Statin Indication Research Articles

Guideline recommended statin eligibility and use among U.S. adults ages 20 to 39 years

Objective: Guidelines for statin therapy emphasize treatment of adults ages 40-75 years, with less guidance for the treatment of younger adults, ages 20-39 years. Only two class 1 recommendations for statin apply to younger adults: 1) secondary prevention and 2) severe hypercholesterolemia (LDL-C ≥ 190 mg/dL). The implementation of guidelines within this age group has not been well studied. Methods & Results: Here, we use data from the National Health and Nutrition Examination Survey (2013-2020) to estimate statin eligibility and use among US younger adults. Based on this nationally representative sample, we extrapolate that approximately 923,000 younger adults had a history of atherosclerotic cardiovascular disease, but only ∼24% were on statin. Among younger adults in the primary prevention group, we extrapolate that at least 1.09 million had severe hypercholesterolemia. To expand on this analysis, we calculated untreated LDL-C values for individuals on statin using two methods, and we estimate that only ∼11-20% of younger adults with severe hypercholesterolemia were on statin. Lastly, among untreated younger adults with a class 1 indication for statin, fewer than 25% reported that a doctor or healthcare provider had recommended cholesterol medication. Conclusion: The implementation of class 1 recommendations for statin treatment in younger adults is poor. While efforts to improve risk prediction in the young have recently received significant attention, our results indicate that identifying high risk younger adults is insufficient. We must also improve guideline-recommended treatment in this age group.

Failure of primary prophylaxis: statin use, risk profile, and outcomes in contemporary patients treated with PCI for first atherosclerotic event

Abstract Background Atherosclerosis and coronary artery disease (CAD) are potentially preventable through lifestyle modifications and the use of medical cholesterol-lowering drugs in individuals at risk. However, guidelines for optimal use of statins are debated, and not enough is known about the real-world barriers to effective CAD-prevention. Understanding the mechanisms of prophylactic treatment failure in patients who undergo PCI for their first atherosclerotic event could help improve primary prevention strategies. Purpose To 1) examine the relative contribution of failure mechanisms of medical prophylaxis in patients undergoing PCI for their first atherosclerotic event, 2) examine how clinical characteristics differ between patients with different failure mechanisms, and 3) examine whether long-term outcomes after PCI differ depending on the mechanism of prophylactic failure. Methods A retrospective study was conducted to study electronic healthcare records for all patients ≥18 years treated with PCI at Gentofte Hospital, Denmark in 2019. Data was extracted from electronic health care records. Patients with first atherosclerotic event were divided into cardiovascular risk groups based on the ESC/EAS guidelines and further into four different prophylactic failure mechanism groups based on cardiovascular risk, statin indication, statin use and whether the risk-based LDL-C treatment goals were reached. Results 507 patients were treated with PCI for their first atherosclerotic event. 54% were categorized as low-moderate cardiovascular risk. 41% were not on statin and did not have class I indication for statin treatment (strategy failure). 26% were not on statin treatment despite class I indication for statin treatment (implementation failure). 18% were on statin treatment but had not reached their LDL-C target (efficiency failure), and 16% were on statin treatment, and had reached the LDL-C target (efficacy failure). Patients with strategy failure, were more likely to be younger, mostly males, and often had a smoking history. Patients with implementation failure, were typically elderly, with relatively few comorbidities. The frequency of death, myocardial infarction, stroke, or repeat revascularization over 4 years was 15.3%, with no statistically difference between the groups (p =0.3). Conclusion In this cohort study, patients treated with PCI for first atherosclerotic event were often classified as low or intermediate risk, and a majority had not been on statin treatment before. Improved primary prevention should focus on at-risk groups that are either not included in current recommendation for statin treatment, especially young smokers, or patients not receiving treatment despite recommendations, especially older patients with few medical contacts.Cardiovascular risk & failure mechanismKaplan-Meier MACE

Sex differences in management of LDL-cholesterol in patients with chronic coronary syndrome

Abstract Background Effective management of low-density lipoprotein cholesterol (LDL-C) is crucial for preventing recurrent cardiovascular (CV) events in patients with chronic coronary syndrome (CCS). Sex may impact the LDL-C management, by gender bias and/or sex-specific responses to pharmacological interventions. Purpose We examined sex-specific LDL-C management in CCS patients, assessing target achievement rates and their implications for CV outcomes. Methods In the international CLARIFY registry, we included 22,134 CCS patients with baseline LDL-C measurements. LDL-C levels were monitored annually over the 5-year follow-up period. Target LDL-C was set at 100 mg/dL, in line with prevailing recommendations at that time. Sex-specific differences in LDL-C were adjusted for age, geographical region and indication for lipid lowering drugs (stroke, MI, PAD). The primary endpoint was the incidence of MACE, defined as CV death or MI during the 5-year follow-up, evaluated using multivariable analysis adjusted for known predictors of recurrent CV events in CCS patients. Results Of 22,134 patients, 21.6% were women. Upon inclusion (6.5 ± 6.3 years after CCS diagnosis), women were more likely than men to have LDL-C levels above the recommended threshold (45.6% vs. 37.4%; aOR 1.47, 95%CI 1.38-1.58, p<0.001) and less likely to receive statin treatment (82.7% vs. 85.4%, p<0.001). Although women and men had comparable numbers of LDL-C measurements during follow-up, the discrepancies endured over the 5-year observation period, with women consistently showing lower likelihoods of achieving LDL-C targets at 1, 2, 3, 4, and 5 years post-inclusion (p<0.001 for all time points). Overall, women were less likely than men to have all available LDL-C concentrations within the target range (37.8% vs. 44.6%; aOR 0.70, 95% CI 0.64-0.76, p<0.001) and more likely to never reach the target LDL-C goal during follow-up (22.6% vs. 17.5%; aOR 1.43, 95% CI 1.32-1.55, p<0.001). Failing to achieve at least one LDL-C concentration below 100 mg/dL was associated with an increased risk of subsequent MACE (adjusted HR 1.57, 95%CI 1.38-1.77, p<0.001), with similar associations observed in both men (aHR 1.66, 95% CI 1.44-1.91, p<0.001) and women (aHR 1.31, 95% CI 1.01-1.70, p=0.05). Conclusion In patients with CCS, women consistently showed lower likelihood of reaching LDL-C targets throughout follow-up compared to men, even after adjusting for age, geographical region and other statin indications. Notably, women were more likely to have no LDL-C concentration within recommended range during follow-up, which is particularly concerning given its association with an increased risk of CV events. A contributing factor to this sex disparity in LDL-C control is women's lower likelihood of receiving lipid-lowering drugs than men. These results highlight the need for tailored interventions to address sex-related disparities in LDL-C management and improve cardiovascular outcomes in CCS patients.

6550 National Statin Prescription Trends in Patients With Breast Cancer and Diabetes for Primary Cardiovascular Disease Prevention

Abstract Disclosure: A.B. Yang: None. G. Mhango: None. C. Kong: None. J.J. Lin: None. J.P. Wisnivesky: Consulting Fee; Self; Sanofi, Banook, PPD. Grant Recipient; Self; Sanofi, Regeneron Pharmaceuticals, Axella, Arnold Consultants. A. Leiter: None. Background: Cardiovascular disease (CVD) is the leading cause of death in older early-stage breast cancer (BC) survivors. Due to cardiotoxic BC treatments such as chemotherapy and radiation, patients with BC and diabetes (DM) are at increased risk of CVD. In patients with BC and DM, statins decrease CVD mortality. Since 2013, many clinical guidelines broadened statin indications for primary CVD prevention in patients with DM, making >85% of patients eligible. Little is known about statin prescription (Rx) patterns in older BC survivors with DM, a group at high risk of CVD. Hypothesis: We hypothesized that statin Rxs increased over time, but were less likely in BC survivors with more advanced locoregional BC and lower comorbidity burden. Methods: A population-based, retrospective cohort study was conducted using Surveillance, Epidemiology and End Results (SEER) cancer registry data linked to Medicare claims. We identified women with preexisting DM who were diagnosed with stage 0-III primary BC between 2008-17. We excluded patients with prior CVD who died <1 year after BC diagnosis. Statin Rx (atorvastatin, pravastatin, rosuvastatin, simvastatin, fluvastatin, lovastatin) was defined as ≥1 statin pharmacy claim <1 year after BC diagnosis. Comorbidity burden was assessed with a modified Charlson Comorbidity Index (CCI). We compared patient demographic and clinical characteristics by statin Rx status using the chi-square test. Using a multivariate logistic regression adjusting for age, race, CCI, BC stage, and diagnosis year, independent predictors of statin Rx were identified. Results: Of 8,423 BC patients with pre-existing DM, 5,698 (68%) had a statin Rx. Statin Rx increased over time (BC diagnosis year 2008-10: 66%, 2011-13: 66%, 2014-15: 69%, 2016-17: 70%; p=0.01) and differed by age (66-69: 66%, 70-74: 70%, 75-79: 69%, ≥80: 65%; p<0.01) and race (White: 68%, Black: 62%, Latinx: 66%, Other: 72%; p<0.01). Statin Rx did not differ by comorbidity burden (CCI 0: 68%, 1-2: 67%, ≥3: 67%; p=0.87) and declined with higher BC stage (0: 73%, I: 70%, II: 65%, III: 63%; p<0.01). In adjusted analyses, more recent BC diagnosis (2016-17 vs. 2008-10: odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.04-1.38), age group (70-74 vs. 66-69: OR: 1.24, 95% CI: 1.09-1.41), race (Black vs. White: OR 0.77, 95% CI: 0.66-0.89) and higher BC stages (II vs. 0: OR: 0.76, 95% CI: 0.58-1.00; III vs. 0: OR: 0.72, 95% CI: 0.54-0.97) remained predictors of statin Rx. Conclusions: In a nationally representative cohort analysis of older early-stage BC patients, statin Rx increased between 2008-17 and varied by age, race, and BC stage. Elucidating gaps in statin Rx can potentially improve guideline-concordant Rx in a group at high risk for CVD and reduce disparities. Presentation: 6/2/2024

Optimizing statin prescriptions for people living with HIV: Evidence for improved communication and shared care between primary care and specialist HIV services.

Our objective was to assess the numbers of eligible people living with HIV attending one HIV clinic and receiving statins, the factors increasing the likelihood of statin prescription, the knowledge and involvement of primary care in cardiovascular risk prevention in people living with HIV, and the barriers to and drivers of shared care between general practitioners (GPs) and an HIV centre. This was a retrospective case note review identifying cardiovascular risk, medications, and communication between the HIV clinic and GPs via an electronic survey of GPs identifying their knowledge about statin indications in people living with HIV. In total, 62% of GPs were unaware of the indication for statins in people living with HIV aged >40 years. A total of 33% of patients received statins, rising to 61% of patients with independent indications for statins. 92% of all statin prescriptions were provided by the GP. Statins were recommended in 25% of clinic letters but were not prescribed in 72% of these cases. There was discordance between antiretrovirals prescribed by the HIV clinic and those documented on the GP record in 60% of cases and in 40% of non-antiretroviral medications. Our results indicate that GPs can engage people living with HIV in cardiovascular risk reduction measures but may not consider HIV a cardiovascular risk. Written communication alone is insufficient to improve safe patient care. Shared HIV care needs bidirectional shared medical records. Ongoing work needs to ensure that HIV is recognized as an independent cardiovascular risk factor.

Statin use and development and progression of non-alcohol fatty liver disease based on ultrasonography: a cohort study.

Non-alcohol fatty liver disease (NAFLD) has emerged as a public health issue, while no drugs have been specifically approved for treatment. This study aimed to examine the association between statin use and NAFLD occurrence, progression, and regression. A cohort study was designed based on the Kailuan Study and electronic medical records (EMRs) from the Kailuan General Hospital. Participants aged 18 years with statin indication, including statin and non-statin users, were enrolled in 2010-2017. Propensity score-matched cohorts were also used. In the entire cohort, 21 229 non-NAFLD and 22 419 NAFLD patients (including 12 818 mild NAFLD) were included in the final analysis. After a median follow-up of about four years, the incidence of NAFLD occurrence and progression for statin users were lower than those for non-statin users (occurrence: 84.7 vs. 106.5/1000 person-years; progression: 60.7 vs. 75.5/1000 person-years). Compared with non-statin users, the risk of NAFLD occurrence (hazard ratio [HR]: 0.78, 95% confidence interval [CI]: 0.70-0.87) and regression (HR [95%CI], 0.71[0.60-0.84]) was decreased in statin users. The significantly negative association was only observed in those with cumulative statin duration ≥ 2 years (HR [95%CI] for occurrence 0.56 [0.46-0.69] vs. 0.52 [0.30-0.90] for progression) and those with low or moderate ASCVD-risk (HR [95%CI] for occurrence 0.74 [0.66-0.82] vs. 0.68 [0.57-0.80] for progression). No significant correlation was observed between statin use, statin use duration, and NAFLD regression. The PS-matched cohort had similar results. Taking statin may decrease the risk of NAFLD occurrence and progression in the population with statin indication, suggesting the potential role of statin in both primary and secondary prevention strategies for NAFLD, especially among those with low or moderate ASCVD risk.

Long-term statin use and risk of cancers: a target trial emulation study

Background and ObjectivesControversy exists regarding potential cancer risks associated with long-term statin use. This study aimed to use real-world data to investigate the association between cancer incidence and sustained statin use over a 10-year period. MethodsUsing territory-wide public electronic medical records in Hong Kong, we emulated a sequence of nested target trials on patients who met indications for statin initiation in each calendar month from January 2009 to December 2011. Statin initiators and noninitiators were matched in a 1:1 ratio to mimic the randomization of eligible person-trials at baseline. Pooled logistic regression was applied to obtain the hazard ratios for the cancer incidence of statin initiation in intention-to-treat analysis, with the adjustment of baseline confounders and the inverse probability weighting accounting for the postbaseline confounders in per-protocol analysis. ResultsAmong 8,560,051 eligible person-trials, 119,715 noninitiators were matched to 119,715 initiators for analysis. Over the 10-year study period, the estimated hazard ratio of overall cancer incidence was 0.96 (0.87, 1.05), and the standardized 10-year risk difference was −0.4% (−1.3%, 0.4%) in the per-protocol analysis. For the cancer subtypes of interest (ie, breast cancer, colorectal cancer, hematological cancer, pancreatic cancer, prostate cancer, urothelial carcinoma, and lung cancer), the 10-year risk differences ranged from −0.3% to 0.2% in the per-protocol analysis. No observable risk change for cancer was found in all patient subgroups with regards to their sex, age (<70/≥70 years), Charlson Comorbidity Index (≤4/>4), and statin indication. ConclusionStatin use has no impact on cancer incidence over a 10-year follow-up period, including all cancer subtypes of interest and patient subgroups with regards to sex, age, comorbidities, and statin indications.

European and US Guideline-Based Statin Eligibility, Genetically Predicted Coronary Artery Disease, and the Risk of Major Coronary Events.

A study was designed to investigate whether the coronary artery disease polygenic risk score (CAD-PRS) may guide lipid-lowering treatment initiation as well as deferral in primary prevention beyond established clinical risk scores. Participants were 311 799 individuals from the UK Biobank free of atherosclerotic cardiovascular disease, diabetes, chronic kidney disease, and lipid-lowering treatment at baseline. Participants were categorized as statin indicated, statin indication unclear, or statin not indicated as defined by the European and US guidelines on statin use. For a median of 11.9 (11.2-12.6) years, 8196 major coronary events developed. CAD-PRS added to European-Systematic Coronary Risk Evaluation 2 (European-SCORE2) and US-Pooled Cohort Equation (US-PCE) identified 18% and 12% of statin-indication-unclear individuals whose risk of major coronary events were the same as or higher than the average risk of statin-indicated individuals and 16% and 12% of statin-indicated individuals whose major coronary event risks were the same as or lower than the average risk of statin-indication-unclear individuals. For major coronary and atherosclerotic cardiovascular disease events, CAD-PRS improved C-statistics greater among statin-indicated or statin-indication-unclear than statin-not-indicated individuals. For atherosclerotic cardiovascular disease events, CAD-PRS added to the European evaluation and US equation resulted in a net reclassification improvement of 13.6% (95% CI, 11.8-15.5) and 14.7% (95% CI, 13.1-16.3) among statin-indicated, 10.8% (95% CI, 9.6-12.0) and 15.3% (95% CI, 13.2-17.5) among statin-indication-unclear, and 0.9% (95% CI, 0.6-1.3) and 3.6% (95% CI, 3.0-4.2) among statin-not-indicated individuals. CAD-PRS may guide statin initiation as well as deferral among statin-indication-unclear or statin-indicated individuals as defined by the European and US guidelines. CAD-PRS had little clinical utility among statin-not-indicated individuals.

Evaluation of Statin Indication and Dose Intensification Among Type 2 Diabetic Patients at a Tertiary Hospital.

Diabetes mellitus (DM) increases cardiovascular disease (CVD) incidence and mortality. While guidelines endorse statin use in type 2 DM (T2DM) to mitigate cardiovascular risks and mortality, challenges like statin initiation and prompt treatment adjustments affect patient outcomes. This study aimed to assess the appropriateness of indications for and dose intensification of statin therapy among T2DM patients at Tikur Anbessa Specialized Hospital (TASH). A hospital-based cross-sectional study was conducted from April 1 to June 30 2020. In total, 405 T2DM patients were selected using a systematic random sampling technique. The data were analyzed using SPSS version 26.0. An adjusted odds ratio (OR) was used and a 95% confidence interval (CI) and p-values of <0.05 were utilized to determine statistical significance. Of the total 405 participants, 346 (85.4%) started taking statins for primary or secondary prevention purposes. Indication for statin use was appropriate in 96.2% patients, while for 216 (62.4%) patients their doses were appropriately intensified. Predictors of the inappropriateness of statin use were an atherosclerotic cardiovascular disease (ASCVD) score of ≥7.5% (AOR=0.28; 95% CI: 0.102-0.738, p=0.01), the presence of dyslipidemia (AOR=4.48; 95% CI: 1.85-10.84; p=0.001), initiation of aspirin therapy (AOR=3.7; 95% CI: 1.522-9.144; p=0.004), and an LDL-cholesterol level of 70-189 mg/dL (AOR=0.124; 95% CI: 0.042-0.365; p=0.001). DM duration of ≥10 years (AOR=2.51; 95% CI: 1.35-4.66, p=0.004), male gender (AOR=2.04; 95% CI: 1.16-3.58, p=0.013), age ≥65 years (AOR=2.15; 95% CI: 1.23-3.75, p=0.007) and uncontrolled blood pressure (AOR=2.09; 95% CI: 1.07-4.08, p=0.031) were associated with inappropriate statin intensification. The study found that indication of statins was optimal and about two-thirds of patients had their doses appropriately intensified. Monitoring is needed to avoid inappropriate intensification of statin therapy, particularly in patients with longer diabetes duration, those of male gender and advanced age, and those with uncontrolled blood pressure.

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

Patients with cancer are at increased cardiovascular (CV) 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 (2013-18), we analysed data from 17 050 US 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 comorbidities. Stratified by age groups, they were more likely to have a secondary prevention indication compared with 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 with 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 CV health in patients with cancer, as individuals with cancer were more likely to have a Class 1 indication for statin treatment when compared with individuals without cancer. Important differences in statin use among cohorts based on sex, age, ethnicity, and socioeconomic status were identified, which may provide a framework through which CV risk factor control can be targeted in this population. Higher statin use in cancer patients: Among those with Class 1 recommendation to take statins, 60.8% of cancer patients were using them, compared with 47.8% of non-cancer individuals, indicating a greater adherence to heart health recommendations in the cancer group. Demographic variations in statin use: The study found notable differences in statin use among younger individuals, ethnic minorities, and those with lower income within the cancer patient group, suggesting disparities in how these subgroups manage their cardiovascular health.

Older Adult Perspectives on Statin Continuation and Discontinuation in Primary Cardiovascular Disease Prevention: A Mixed-Methods Study.

Evidence for statin use for primary cardiovascular disease prevention in older adults is limited. When evidence on risk-benefit profile of a medication is uncertain, using it or not becomes a preference-sensitive decision. We aimed to assess and explore patient perspectives on continuation and discontinuation of statins used for primary cardiovascular prevention in older adults. We used a convergent mixed-methods design, conducting in parallel a survey among 47 patients and three focus groups (FGs) with 14 patients total. We recruited patients aged ≥65 years and taking a statin for primary cardiovascular prevention. The survey and FGs aimed to assess and explore patient experiences of statin use, and views on statin continuation and discontinuation, including patient decision-making. Quantitative and qualitative data were first analyzed separately - descriptive statistics for quantitative data and thematic analysis for qualitative data - and then integrated to create metainferences, using joint displays. Forty-one percent of patients (N=19) were reluctant to discontinue the statin, whereas 22% (N=10) were willing to try discontinuing it. A reason to continue the statin was its perceived necessity, while self-estimated low cardiovascular risk and wish to reduce medication burden were given as reasons to discontinue it. Lack of expertise assumed by the patients to decide about statin continuation or discontinuation, uncertainty about statin indication, and fear of having a cardiovascular event after discontinuation made many patients uncertain about deciding to continue or discontinue the statin. In this context, 70% (N=33) would rather have their physician choose for them, and 94% (N=44) would continue taking the statin for as long as their physician told them to do so. This study highlights factors that influence patient willingness to continue or discontinue statins, patient uncertainty about statin continuation or discontinuation, and the important role physicians play in the decision-making process.

Role of Atorvastatin in the Development and Progression of Glucose Intolerance in Albino Rabbits: An In-vivo Experimental Study

Introduction: Type 2 diabetes is associated with obesity and dyslipidemia, which are risk factors for cardiovascular disease. The Food and Drug Administration (FDA)-approved indications for statins are being broadened due to their lipid-lowering and pleiotropic effects; statins are currently among the most widely used drugs in patients with and without diabetes. Aim: To evaluate the role of atorvastatin at different doses in the development and progression of glucose intolerance or diabetes in albino rabbits. Materials and Methods: An in-vivo experimental study on rabbits was conducted over a total duration of eight months in the Department of Pharmacology at SCB Medical College, Cuttack, Odisha, India. The animals were divided into five groups of six rabbits each. Atorvastatin at 4 mg/kg and 2 mg/kg was calculated based on human doses corresponding to 80 mg and 40 mg, respectively. Both doses were administered to non diabetic rabbits, and 4 mg/kg atorvastatin was administered to alloxan-induced diabetic rabbits orally for six months daily. Diabetes was induced in two groups of rabbits by administering 100 mg/kg alloxan monohydrate in a 5% (w/v) solution in sterile saline intravenously. Rabbits with stabilised moderate diabetes, characterised by a fasting blood glucose level above 200 mg/ dL (at least one month after alloxan injection), were used for the experiments. The effect of atorvastatin on glucose tolerance was assessed by determining Fasting Blood Sugar (FBS) and Glycated Haemoglobin (HbA1c) levels. The results were compared with those of normal and diabetic control rabbits and statistically analysed using Analysis of Variance (ANOVA) and Repeated Measures ANOVA (RMANOVA), followed by appropriate post-hoc analysis. Results: Atorvastatin at a high dose resulted in a 26.74% increase in FBS and a 20.50% increase in HbA1c; at the standard dose, it produced a 21.3% increase in FBS and a 17.99% increase in HbA1c, respectively. The diabetic group receiving high doses also showed a significant increase in FBS (11.7%) and HbA1c (10.25%). The increase in blood glucose parameters was significant in the high-dose group from the fourth month of statin therapy and in the standard-dose group at six months of therapy. Conclusion: The study revealed that atorvastatin at both doses significantly contributed to the initiation and progression of glucose intolerance in diabetic and non diabetic rabbits.

Abstract 12687: Evaluating a Coronary Artery Disease Polygenic Risk Score Screening Strategy in a Diverse Patient Cohort at UCLA

Introduction: Recent efforts to predict and mitigate coronary artery disease (CAD) risk have incorporated polygenic risk scores (PGS). Few studies examine the clinical impact of these PGS screening strategies or quantify their performance in clinical terms. Here we estimate the number needed to screen (NNS) of a PGS screening strategy for CAD based using a diverse electronic health record (EHR) linked biobank at UCLA Health. Methods: We leveraged longitudinal EHR data to conduct a synthetic trial. We assumed PGS screening was performed on 6/1/2013 for patients established prior to 1/1/2013 or 6 months into follow time if established later. Patients with preexisting cardiovascular disease or strong statin indications (LDL &gt; 190, diabetes or already on statins) are excluded. Patients with PGS scores in the top 5% of their genetic ancestry groupings (European, East Asian, African, Hispanic) are assumed to have been started on statins for the median 6.9 years of follow up. CAD diagnosis during follow up time was determined by ICD codes. NNS to prevent one CV event is calculated from cohort size and events assuming a statin number needed to treat of 50. Results: Of 33,789 adults, 17,074 were low risk and eligible for PGS screening (35% male with a mean age of 44). NNS to detect one CAD diagnosis was 351, 359, 814, 159 in the European, Hispanic, East Asian and African ancestry groups and NNS to prevent one cardiovascular event was 17,550, 17,950, 40,700, 7,950 respectively. Conclusion: Although PGS accuracy is lower in African ancestry individuals as compared to Europeans, the clinical utility of this PGS-based screening is highest in African ancestries due to increased baseline rates of disease in the African genetic ancestry grouping. Our results demonstrate that PGS accuracy is distinct from clinical utility of PGS-based strategies. Evaluation of screening strategies rather than accuracy alone will be required before PGS screening implementation.

Statin therapy in multimorbid older patients with polypharmacy- a cross-sectional analysis of the Swiss OPERAM trial population.

Statin therapy in multimorbid older individuals with polypharmacy is controversial, particularly in primary prevention of cardiovascular disease. Thereby, physicians must weigh potential benefits against potential side effects, drug-drug interactions, and limited life expectancy. To assess the prevalence and determinants of potentially inappropriate statin therapy in multimorbid older patients. We conducted a cross-sectional analysis of patients aged ≥70 years with multimorbidity and polypharmacy in the Swiss study center of OPERAM, a cluster-randomized trial on pharmacotherapy optimization to reduce drug-related hospital admissions. We assessed potential underuse (no statin but formal indication) and potential overuse (statin but no formal indication, including predicted >60% one-year mortality based on the Walter Score) based on current guidelines for patients in secondary and primary cardiovascular prevention. We assessed the association of potential statin overuse and underuse with six patient characteristics (age, gender, number of diagnoses, number of medications, mental impairment, being housebound) in LASSO-selection analyses. Of 715 multimorbid older adults (79.7 ± 6.5 years, 39.9% women), 337 (47%) were on statin. Statin therapy was appropriate in 474 (66.3%), underused in 130 (18.2%), and overused in 111 (15.5%) patients. In participants in secondary cardiovascular prevention (n = 437), being female (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.67-4.22) was significantly associated with potential underuse while being housebound (OR 3.53, 95%CI 1.32-9.46) and taking ≥10 medications (OR 1.95,95%CI 1.05-3.67) were associated with potential overuse. In participants in primary cardiovascular prevention (n = 278), 28.1% were potentially under- (9%) or overusing (19%) a statin, with no identified risk factor. A third of hospitalized multimorbid older patients with polypharmacy potentially (either) overused or underused statin therapy. Among patients in secondary cardiovascular prevention, women were at risk for potential statin underuse. Housebound patients and those taking ≥10 medications were at risk for potential overuse of a statin. Physicians should carefully evaluate the indication for statin prescription in multimorbid older patients with polypharmacy.

Statin use for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in breast cancer (BC) patients (pts).

e24051 Background: CVD is the leading cause of non-cancer mortality for BC survivors. Clinical practice guidelines support the assessment and management of ASCVD risk factors among BC pts, including lipid-lowering therapy when indicated. We performed a single-institution, retrospective, longitudinal study of ASCVD risk factors and statin use for primary and secondary ASCVD prevention among BC pts. Methods: Pts diagnosed with BC from 2009-2015 were identified from the institutional cancer registry. Pts with non-metastatic BC or ductal carcinoma in situ and at least 2 years of follow up were included. Records were reviewed at 12-month intervals from BC diagnosis until last follow up or the study end date of 12/31/19. BC characteristics and treatment, prevalent and incident CV risk factors, CV diagnoses, CV medications, and CV events were manually abstracted and confirmed by a second reviewer. 10-year estimated ASCVD risk, based on non-laboratory predictors, was calculated for each pt. Chi-square tests were performed to assess the relationship between race/ethnicity, age category, and statin exposure. Results: 326 pts were included (median age at diagnosis 60.7 yrs; 67% White, 16% Asian (Chinese), 10% Black; 54% with stage I disease). At baseline, 53% had hypertension, 40% had hyperlipidemia, 37% were former or current smokers, 32% had a BMI ≥30, 7% had a history of ASCVD, and 5% had a family history of premature coronary artery disease. 52% received radiation therapy. 114 pts had radiation dosimetry available; 59 (18%) received a mean heart dose ≥1 Gy. Median follow up was 6.5 yrs. At the time of BC diagnosis, 64% of pts had an established indication for lipid-lowering therapy: history of ASCVD, diabetes, or estimated 10-year ASCVD risk ≥7.5% (Table). Of these pts with an indication for statin, 35% were prescribed a statin at baseline and 57% were prescribed a statin at any time during the study period. No association between baseline statin exposure and pt age category (X2 = 3.75, p = 0.290) or race/ethnicity (X2 = 2.64, p = 0.562) was observed. Among 11% of pts with ASCVD at any time, 83% were prescribed a statin but only 40% received a guideline-recommended high-intensity statin. Conclusions: A majority of pts in our study were candidates for statin therapy for primary or secondary ASCVD prevention at the time of BC diagnosis. 43% were never prescribed a statin, predominantly pts whose indication was primary prevention. There is opportunity for improvement in ASCVD prevention during BC treatment and follow up. [Table: see text]

A retrospective single-centre analysis of the prevalence of statin use in geriatric oncology: Is there a role for cessation?

e24016 Background: Statins have become ubiquitous in medicine. There is a myriad of indications, and the duration of treatment required for efficacy is measured in years. There is a need for clarity on their role in geriatric oncology and when to de-prescribe. Within a sample of Irish patients in 1987, 8% would have been eligible for a statin. By 2016, this had climbed to 61%. During this time, the number needed to treat increased from 40 to 400. In terms of benefit, a meta-analysis concluded that 100 patients need treatment for 2.5 years to prevent one major adverse cardiovascular event (MACE) in the primary preventative setting. It is not clear whether this benefit is derived in later life. As a result, the United States preventive service task force concluded that evidence is insufficient to recommend initiating a statin for primary prevention in adults over 75. The aim of our study was to assess the prevalence of statin use in older adults with cancer, and the evidence for de-prescribing. Methods: Data was retrospectively collected from a prospectively maintained database of patients attending the Geriatric Oncology Assessment and Liaision (GOAL) clinic in the South East Cancer Centre, University Hospital Waterford, Ireland. Data collected includes age at cancer diagnosis, stage, co-morbidities, and medications. We determined how many patients were taking statins (or ezetimibe) prior to first oncology review, their indication and overall survival. Indications for statins were categorised using a hierarchy of indications, as described by Wallach Kildemoes et al. Results: 138 of 233 patients were taking statins at the time of their review (59%). The average age at cancer diagnosis was 78.6 years. Seventy-nine were taking statins for primary prevention (58%). 15 of 79 whom had diabetes. Stage 3 or 4 disease accounted for 78% of this group. Overall survival in this group was 1.59 years. Within the group with stage 4 disease (n = 100), 53 were taking a statin. Twenty-eight (52.8%) were for primary prevention. Within this group, 6 had diabetes. Overall survival in this group was 1.44 years. Conclusions: Overall survival of patients was short of the 2.5 years required to provide benefit. Therefore, there is evidence to stop this medication in the primary preventative group, once diagnosed with advanced cancer. The stage 4 disease group included patients undergoing secondary prevention, so treatment is more efficacious. However, with an overall survival of 1.44 years, the window for benefit is small.[Table: see text]

High risk dyslipidemia: can we predict early coronary disease?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The AHA/ACC guidelines on the management of blood cholesterol (2013 and 2018) classified the LDL-c &amp;gt;190 mg/dL as high-risk patients, with the indication of high-intensity statins (c-LDL reduction greater than 50%). Recently the 2019 ESC guidelines(1) also classify these patients as high cardiovascular (CV) risk. Objective Determine factors associated with the development of early coronary disease (ECD) in patients with high-risk dyslipidemia (HRD). Methods Observational retrospective cohort of 160 patients with historical maximum LDL-c ≥190 mg/dL without secondary cause. We compared the clinical characteristics, the baseline blood test with maximum LDL-c (BT1), and the effects of lipid-lowering treatment on the last blood test (BT2), between patients with ECD (53 patients Group A) and patients without cardiovascular events (107 patients Group B). Results Group A, presented maximum LDL-c at a younger age, had dyslipidemia of longer evolution time, had a higher proportion of men, smokers, diabetics, and had a higher number of associated risk factor's (Table 1). In the BT1 they presented greater proportion of HDL-c values below 45 mg/dL (35.3% vs 12.3%, p=0.001), and a higher proportion of remnant cholesterol (Non HDLc - LDLc = &amp;gt;30 mg/dL, 51% vs 33.3%, p=0.037). Patients with ECD received high-intensity lipid-lowering treatment, statin + ezetimibe (73.6% vs 29.8%, p&amp;lt;0.0001), IPCSK9 (7.5% vs 2.9%, p=0.18), and achieving LDL-c goals (32.1% vs 13.6%, p=0.006) and Non HDL-c (47.2% vs 14.6%, p&amp;lt;0.0001) according to cardiovascular risk. There were no variation between BT1 and BT2 in HDL-c levels in both groups. In the Cox regression model, male sex (HR 2.8 (1.4-5.7), p=0.003), tobacco (HR 2.5 (1.3-4.7), p=0.005), and the relation between Non HDL-c/HDLc (&amp;gt;4.5 male, &amp;gt;4 female, in primary prevention) in BT1 (HR 1.65, (1.15-1.86) p=0.02) increase independently the risk of ECD in patients with HRD. Conclusion In patients with HRD the presence of male sex, tobacco, increase relation between Non HDLc/HDLc, diabetes, a greater number of cardiovascular risk factors, most atherogenic blood test (HDLc &amp;lt;45 mg/dL and remnant cholesterol) have been associated with the development of ECD. We have had some apreciated 5.45 (± 4) years since the BT1 to prevent ECD.

Consequences of diabetes and high-risk dyslipidemia

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Diabetic patients develop both, microvascular and macrovascular long-term complications, and have double the risk of cardiovascular (CV) disease being the main cause of death. The 97% of diabetic patients are classified as high or very high CV risk. The 2019 ESC guidelines for the managment of dyslipidaemia, classified patients with LDL-c &amp;gt;190 mg/dL as high-risk patients, with the indication of high-intensity statins (LDLc reduction greater than 50% and LDLc below 70 mg/dL). Objective To analyze, in a group of patients with high risk dyslipidaemia (HRD, LDLc &amp;gt;190 mg/dL without secondary cause), the consecuences of its association with type 2 diabetes. Methods Observational retrospective cohort of 153 patients with HRD. We compared 35 diabetic patients (G1) vs 118 non diabetic patients (G2), and we analysed clinical characteristics, cardiovascular risk factor’s (CVRF), tase of cardiovascular disease, the baseline blood test with maximum LDL-c (BT1), lipid profile on the last blood test (BT2) and the effects of lipid-lowering treatment. Results There were no differences in relation to sex. G1 were older (69.2 (±12.8) vs 56.8 (±12.5) years old, p=0.001), had a higher body mass index (BMI) (31.4 (±5.9) vs 28.9 (±4.4) kg/m2, p=0.018), higher number of CVRF (3 CVRF, 54.3% vs 10.2%, p&amp;lt;0.0001, and 4 CVRF, 37.1% vs 0%, p&amp;lt;0.0001). Regarding mayor CV events, 80% develop CV disease vs 38.1% (p&amp;lt;0.0001), and 40% develop early coronary disease (ECD) vs 25% (p&amp;lt;0.0001). In the BT1, G1 presented a more atherogenic lipidogram, lower HDL-c &amp;lt;40-45mg/dL values (22.9% vs 9.3%, p=0.033), higher proportion of triglycerides &amp;gt;150mg/dL (74.3% vs 46.6%, p=0.001), higher proportion of small and dense LDL-c (88.6% vs 62.7%, p=0.004) and a higher proportion of VLDL-c &amp;gt;30mg/dL (74.3% vs 45.8%, p=0.003). There were no differences in lipid-lowering treatment (statin 88.6% vs 86.4%, p= 0.7; ezetimibe 68.6% vs 53.4%, p=0.1) or in the lipid-lowering power of LDL reduction &amp;gt;50% (77.1% vs 70.3%, p=0.4), except for a greater prescription of fibrates in G1 (11.4% vs 1.7%, p=0.027). In BT2, lower rates of HDL-c &amp;lt;40-45mg/dL (34.3% vs 16.1%, p= 0.019) and small and dense LDL-c (80% vs 50.9%) persisted in G1, p=0.002) and a higher proportion of chronic kidney disease (25.8% vs 2.6%, p&amp;lt;0.0001). Conclusions Patients with HRD and diabetes have higher CVRF, a more atherogenic lipid profile that persists despite lipid-lowering treatment, and double the rate of CV disease, were half of these events occurs at early age. This association of CVRF should alert us, implementing an early and agressive prevention treatment of all CVRF.

Evaluation of Statin Prescribing Practices and Predictors of Statin Underutilization in Persons With HIV.

Persons with HIV (PWH) have an increased risk of cardiovascular disease (CVD) compared with those without HIV. Despite the increased risk, PWH are less likely to be prescribed statin therapy compared with the general population. The purpose of this study is to describe the statin prescribing practices of an outpatient HIV clinic and identify potential predictors of statin underutilization. This study was a retrospective, single-center chart review of PWH ages 40-79 years receiving care at an HIV clinic. Statin eligibility, statin prescribing practices, and appropriateness of statin therapy were evaluated. Logistical regression analyses were conducted to assess for predictors of underutilization of statin therapy. Of the 606 patients, statin therapy was indicated in 362 patients (60%). Among those with a statin indication, 60.2% were prescribed appropriate statin therapy, 11.6% were prescribed statin therapy but not at the indicated intensity, and 28.2% were not prescribed statin therapy. Tobacco use ( P = 0.0023) was identified as a predictor of statin underutilization. The odds of statin prescribing were higher for those with clinical atherosclerotic CVD ( P = 0.004) and hypertension ( P = 0.017). Statin underutilization was significantly higher in PWH smoking tobacco and PWH without atherosclerotic CVD or low-density lipoprotein-cholesterol 190 mg/dL or higher. In addition, this study highlights the need for more robust CVD prevention efforts in PWH. Identifying predictors of statin underutilization may aid in elucidating where gaps in cardiovascular prevention care may exist.

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.