAS and 2013 KDIGO guidelines were analyzed as well as the achievement of LDL-C goals. A total of 300 patients were included. According to ESC/EAS guidelines, 62.3 and 37.7% of the population was classified at high or very high cardiovascular risk. In total, 52% of patients received statins. Applying the 2013 KDIGO and the 2019 ESC/EAS guidelines, 92.4 and 95.8% of the population without lipid-lowering treatment were eligible for statin therapy, respectively. Globally, only 9.1 and 10.6% of the patients with high or very high risk achieved the suggested lipid goals. A large proportion of patients with CKD showed considerable cardiovascular risk and were eligible for statin therapy according to the two strategies evaluated. However, observed statin use was deficient and current lipid goals were not achieved in most cases.

Randomized trial of atorvastatin during and following receipt of doxorubicin for breast cancer and lymphoma (WF-98213).

12072 Background: Statins taken for cardiovascular (CV) indications by breast cancer (BC) and lymphoma survivors during doxorubicin (DOX) treatment may attenuate left ventricular ejection fraction (LVEF) decline, but statin impact among these survivors with no CV indications is unknown. Methods: In 279 patients from 31 cancer centers, we conducted a double blind, placebo-controlled, 24-month randomized trial of 40mg/day atorvastatin among those receiving DOX for BC or lymphoma. At pretreatment, six and 24 months after initiating DOX for BC or lymphoma, we assessed LV volumes, strain, mass, and LVEF (via cardiac magnetic resonance), cognitive function and serum markers of inflammation. Using a linear model adjusted for pretreatment measures, our primary analysis assessed change in LVEF over time by randomization group. Results: Participants were aged 49±12 years; 92% women, 83% white race. The mean pooled LVEF decline from pretreatment to 24 months was 62.2±6.0% to 57.6±6.3% (p &lt; 0.001). Adjusting for pretreatment LVEF, 24-month declines in LVEF averaged 3.5±0.5% and 3.3±0.5% respectively for placebo vs statins (p = 0.83). Both randomized groups were similar for: incidence of &gt; 10% change in LVEF, LV strain, LV mass, cognition and inflammation biomarkers, including among those &gt; 90% study drug compliant (p &gt; 0.05 for all). Conclusions: In BC and lymphoma survivors with no existing indication for statin therapy, prospective statin administration does not appear to impact LVEF declines two years after doxorubicin. Clinical trial information: NCT01988571. [Table: see text]

Rheumatoid Arthritis, Statin Indication and Lipid Goals: Analysis According to Different Recommendations.

Different strategies have been proposed for the cardiovascular risk management of patients with rheumatoid arthritis (RA). (1) To estimate the cardiovascular risk by different strategies in RA patients, analyzing which proportion of patients would be candidates to receive statin therapy; (2) to identify how many patients meet the recommended lipid goals. A cross-sectional study was performed from a secondary database. The QRISK-3 score, the Framingham score (adjusted for a multiplying factor×1.5), the ASCVD calculator and the SCORE calculator were estimated. The indications for statin therapy according to NICE, Argentine Consensus, ACC/AHA, and new European guidelines were analyzed. The recommended LDL-C goals were analyzed. A total of 420 patients were included. In total, 24.7% and 48.7% of patients in primary and secondary prevention were receiving statins, respectively. Only 19.4% of patients with cardiovascular history received high intensity statins. Applying the ACC/AHA guidelines (based on ASCVD score), the Argentine Consensuses (based on adjusted Framingham score), the NICE guidelines (based on QRISK-3) and European recommendations (based on SCORE), 26.9%, 26.5%, 41.1% and 18.2% of the population were eligible for statin therapy, respectively. Following the new European recommendations, 50.0%, 46.2% and 15.9% of the patients with low-moderate, high or very high risk achieved the suggested lipid goals. Applying four strategies for lipid management in our population, the cardiovascular risk stratification and the indication for statins were different. A significant gap was observed when comparing the expected and observed statin indication, with few patients achieving the LDL-C goals.

Rheumatoid Arthritis, Statin Indication and Lipid Goals: Analysis According to Different Recommendations

BackgroundDifferent strategies have been proposed for the cardiovascular risk management of patients with rheumatoid arthritis (RA). Objectives(1) To estimate the cardiovascular risk by different strategies in RA patients, analyzing which proportion of patients would be candidates to receive statin therapy; (2) to identify how many patients meet the recommended lipid goals. MethodsA cross-sectional study was performed from a secondary database. The QRISK-3 score, the Framingham score (adjusted for a multiplying factor×1.5), the ASCVD calculator and the SCORE calculator were estimated. The indications for statin therapy according to NICE, Argentine Consensus, ACC/AHA, and new European guidelines were analyzed. The recommended LDL-C goals were analyzed. ResultsA total of 420 patients were included. In total, 24.7% and 48.7% of patients in primary and secondary prevention were receiving statins, respectively. Only 19.4% of patients with cardiovascular history received high intensity statins. Applying the ACC/AHA guidelines (based on ASCVD score), the Argentine Consensuses (based on adjusted Framingham score), the NICE guidelines (based on QRISK-3) and European recommendations (based on SCORE), 26.9%, 26.5%, 41.1% and 18.2% of the population were eligible for statin therapy, respectively. Following the new European recommendations, 50.0%, 46.2% and 15.9% of the patients with low-moderate, high or very high risk achieved the suggested lipid goals. ConclusionApplying four strategies for lipid management in our population, the cardiovascular risk stratification and the indication for statins were different. A significant gap was observed when comparing the expected and observed statin indication, with few patients achieving the LDL-C goals.

Statin Therapy in Patients Undergoing Thoracic Aorta Replacement for Aortic Aneurysms.

Background  Patients undergoing surgery for thoracic aortic aneurysms receive statin therapy out of proportion to cardiovascular comorbidity. We sought to determine the prevalence of statin use among patients presenting for thoracic aortic aneurysm surgery and investigate its effect on outcomes. Methods  From January 1, 2005 to January 1, 2011, 1,839 consecutive patients underwent aortic replacement for degenerative thoracic aortic aneurysm at Cleveland Clinic. Of these, 771 (42%) were on statins preoperatively. Statin users (vs. nonstatin users) were older (65 ± 11 vs. 56 ± 16 years) and had more hypertension (78 vs. 59%). Propensity matching based on 56 preoperative variables other than lipid levels was used to compare outcomes among 570 matched patient pairs (74% of possible pairs). Results  Propensity-matched statin and nonstatin users were aged 64 ± 11 years, 394 (69%) versus 387 (68%) were male, and 437 (77%) versus 442 (78%) had ascending aortic aneurysms, respectively. Overall, 25% of patients were followed for more than 8.2 years and 10% for more than 10 years. Perioperative outcomes were similar, including hospital mortality (11 [1.9%] vs. 5 [0.88%]) and stroke (22 [3.9%] vs. 13 [2.3%]), but 16 statin users (2.8%) versus 5 nonstatin users (0.88%) required temporary dialysis after surgery ( p  = 0.02). At 6 years, 3.7% of statin users versus 5.1% of nonstatin users ( p [log-rank] = 0.5) underwent further aortic surgery, and at 10 years, mortality was 25% in both groups ( p  > 0.5). Conclusion  Patients presenting for thoracic aortic aneurysm surgery frequently receive unnecessary statins. Additionally, statin use was associated with more postoperative renal failure, but not less intermediate-term risk for aortic reintervention or all-cause mortality after surgery. Therefore, presence of a thoracic aortic aneurysm should not be considered an indication for statin therapy in the absence of well-established indications.

Cholesterol Control for Subclinical Coronary Atherosclerosis in Subjects Without Indication for Statin Therapy

Low-risk individuals still experience adverse cardiac events. We sought to evaluate long-term cardiac events and predictors for subclinical coronary atherosclerosis in subjects without indication for statin therapy. We analyzed 3,272 individuals without indication for statin therapy who voluntarily underwent coronary computed tomography angiography as part of a general health examination. A cardiac event was defined as a composite of cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, or late coronary revascularization. The prevalence of normal coronary arteries, nonobstructive coronary artery disease (CAD) (diameter stenosis < 50%), and obstructive CAD (diameter stenosis ≥50%) was 2,338 (71.5%), 809 (24.7%), and 125 (3.8%), respectively. During the follow-up period (median 5.3 [interquartile range, 4.3-6.3] years), the 6-year event-free survival rates were 99.2%±0.2% in subjects with normal coronary arteries, 98.2%±0.6% in those with nonobstructive CAD, and 90.2%±2.7% in those with obstructive CAD (log-rank p < 0.001). Multivariable regression analysis showed that low-density lipoprotein cholesterol (LDL-C, odds ratio [OR]: 1.012; 95% confidence interval (CI): 1.005-1.019) and high-density lipoprotein cholesterol (HDL-C, OR: 0.968; 95% CI: 0.952-0.984) levels were associated with subclinical obstructive CAD, together with age (OR: 1.080; 95% CI: 1.040-1.121) and male sex (OR: 3.102; 95% CI: 1.866-5.155) (all p < 0.05). In conclusion, LDL-C and HDL-C are significantly associated with the presence of subclinical obstructive CAD with a worse prognosis in subjects without indication for statin therapy. These findings suggest that stricter control of LDL-C and HDL-C levels may be necessary for primary prevention even in a relatively low-risk population.

Real world cardiovascular risk assessment using reduced DAD, SCORE and Framingham equations in a German HIV cohort

Abstract Introduction People living with HIV are at increased risk for cardiovascular disease (CVD). Therefore, prevention of CVD should be integrated in HIV care. Although several risk scores exist to predict the risk of developing CVD, none of this specifically addresses the fact of HIV. Previously, the reduced Data Collection on Adverse Events of Anti-HIV Drug score (D:A:D-R) model has been proposed to assess the CVD risk for HIV patients. However, this score has not been validated in an independent cohort, or compared to traditional CVD prediction models established in the non-HIV population. Purpose We aim to compare the predictive value of the CVD risk scores D:A:D-R, SCORE and Framingham CVD in a German HIV population and evaluate their CVD risk in a real world setting. Methods This is a prospective, cross-sectional, single center study. Patients with HIV and older than 30 years were enrolled between January 2018 and December 2019. Exclusion criteria were preexisting CVD and statin therapy. CVD risk estimates were calculated using the D:A:D-R, Framingham CVD (FRS), and SCORE models. Agreement between estimates was assessed using Cohen's kappa coefficient. The indication for statin therapy was calculated using the AHA and EACS guidelines. Results 488 patients with HIV and a median age of 47.8 years were included. Median time since HIV diagnosis was 9.9 years. All, but one Patient were on ART for a median time of 5.9 years. 61% were female. Using the D:A:D-R score, the highest proportion of patients with high or very high risk for CVD were identified (17.8%). In comparison, using SCORE and FRS only 4.7% and 13.7% of patients were identified as high or very high risk, respectively. There was a poor agreement between D:A:D-R and SCORE (k=0.11), and D:A:D-R and FRS (k=0.33). Based on the calculated CVD risk using the three models, indication for primary statin medication varied between 34.8% to 92%. Conclusion Our data demonstrate that standard CVD risk scores underestimate the CVD risk in patients with HIV. Using SCORE and FRS, a high proportion of patients with HIV and at high risk for CVD would be underestimated and miss the indication for statin medication. Therefore, using scores including HIV specific parameters should be considered in this patient population. Funding Acknowledgement Type of funding source: None

The Role of Red Yeast Rice Based Preparations for Non-Pharmacological Correction of Dyslipidemia in Patients with Low and Moderate Cardiovascular Risk (Expert Opinion)

The Russian Federation is among countries with high cardiovascular risk. Hypercholesterolemia is a leading risk factor for the development of atherosclerotic cardiovascular diseases. To achieve low-density lipoprotein cholesterol (LDL-C) targets, such approaches as lifestyle changes and pharmacological correction, based on the use of statins, are applied. At the same time, a significant proportion of the population has moderate hypercholesterolemia and is characterized by low or moderate cardiovascular risk. Although first-line recommendations should be followed, a healthy lifestyle alone is not enough to achieve target levels of LDL-C, which means that even people with low to moderate risk may end up with the prospect of lifelong therapy with lipid-lowering drugs. These individuals do not have an indication for lipid-lowering therapy, and they are usually recommended a change in diet and supplementation. Innovative nutritional strategies have been developed to manage dyslipidemia. They were based either on changing some “risky” food components or on encouraging the consumption of “healthy” functional foods and/or nutraceuticals. Nutraceuticals (registered as food supplements in Russia) is an innovative way to help control LDL-C at low and moderate risk individuals without lipid-lowering drugs and as nutritive support for the cholesterol-lowering diet. Red yeast rice (RYR) based preparations have been already developed and available at the moment. RYR based preparations can be considered in patients with low and moderate cardiovascular risk, who have not reached the target level of LDL-C and have no indications for statin therapy or have statin intolerance. RYR based preparations contains a statin-like substance monacolin K in a dose of 3 mg. In randomized clinical trials, it was proved that the use of high-quality RYR nutraceutical leads to a decrease in LDL-C by an average of 20% without increasing the risk of side effects like for statins. Evaluation of dietary supplements and functional foods should necessarily include not only evidence of beneficial effects with respect to effects on the lipid profile and atherosclerosis, but also proven good tolerability. The manufacturing standard for these products is also important, guaranteeing component standardization and quality. RYR analogues should guarantee the absence of mycotoxin in their composition. In Russia, programs are needed for the primary prevention of atherosclerotic cardiovascular diseases with effects on hypercholesterolemia at the population level.

QUANTIFYING THE CHALLENGE OF UNTREATED SEVERE HYPERLIPIDEMIA: THE CORCAL VANGUARD TRIAL

Severe hyperlipidemia (LDL-C >=190mg/dL) is an indication for statin therapy, with LDL-C >=160mg/dL a treatment enhancing factor (2018 AHA/ACC Cholesterol Treatment Guideline). The CorCal Vanguard Trial randomly invited 3770 Intermountain patients of age >=50yo without ASCVD or statin use to