Initiation Of Statin Therapy Research Articles

Lipid levels and major adverse cardiovascular events in patients initiated on statins for primary prevention: an international population-based cohort study protocol.

BackgroundClinical guidelines recommend specific targets for low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) for primary prevention of cardiovascular disease (CVD). Furthermore, individual variability in lipid response to statin therapy requires assessment of the association in diverse populations.AimTo assess whether lower concentrations of LDL-C and non-HDL-C are associated with a reduced risk of major adverse cardiovascular events (MACE) in primary prevention of CVD.Design & settingAn international, new-user, cohort study will be undertaken. It will use data from three electronic health record databases from three global regions: Clinical Practice Research Datalink, UK; PREDICT-CVD, New Zealand (NZ); and the Clinical Data and Analysis Reporting System, Hong Kong (HK).MethodNew statin users without a history of atherosclerotic CVD, heart failure, or chronic kidney disease, with baseline and follow-up lipid levels will be eligible for inclusion. Patients will be classified according to LDL-C (<1.4, 1.4–1.7, 1.8–2.5, and ≥2.6 mmol/l) and non-HDL-C (<2.2, 2.2–2.5, 2.6–3.3, and ≥3.4 mmol/l) concentrations 24 months after initiating statin therapy. The primary outcome of interest is MACE, defined as the first occurrence of coronary heart disease, stroke, or cardiovascular death. Secondary outcomes include all-cause mortality and the individual components of MACE. Sensitivity analyses will be conducted using lipid levels at 3 and 12 months after starting statin therapy.ConclusionResults will inform clinicians about the benefits of achieving guideline recommended concentrations of LDL-C for primary prevention of CVD.

Comparison of LDL-C calculation by friedewald and martin/hopkins methods in 12,243 adults from the United States of America

Abstract Background Low-density lipoprotein cholesterol (LDL-C) is an established risk factor for cardiovascular disease (CVD), and a target for lipid-lowering therapy. LDL-C is typically not measured directly but is estimated using the Friedewald formula, which assumes a fixed factor for the ratio of triglycerides (TG) to very low-density lipoprotein cholesterol (VLDL-C). However this assumption is sometimes not valid. The Martin/Hopkins (M/H) formula estimates LDL-C using an adjustable factor for the TG:VLDL-C ratio and is expected to improve upon Friedewald when predicting measured LDL-C, and apolipoprotein B (ApoB), one molecule of which is associated with each LDL particle. Purpose We compared values of LDL-C calculated by the Friedewald and M/H methods with respect to their correlation with non-high density lipoprotein cholesterol (non-HDL-C) and ApoB, and their classification of individuals based upon attainment of the threshold value of 70 mg/dl (1.8 mmol/l) of LDL-C. This cut-point is a treatment target for individuals at high risk of CVD in the 2019 ESC guidelines for lipid modification, and a threshold for initiating statin therapy in the 2019 ACC/AHA guidelines. Methods In this analysis we included participants in the National Health and Nutrition Examination Survey (NHANES) from 2005–2016, age ≥18, &amp;lt;80 years who had measurements for total cholesterol (TC), TG and HDL-C. LDL-C was calculated using Friedewald and M/H. We correlated LDL-C (calculated using the two methods) with non-HDL-C and ApoB. We identified individuals with LDL-C &amp;lt;70 mg/dl using both methods. When LDL-C (Friedewald) was &amp;lt;70, but LDL-C (M/H) was &amp;gt;70, we classified these participants as discordant. Statistical analyses were performed in IBM SPSS for Windows v26. Results 12,243 individuals were included. 51.8% were female, mean (±SD) age was 45.5±17.4, 15.3% were treated with statins, ApoB was available for 2179 participants. Mean lipid concentrations (mg/dl) were: TC: 191.5±41.0, TG: 120.0±67.0, HDL-C: 54.1±15.7, LDL-C (Friedewald): 113.3±35.4; LDL-C (M/H): 114.9±35.2. In the whole population, LDL-C (M/H) was more strongly correlated than LDL-C (Friedewald) with ApoB (r=0.935 v 0.894) and non-HDL-C (r=0.981 v 0.944). In statin-treated participants, LDL-C (M/H) was also more strongly correlated with ApoB (r=0.951 v 0.914) and non-HDL-C (r=0.979 v 0.928). 1139 participants had LDL-C (Friedewald) &amp;lt;70 mg/dl. Of these, 206 individuals (18.1%) were discordant, having LDL-C (M/H) &amp;gt;70 mg/dl. Amongst statin-treated patients, 22.9% were discordant. Only 5.5% of individuals with LDL-C (M/H) &amp;lt;70 mg/dl showed reverse discordance (LDL-C (Friedewald) &amp;gt;70 mg/dl). Conclusions The M/H method of calculating LDL-C correlates more strongly with non-HDL-C and ApoB than Friedewald. Importantly the discordant results confirm previous observations that Friedewald underestimates LDL-C at low concentrations. This may result in under-use of lipid-lowering therapies. Funding Acknowledgement Type of funding source: None

Usefulness of the coronary artery calcium (CAC) score for statin prescription in primary prevention: results in over 16.000 assessments

Abstract Background The latest AHA/ACC cholesterol guidelines on primary prevention of coronary artery disease (CAD) recommend the use of the CAC-score to help in decision making for not using or using statins: If the CAC-score is 0, it is reasonable to withhold statin therapy (as long as higher conditions are absent). If CAC-score is 1 - 99, it is reasonable to initate statin therapy for patients ≥55 years of age. If the CAC-score is ≥100, it is reasonable to initiate statin therapy. Therefore, in the present analysis, we assessed the impact of these guidelines in everyday cardiology practice. Methods We analysed our data base with 16083 assessments of the CAC-score in persons with no known coronary or other cardiovascular disease and no exercise-dependent chest pain or shortness of breath. The CAC-score was determined with a multi-slice CT. Using the “step-and-shoot” acquisition protocol, the average dose was around 1 mSv. Results In the total group, a CAC-score of 0 was found in 35%, a CAC-score of &amp;gt;0 up to &amp;lt;100 in 36% and ≥100 in 29%. The percentage of the above mentioned 3 CAC-score groups depending on age and gender are listed in table 1. Conclusion With the support of the CAC-score, a prescription of statins can be avoided in up to appr. 60% of middle-aged male and up to appr. 80% of middle-aged female persons. On the other hand, the use of statin is reasonable in appr. two thirds of higher-aged male and one third of higher-aged female persons for primary prevention. Funding Acknowledgement Type of funding source: None

Reporting the Presence of Coronary Artery Calcium in the Final Impression of Non-gated CT Chest Scans Increases the Appropriate Utilization of Statins.

BackgroundCoronary artery calcium (CAC) scoring based on gated non-contrast cardiac computed tomography (CT) is a validated risk marker of major adverse cardiovascular events (MACE). Reporting of CAC on non-gated CT chest (NGCT) scans and the impact on medical therapy is not well studied.MethodsA retrospective cohort of 5,043 NGCT scans was reviewed for the presence of CAC. The radiology report was reviewed to determine whether CAC was mentioned in either the body of the report or the final impression. Electronic medical records (EMR) were abstracted for baseline demographics, cardiovascular (CV) risk factors, lipid-lowering agents, and aspirin (ASA) prior to and after NGCT.ResultsCAC was present in 63.0% of NGCT scans. Of these scans, CAC was mentioned in the body of the report in 81.6% of studies. Conversely, CAC was mentioned in the final impressions in only 15.1% of these scans. Amongst patients with CAC, initiation of a statin in treatment-naive patients was more common when CAC was mentioned in the final impression versus the body only (12.3% vs. 4.9%, p=0.001) despite the fact that baseline utilization of statins in this cohort was higher (71.1% vs. 64.1%, p=0.005). Initiation of a statin in treatment-naive patients had a trend towards significance when CAC was mentioned in the body of the report versus not reported (4.9% vs. 2.62%, p=0.142). Reporting of CAC in the final impression significantly increased the initiation of ASA in treatment-naive patients (9.52% vs. 4.33%, p=0.033). Reporting of CAC in either the final impression or the body of the report did not affect the initiation of non-statin lipid-lowering therapies in patients with CAC.ConclusionThe inclusion of CAC in the final impression of NGCT radiology reports positively impacts the appropriate initiation of statin and aspirin therapy in treatment-naive patients. Universal adherence to a standardized reporting system for the presence of CAC on NGCT should be considered to improve the initiation of guideline-directed medical therapy.

Incidental Coronary Artery Calcium on Breast Radiation Therapy Planning Scans Identifies Patients for Cardiac Preventive Therapy.

The presence of coronary artery calcium (CAC>0) is associated with increased cardiac-related mortality and is a common indication to initiate statin therapy to prevent future long-term cardiac-related adverse events. CAC is also well visualized on noncontrast chest computed tomography simulation (CT sim) scans used for breast radiation planning. We hypothesize that by screening for incidental CAC on CT sims, radiation oncologists could help identify patients who may benefit from additional preventive medical interventions with their primary care physician or cardiologist. A retrospective analysis of 126 consecutive patients with breast cancer treated with external beam radiation therapy at a single institution was performed. Noncontrast CT sim scans were reviewed for the presence of CAC and the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) was calculated to identify patients who may benefit from initiating statin therapy. Patients with CAC>0 and/or ASCVD risk >20% were identified as those who may benefit from statin therapy. Out of 72 patients with CAC>0, only 12(16%) had reported pre-existing coronary artery disease and 32(44%) were not already on recommended statin therapy. CAC>0 visualized on CT sim was able to identify 29 additional patients who would benefit from statin beyond what the ASCVD risk calculator could identify. Observation of incidental CAC on breast radiation-planning CT scans identified patients who could benefit from cardiac-related preventive strategies. By increasing attention, awareness, and reporting of incidental CAC visible on CT sims, radiation oncologists may fulfill a unique role to bridge a potential gap in cardiovascular preventive medicine.

Initiating statin therapy in children with familial hypercholesterolemia reduces the risk of cardiovascular disease in adulthood

Abrazo Family Medicine Residency Program, Phoenix, AZ The author declares no conflicts of interest.

Should Lipoprotein(a) be Measured in Youth?

Should Lipoprotein(a) be Measured in Youth?

Optimization of Lipid-Lowering Therapy for High Cardiovascular Risk Patients Through Electronic Medical Record Reporting and Pharmacist Evaluation.

Identification of high cardiovascular risk patients on suboptimal lipid-lowering therapy (LLT) may be possible through electronic medical record (EMR) reporting, presenting an opportunity for pharmacist involvement in optimizing drug regimens. To (a) identify high cardiovascular risk patients with opportunities for LLT optimization through EMR reporting and (b) evaluate effectiveness of pharmacist review and treatment algorithm on recommending treatment modifications compared with algorithm application alone. We generated an EMR report to identify adult patients aged 21-75 years with clinical atherosclerotic cardiovascular disease and low-density lipoprotein cholesterol (LDL-C) level ≥ 70 mg/dL during a 6-month period and collected pertinent data elements. We selected a subgroup of patients for remote pharmacist review and determined recommendations based on our predefined LLT optimization algorithm and pharmacist clinical judgment. One pharmacist was responsible for making all recommendations and communicated potential treatment modification to primary care providers via email and/or EMR messaging. We tracked provider acceptable/rejection rate to all recommendations made. We also compared recommendations based on using the algorithm alone to combining pharmacist chart review and algorithm and examined reasons for any discrepancies. 941 patients met inclusion criteria, with 399 patients (42.4%) not currently on any LLT. At baseline, 249 patients (25.3%) were on a high-intensity statin, and 19 (1.9%) were on a proprotein convertase subtilisin/kexin type 9 inhibitor. A subgroup of 34 patients were reviewed, of which 30 (88.2%) were on suboptimal therapy despite not achieving LDL-C goals. The pharmacist recommended to intensify statin therapy for 16 patients (47.1%), initiate nonstatin therapy for 9 patients (26.5%), and initiate statin therapy in 5 patients (14.7%). Pharmacist recommendation acceptance rate was 53.3%, with no response received in 26.6% of cases. The algorithm evaluation alone yielded the same recommendation as the combined pharmacist review with algorithm in 30 (88.2%) of the cases and differed in 4 cases. The underutilization of LLT among high cardiovascular risk patients remains a growing issue despite effective treatment options with cardiovascular benefits. Pharmacists may be able to identify these patients by using reportable EMR data elements and applying a treatment optimization algorithm to make therapy recommendations and improve outcomes. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no relevant declarations of interest to disclose. This study was presented as a poster presentation at the APhA Annual Meeting, March 2019, Seattle, WA, and as a platform presentation at the Eastern States Conference, May 2019, Hershey, PA.

Association Between an Acute, Drug-Induced Decrease in High-Density Lipoprotein Cholesterol Levels and Risk of Cardiovascular Events.

A retrospective cohort study was conducted using the Clinical Practice Research Datalink (CPRD) between 2006 and 2014. The study enrolled patients who initiated statin therapy for a short term, to identify patients with an acute, short-term decrease in HDL levels rather than to assess sustained treatment. HDL-C measurements were assessed within 9months before and after statin initiation and patients were followed up for up to 5years for CV events, comparing those with a decrease in HDL-C with those with constant HDL-C levels. The primary composite endpoint of major adverse cardiac events (MACE) was defined as CV death, myocardial infarction, revascularisation, and hospitalised ischaemic stroke. We estimated crude and propensity score weighted 5-year cumulative risk differences and hazard ratios (HR) comparing both groups. A total of 17,543 patients (HDL-C decrease group, n = 6454; HDL-C constant group, n = 11,089) were included in the study. The 5-year cumulative incidence of MACE in the HDL-C constant cohort was 5.91%. The corresponding risk differences for HDL-C decrease versus the constant group was 1.23% (95% confidence interval [CI] 0.28-2.18) and the HR was 1.20 (95% CI 1.04-1.39). This was mainly driven by an increased risk in ischaemic stroke (HR 1.44, 95% CI 1.08-1.90) and CV death (HR 1.23, 95% CI 0.93-1.63). Patients with a short-term, drug-induced decrease in HDL-C had a moderately increased long-term risk of CV events compared with those with constant HDL-C levels. 207595 (GlaxoSmithKline Trial registry; https://www.gsk-studyregister.com/ ).

Lipid-lowering therapy for primary prevention of premature atherosclerotic coronary artery disease: Eligibility, utilization, target achievement, and predictors of initiation

ObjectivesDespite advances in screening and prevention, rates of premature coronary artery disease (CAD) have been stagnant. The goals of this study were to investigate the barriers to early risk detection and preventive treatment in patients with premature CAD. In particular, we: 1) assessed the performance of the latest versions of major international guidelines in detection of risk of premature CAD and eligibility for preventive treatment; and, 2) investigated real-life utilization of primary prevention with lipid-lowering therapies in these patients. MethodsWe included patients in the Study to Avoid cardioVascular Events in British Columbia (SAVE BC), an observational study of patients with premature (males ​≤ ​50 years, females ​≤ ​55 years) angiographically confirmed CAD. Eligibility for primary prevention and treatment received were assessed retrospectively based on information recorded prior to or at the index presentation with CAD. ResultsOf 417 patients (28.1% females) who met the criteria, 94.3% had at least one major cardiovascular risk factor. In the retrospective risk assessment, 41.7%, 61.4%, and 34.3% (p ​< ​0.001) of patients met criteria for initiation of statin therapy, and an additional 13.9%, 8.4%, and 46.8% may be considered for treatment using the American College of Cardiology/American Heart Association, Canadian Cardiovascular Society, and European Society of Cardiology guidelines, respectively. Only 17.1% of patients received statins and 11.0% achieved guideline-recommended lipid goals before presentation. Diabetes and elevated plasma lipid levels were positively associated with treatment initiation, while smoking was associated with non-treatment. ConclusionsThe current versions of major guidelines fail to recognize many patients who develop premature CAD as being at risk. The vast majority of these patients, including patients who have guideline-directed indications, do not receive lipid-lowering therapy before presenting with CAD. Our findings highlight the need for more effective screening and prevention strategies for premature CAD.

Cost-effectiveness of Contemporary Statin Use Guidelines With or Without Coronary Artery Calcium Assessment in African American Individuals

Clinical and economic consequences of statin treatment guidelines supplemented by targeted coronary artery calcium (CAC) assessment have not been evaluated in African American individuals, who are at increased risk for atherosclerotic cardiovascular disease and less likely than non-African American individuals to receive statin therapy. To evaluate the cost-effectiveness of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline without a recommendation for CAC assessment vs the 2018 ACC/AHA guideline recommendation for use of a non-0 CAC score measured on one occasion to target generic-formulation, moderate-intensity statin treatment in African American individuals at risk for atherosclerotic cardiovascular disease. A microsimulation model was designed to estimate life expectancy, quality of life, costs, and health outcomes over a lifetime horizon. African American-specific data from 472 participants in the Jackson Heart Study (JHS) at intermediate risk for atherosclerotic cardiovascular disease and other US population-specific data on individuals from published sources were used. Data analysis was conducted from November 11, 2018, to November 1, 2019. Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually. In a model-based economic evaluation informed in part by follow-up data, the analysis was focused on 472 individuals in the JHS at intermediate risk for atherosclerotic cardiovascular disease; mean (SD) age was 63 (6.7) years. The sample included 243 women (51.5%) and 229 men (48.5%). Of these, 178 of 304 participants (58.6%) who underwent CAC assessment had a non-0 CAC score. In the base-case scenario, implementation of 2013 ACC/AHA guidelines without CAC assessment provided a greater quality-adjusted life expectancy (0.0027 QALY) at a higher cost ($428.97) compared with the 2018 ACC/AHA guideline strategy with CAC assessment, yielding an incremental cost-effectiveness ratio of $158 325/QALY, which is considered to represent low-value care by the ACC/AHA definition. The 2018 ACC/AHA guideline strategy with CAC assessment provided greater quality-adjusted life expectancy at a lower cost compared with the 2013 ACC/AHA guidelines without CAC assessment when there was a strong patient preference to avoid use of daily medication therapy. In probability sensitivity analyses, the 2018 ACC/AHA guideline strategy with CAC assessment was cost-effective compared with the 2013 ACC/AHA guidelines without CAC assessment in 76% of simulations at a willingness-to-pay value of $100 000/QALY when there was a preference to lose 2 weeks of perfect health to avoid 1 decade of daily therapy. A CAC assessment-guided strategy for statin therapy appears to be cost-effective compared with initiating statin therapy in all African American individuals at intermediate risk for atherosclerotic cardiovascular disease and may provide greater quality-adjusted life expectancy at a lower cost than a non-CAC assessment-guided strategy when there is a strong patient preference to avoid the need for daily medication. Coronary artery calcium testing may play a role in shared decision-making regarding statin use.

Time trends analysis of statin prescription prevalence, therapy initiation, dose intensity, and utilization from the hospital information system of Jinshan Hospital, Shanghai (2012\u20132018)

BackgroundStatin remains a mainstay in the prevention and treatment of cardiovascular diseases. Statin utilization has evolved over time in many countries, but data on this topic from China are quite limited. This study aimed to investigate the changing trends of statins prescription, as well as detail the statin utilization through a successive longitudinal study.MethodsThe prescription database was established based on electronic health records retrieved from the hospital information system of Jinshan Hospital, Fudan University from January 2012 to December 2018 in Shanghai, China. The prescription rates and proportions of different statin types and doses among all patients were examined. Sub-analyses were performed when stratifying the patients by age, gender, dose intensity, and preventative intervention.ResultsDuring the study period, a total of 51,083 patients, who were prescribed for statins, were included in this study (mean [SD] age, 59.78 [±13.16] years; 53.60% male, n = 27, 378). The overall statins prescription rate in which patients increased from 2012 (1.24, 95% CI: 1.21-1.27%) to 2018 (3.16, 95% CI: 3.11–3.20%), P < 0.001. Over 90% of patients were given a moderate dose of statins. Patients with a history of coronary and cerebrovascular events (over 32%) were more likely to be prescribed with statins for preventative intervention. Furthermore, our study has witnessed a significant rise in statin therapy in primary and secondary prevention.ConclusionsIn conclusion, statins were frequently prescribed and steadily increased over time in our study period. There were also changes in statin drug choices and dosages. A coordinated effort among the patient, clinical pharmacist, stakeholders and health system is still needed to improve statin utilization in clinical practice in the future.

Effects of Statins for Secondary Prevention on Functioning and Other Outcomes Among Nursing Home Residents

ObjectivesStudies examining the effects of statins after acute myocardial infarction (AMI) excluded frail older adults, especially nursing home (NH) residents, and few examined functional outcomes. Older NH residents may benefit less from statins and be particularly susceptible to adverse drug events like myopathy-related functional decline. We evaluated the effects of statins on 1-year functional decline, rehospitalization, and death in NH residents. DesignWe conducted a retrospective cohort study using 2007-2010 linked national data from Minimum Data Set (MDS) assessments, Medicare claims, and Online Survey Certification and Reporting System records. Setting and ParticipantsWe included US NH residents 65 years and older who were statin nonusers, were hospitalized for AMI between May 2007 and March 2010, and returned to the NH. MeasuresOutcomes were functional decline, death, and rehospitalization in the first year after post-AMI NH admission. New statin users were 1:1 propensity-score matched to nonusers to adjust for 92 characteristics. We estimated hazard ratios (HRs) and restricted mean survival time differences with 95% confidence intervals (CIs) comparing individuals who did vs did not initiate statin therapy after AMI hospitalization. ResultsPropensity-score matching yielded a cohort of 5440 residents. Mean age was 83 years and 69% were female. Statin use was associated with a reduction in mortality (HR 0.80, 95% CI 0.73-0.87), corresponding to a mean of 15.9 (95% CI 9.9-22.0) days of extended life expectancy. No overall differences in rehospitalization (HR 1.06, 95% CI 0.98-1.14) or functional decline (HR 1.00, 95% CI 0.88-1.14) were observed. Conclusions and ImplicationsStatins may reduce 1-year mortality by 20% without affecting function among older NH residents who wish to live longer after AMI. During shared decision making with these patients or their representatives, clinicians should consider communicating that the average benefit of statins is 16 days of additional survival over 1 year.

Statins and All-Cause Mortality in Patients Undergoing Hemodialysis.

BackgroundRecommendations have not yet been established for statin therapy in patients on maintenance dialysis. In this study, we aimed to evaluate the effects of statin therapy on all‐cause mortality in patients undergoing maintenance hemodialysis.Methods and ResultsThis retrospective cohort study analyzed data from adults, aged ≥30 years, who were on maintenance hemodialysis for end‐stage renal disease. Data on statin use, along with other clinical information between 2007 and 2017, were extracted from the Health Insurance Review and Assessment Service database in Korea. In total, 65 404 patients were included, and 41 549 (73.2%) patients had received statin therapy for a mean duration of 3.6±2.6 years. Compared with statin nonusers before and after the initiation of hemodialysis (entry), patients who initiated statin therapy after entry and patients who continued statins from the pre–end‐stage renal disease to post–end‐stage renal disease period had a lower risk of all‐cause mortality; the adjusted hazard ratios (95% CIs) were 0.48 (0.47–0.50; P<0.001) for post–end‐stage renal disease only statin users and 0.59 (0.57–0.60; P<0.001) for continuous statin users. However, those discontinuing statins before or at entry showed a higher risk of all‐cause mortality. Statin‐ezetimibe combinations were associated with better survival benefits than fixed patterns of statin therapy. These results were consistent across various subgroups, including elderly patients aged >75 years, and were maintained even after propensity score matching.ConclusionsOur results showed that in adult patients undergoing maintenance hemodialysis, statin therapy, preferably combined with ezetimibe, was associated with a lower risk of all‐cause mortality.

The Use of Sex-Specific Factors in the Assessment of Women's Cardiovascular Risk.

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. As compared with men, women are less likely to be diagnosed appropriately, receive preventive care, or be treated aggressively for CVD. Sex differences between men and women have allowed for the identification of CVD risk factors and risk markers that are unique to women. The 2018 American Heart Association/American College of Cardiology Multi-Society cholesterol guideline and 2019 American College of Cardiology/American Heart Association guideline on the primary prevention of CVD introduced the concept of risk-enhancing factors that are specific to women and are associated with an increased risk of incident atherosclerotic CVD in women. These factors, if present, would favor more intensified lifestyle interventions and consideration of initiation or intensification of statin therapy for primary prevention to mitigate the increased risk. In this primer, we highlight sex-specific CVD risk factors in women, stress the importance of eliciting a thorough obstetrical and gynecological history during cardiovascular risk assessment, and provide a framework for how to initiate appropriate preventive measures when sex-specific risk factors are present.

Early and Late Initiation Time of Statin Administration Effects on Early and Long-Term Outcome in Acute Coronary Syndrome Patients: A Literature Review

Early treatment in acute coronary syndrome plays as key role in short-term and long-term outcome. Some studies showed that statin treatment may improve long-term outcomes in post-ACS patients as secondary prevention. The most effective time to give statin in ACS patients is not well-known. The aim of this study is to review previous studies as to when is the best time to initiate statin therapy to reach the best long-term outcome in patients with ACS. PubMed and Medline database were searched with keywords in search engine. The inclusion criteria were: 1) trials that compared one of the statin drugs to placebo or standard care; 2) follow up at least 30 days; 3) publication between 2000-2018. Total of six studies was collected in this review. Many studies showed that early treatment with statin in patients with ACS in admission is associated with reduced one-year mortality. Moreover, early statin therapy reduced one-year major adverse cardiac effect. Statin therapy should be administered early during hospitalization for ACS on the basic data that early therapy with statin is proven reduced one-year mortality and MACE. Further investigation still needs to specify when is the most effective time to give statin in patient with ACS.

76-Year-Old Woman With Generalized Weakness

76-Year-Old Woman With Generalized Weakness

Statin Therapy and Risk of Incident Diabetes Mellitus in Adults With Cardiovascular Risk Factors

The association between statins and diabetes mellitus (DM) remains controversial. The Kaiser Permanente CHAMP Study identified adults without DM who had cardiovascular (CV) risk factors and no previous lipid lowering therapy (LLT) between 2008 and 2010. The CV risk factors included known atherosclerotic CV disease (ASCVD), elevated low-density lipoprotein cholesterol ≥190 mg/dl, or a low-density lipoprotein cholesterol between 70 and 189 mg/dl and an estimated 10-year ASCVD risk ≥7.5%. Incident DM was defined as ≥2 abnormal tests (i.e., A1C ≥6.5% or a fasting blood glucose ≥126 mg/dl) or ≥1 abnormal test result plus a new diagnostic code or medication for DM. Among 213,289 eligible adults, 28,149 patients initiating statins were carefully matched to an equal number of patients who remained off LLT during follow-up. Compared with matched patients not receiving statins, those initiating statin therapy had the same mean age (67.9 ± 9.4 years) and gender (42.8% women). The crude rate (per 100 person-years) of incident DM was low (0.55, 95% confidence interval [CI] 0.52 to 0.59) but was marginally higher in patients who were treated with a statin (0.69, 95% CI 0.64 to 0.74) versus no LLT (0.42, 95% CI 0.38 to 0.46). After additional adjustment, statin therapy was associated with a modestly increased risk of incident DM (adjusted hazard ratio 1.17, 95% CI 1.02 to 1.34). In conclusion, in adults without DM at increased ASCVD risk, initiation of statin therapy was independently associated with a modestly higher risk of incident DM.

Impact of a Pharmacist-Led Diabetes Clinic in a Correctional Setting

Incarcerated patients often have a high disease burden and poor access to care in the community. In an effort to ensure glycemic control and appropriate initiation of statin therapy for cardiovascular (CV) risk reduction, a pilot program of pharmacist-led diabetes clinic (PLDC) was implemented in a large inner-city jail. A pre-post study was conducted as a quality improvement initiative. Inclusion criteria were inmate-patients (IPs) diagnosed with type 2 diabetes mellitus, treated with oral antidiabetic medications, managed by PLDC, and with at least 2 glycosylated hemoglobin A1cs (HbA1c). The primary outcome was the change in HbA1c after PLDC. The secondary outcome was the frequency of statin therapy. A total of 240 IPs met the inclusion criteria. Mean HbA1c was 8.2% at baseline and 7.6% at the last follow-up encounter, a change of −0.7% (95% confidence interval [CI]: −0.41% to −0.93%). The most dramatic change was seen in the group with the highest initial HbA1c (HbA1c ≥ 10%), from a mean baseline HbA1c of 11.6% to 8.5%, a change of −3.1% (95% CI: −2.5% to −3.7%). IPs with an initial HbA1c between 7% and 9.9% showed a change in mean HbA1c from 8.4% to 8.0%, a change of −0.4% (95% CI: −0.1% to −0.7%). Of the 240 included IPs, 141 were not on a statin at baseline. The frequency of statin use increased by 50.4% after PLDC. PLDC significantly improved glycemic control and guideline concordance for CV risk reduction. Adding PLDC to multidisciplinary care teams has the potential to improve population health outcomes for this medically complex, yet underserved patient population.

337. Switching from TDF to TAF: Missed Opportunities for Statin Use in HIV

BackgroundPeople living with HIV (PLWH) have been observed to have twice the risk for atherosclerotic cardiovascular disease (ASCVD) as the general population. Increases in total and low-density lipoprotein cholesterol have been observed in PLWH switching from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF). Changes in regimens represent an opportunity for healthcare providers to assess health markers and address clinical concerns. Current guidelines recommend initiating statin therapy in individuals with an elevated ASCVD risk. Failure to initiate statins in PLWH with an ASCVD ≥ 7.5% at switch represents a missed opportunity for statin initiation. We aimed to assess missed opportunities for statin therapy in PLWH switching from TDF to TAF-containing antiretroviral therapy.MethodsAdults switching from TDF to TAF with ≥1 lipid measure on TDF ≤6 months prior to switch and ≥1 lipid measure ≥7 days after switch to TAF were identified in the OPERA® cohort (84 clinics in 18 US states/territories). The proportion of PLWH prescribed statins pre- and post-switch was stratified by ASCVD risk (recommended threshold: ASCVD ≥ 7.5%). The ASCVD score was imputed using the limit value for components out of the pre-specified range.Results6,451 PLWH switched from TDF to TAF (Figure 1); over 90% had ASCVD scores available pre- (n = 5801) and post-switch (n = 5881). High ASCVD risk (≥7.5%) was more likely post-switch (34.1) than pre-switch (32.1%, P = 0.02; Figure 2). Of those with high ASCVD risk, only 31% and 41% were prescribed statins pre- vs. post-switch, respectively (Figure 3), representing a considerable missed opportunity for ASCVD prevention, with 59% of PLWH with an elevated risk of ASCVD not prescribed statins after switch from TDF to TAF. ASCVD scores were imputed for those outside the range of the score (e.g., patients < 40 years of age) to evaluate the entire population. Comparable results were obtained when the analysis was limited to PLWH who did not require ASCVD score imputation.ConclusionDespite a switch from TDF to TAF being associated with higher numbers of PLWH with elevated ASCVD risk, most did not receive a statin, representing considerable missed opportunities to reduce risk of cardiovascular disease in this at-risk population. Disclosures All authors: No reported disclosures.