Medications For Primary Prevention Research Articles

The Effect of Exercise Training on Blood Lipids: A Systematic Review and Meta-analysis.

Dyslipidemia is a primary risk factor for cardiovascular disease (CVD). Exercise training (EXTr) improves some lipid markers but not others; the literature is dated and analyses may be underpowered. To clarify which lipid markers are altered with ExTr and establish if information size had yet reached futility. We conducted a systematic review/meta-analysis, with meta-regression, to establish expected effect size in lipid profile with aerobic (AT), resistance (RT) and combined (CT = AT + RT) ExTr. We conducted trial sequence analysis (TSA) to control for type I and II error and establish if information size had reached futility. We included 148 relevant randomized controlled trials (RCTs) of ExTr, with 227 intervention groups, total 8673 participants; exercise 5273, sedentary control 3400. Total cholesterol (TC) MD - 5.90mg/dL (95% confidence interval (CI) - 8.14, - 3.65), high-density lipoprotein cholesterol (HDL) 2.11 (95% CI 1.43, 2.79), low-density lipoprotein cholesterol (LDL) - 7.22 (95% CI - 9.08, - 5.35), triglycerides - 8.01 (95% CI - 10.45, - 5.58) and very low-density lipoprotein cholesterol (VLDL) - 3.85 (95% CI - 5.49, - 2.22) all showed significant but modest 3.5-11.7%, improvements following ExTr. TSA indicated all analyses exceeded minimum information size to reach futility. CT was optimal for dyslipidemia management. Meta-regression showed every extra weekly aerobic session reduced TC - 7.68mg/dL and for every extra week of training by - 0.5mg/dL. Each minute of session time produced an additional 2.11mg/dL HDL increase. TSA analysis revealed sufficient data exist to confirm ExTr will improve all five lipid outcomes. CT is optimal for lipid management. The modest effect observed may moderate dyslipidemia medication for primary prevention. Prediction intervals suggest TC, HDL, LDL and TGD are only improved in one-quarter of studies.

Integrating cardiovascular risk assessment into mobile low-dose CT lung screenings in rural Appalachia: A comprehensive analysis of the relationship between lung cancer risk, coronary artery calcium burden, and cardiovascular risk reduction strategies

ObjectiveMobile low-dose computed tomography (LDCT) lung screenings are part of an outreach program in rural Appalachia to detect early lung cancer. Coronary artery calcium (CAC) scoring on LDCT can identify calcium deposits in coronary arteries and can prompt consideration of risk modification for prevention of cardiovascular disease (CVD) events. It is not known if Lung CT Screening Reporting & Data System (Lung-RADS) scoring correlates with CAC scores. There is no clear guidance for patients undergoing LDCT screenings to receive follow-up regarding CAC or prevention of associated CVD risk. MethodsThis was a retrospective review of mobile LDCT LCS in adults with no known history of CVD. CT images were obtained at 100 kVp with a slice thickness of 3 mm. Agatston CAC scoring was performed retroactively. Lung-RADS scores were categorized as: Negative (1), Benign (2), Probably Benign (3), and Suspicious (4). CAC scoring was grouped as 0, 1–100, 101–399, and ≥400. Descriptive statistics and chi-square analyses were utilized. ResultsA total of 526 LDCT screenings were included. Over 54 % of patients had coronary calcification on LDCT LCS. 161 patients (30.6 %) had a CAC score of ≥100 and 75 patients (14.3 %) had a CAC score ≥400. Of patients with a CAC score ≥100, 7.5 % received referrals for follow-up after the LDCT screen and 9.3 % had additional cardiac testing. Of those with a CAC score ≥100 not already on a statin (45.3 %) and not already on aspirin (63.3 %), few were started within 3 months of LDCT for prevention (8.2 % and 5.9 % respectively). Among patients with a Lung-RADS score of 4, 17 % had a CAC score >400, whereas only 12 % with a Lung-RADS score of 1 fell into the same CAC category. Higher Lung-RADS scores correlated with fewer patients with CAC of 0. A significant correlation was observed between higher Lung-RADS scores and elevated CAC scores (p = 0.02). ConclusionIn patients with no CVD history, coronary artery calcification was frequently identified on mobile LDCT lung screenings in rural communities. Patients with higher probabilities of malignant lung nodules may also be at increased risk for significant coronary artery disease. Calcium scoring from LDCT screenings allowed for simultaneous assessment of lung cancer and CVD risk. Unfortunately, few referrals or CVD prevention medications were initiated. Awareness of CAC score utility, follow-up for identified coronary calcifications, and consideration of primary prevention medications when indicated, would be beneficial in patients undergoing LDCT lung screenings, especially in rural areas with limited healthcare access.

Abstract P510: Trends in Statin Therapy for Primary Prevention Among Older Veterans, 2003-2020

Introduction: The burden and risk of atherosclerotic cardiovascular disease (ASCVD) in US Veterans is higher than the general population, yet rates of use of medications for primary prevention, specifically statins, are not well described. Since the early 2000s, trial data have proven the efficacy of statins for primary prevention, further encouraged by updated guidelines (notably 2001, 2013, 2018). Therefore, we sought to examine the proportion of older veterans free of ASCVD and trends of statin use for primary prevention within this cohort from 2003 to 2020. Methods: Study participants comprised all US Veterans ≥65 years, free of ASCVD, and with at least one visit in the Veteran’s Health Administration (VHA) in the year prior. Statin users had at least two or more prescriptions of any statin in each one-year period studied. VA prescription data were linked to Medicare/Medicaid to ensure complete capture of statin use. Descriptive statistics and crude proportions were calculated by year of study entry. Results: From 2003-2020, there were 5.1 million Veterans aged 65 and older who received regular care in VHA. The overall proportion of veterans free of ASCVD in that period was 60% (N=3,159,705). Statin prescriptions for primary prevention have increased from 39% in 2003 to 52% in 2020, remaining steady after 2007. For example, in 2011, 51% were prescribed statins, mean age 73±7, 87% white, 98% male, 82% hypertension, 37% diabetes, 94% hyperlipidemia; while in 2017, 53% were prescribed statins (age 72± 7, 80% white, 97% male, 73% hypertension, 31% diabetes, 74% hyperlipidemia), received statin therapy for primary prevention (Figure). Conclusion: A substantial proportion of Veterans ≥65 years were at risk for ASCVD. While statin prescriptions for primary prevention have increased from 2003-2020, over the past 15 years, they have remained at around 50%. These findings indicate a focus on primary prevention among older Veterans is needed.

Cardioprotective Agents for the Primary Prevention of Trastuzumab-Associated Cardiotoxicity: A Systematic Review and Meta-Analysis.

There are significant considerations about the prevention of cardiotoxicity caused by trastuzumab therapy in patients with breast cancer, leading to discontinuation. Recently, randomized controlled trials (RCTs) have evaluated the effects of early commitment of beta-blockers (BBs), angiotensin receptor blockers (ARBs) and angiotensin converting enzyme inhibitors (ACEIs) during trastuzumab chemotherapy in order to prevent the related cardiotoxicity. The present systematic review and meta-analysis of six RCTs included patients who have predominantly non-metastatic, HER2-positive, breast cancer and received trastuzumab as primary or adjuvant therapy. Those patients did not have any obvious cardiac dysfunction or any previous therapy with cardioprotective agent. We evaluated the efficacy of the aforementioned medications for primary prevention of cardiotoxicity, using random effects models. Any preventive treatment did not reduce cardiotoxicity occurrence compared to controls (Odds ratios (OR) = 0.92, 95% CI 0.54-1.56, p = 0.75). Results were similar for ACEIs/ARBs and beta-blockers. Treatment with ACEIs/ARBs led to a slight, but significant, increase in LVEF in patients compared to the placebo group. Only two studies reported less likelihood of discontinuation of trastuzumab treatment. More adequately powered RCTs are needed to determine the efficacy of routine prophylactic therapy.

Prevalence of cardiovascular disease in Sickle cell disease (SCD)- An echocardiographic and pharmacological analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Sickle cell disease (SCD) is an inherited disorder of globin chains that cause haemolysis and chronic organ damage. It is an autosomal recessive condition. SCD is a condition more prevalent in sub-saharan Africa. It is estimated that there are between 12,500 and 15,000 people with SCD in the United Kingdom (UK) in 2014. The prevalence of the disease is increasing due to immigration into the UK and new births. As a result, there is a need to understand cardiovascular complications within this population, as despite a significant increase in longevity for SCD patients over the last few decades, there are significant cardiac complications. Method We present retrospective data from a single center tertiary centre for SCD. A total of 318 patients were followed up from diagnosis to current day with a mean age of 43.4 and median of 42. 136 (43%) were male and 182 (57%) Female. Results A total of 157 (49%) patients underwent a transthoracic echocardiogram (TTE). 56 (17.5%) had a dilated Left Atrium, 36 (11.3%) had Valvular heart disease, 18 (5.7%) Pulmonary Hypertension (PHT) or Right Heart Dysfunction and 17 (5.34%) had a dilated Left Ventricular cavity. 14 patients had Tricuspid regurgitation (13 mild and 1 severe), 15 had Mitral regurgitation (14 mild and 1 moderate), 7 had mild Aortic regurgitation, 6 had Mild Pulmonary regurgitation, 3 had mild Pulmonary Stenosis and 3 were noted to have sclerotic aortic valve. From a Left ventricular systolic function perspective, 151 patients had a normal ejection fraction, 4 had mild Left ventricular systolic dysfunction (LVSD), 1 moderate LVSD and 1 severe LVSD. A normal ejection fraction was defined as >55%, mild 45-55%, moderate 35-45% and severe <35%. 40 (12.60%) Patients were taking Calcium channel blockers (Dihydropyridine), 25 (7.86%) were taking Angiotensin converting enzyme inhibitor/ Angiotensin receptor blocker, 20 (6.29%) taking an anticoagulant (DOAC), 16 (5.03%) were taking a statin, 15(4.72%) taking B blockers, 11(3.46%) taking an antiplatelet, 5(1.57%) patients were taking a loop diuretic, 4 (1.26%) thiazide diuretic, 4 (1.26%) on an alpha blocker and 1(0.3%) patient on digoxin. The prevalence of Atrial Fibrillation was 1.57% (5 patients). Conclusions The Echocardiographic data suggests the commonest findings are of a dilated left atrium, dilated ventricle, valvular heart disease and PHT. The dilated left atrium is secondary to the hyperdynamic states found in sickle cell disease. Despite this being very common the rates of arrhythmia are low. The prevalence of LVSD remains low. The findings of PHT are of particular interest as it guides SCD management with exchange transfusion. The pharmacological data suggests high burden of cardiovascular risk factors i.e. hypertension and hypercholesterolemia despite the young demographic. It is vital to follow up these patients with aggressive primary prevention medications to reduce risk of future cardiovascular events.

Abstract 15804: Gender-Specific Analysis of Current Trends in Primary Prevention of ASCVD

Introduction: Cardiovascular disease is the leading cause of death in the U.S. for both men and women. Disparities exist not only in women’s outcomes from atherosclerotic cardiovascular disease (ASCVD) but also in assessment of their risk of disease development. This can be attributed in part to the historical misperception that ASCVD affects males at a greater rate than females. This study examines whether female patients are appropriately prescribed statin medication for primary prevention of ASCVD at the same rates as male patients of equivalent risk. Methods: Data were gathered from 11,871 de-identified UC San Diego patient medical records, which included primary care patients ages 40 to 75 without prior ASCVD. The ACC/AHA 10-Year ASCVD Risk Estimator was used to calculate risk scores. The groups of elevated-risk patients, defined by a score greater than or equal to 7.5, of each gender who were and were not prescribed statins were compared using a Chi-Square analysis, conducted in SPSS, in order to determine whether a significant difference existed in appropriate statin prescription between male and female patients. Significance was assessed using the Pearson Chi-Square value compared to a 0.05 significance threshold. Results: In the group of male patients, 796 were on a statin when indicated, compared to the expected value of 803.1, and 807 were not, compared to 789.9 expected. For the female group, 305 patients were on a statin when indicated, compared to 287.9 expected, and 266 were not, compared to 283.1 expected. The Pearson Chi-Square value comparing the groups was 0.095, which is greater than the 0.05 significance threshold. Conclusions: Because of evidence that physicians may be influenced by biases about women’s heart disease risk, this study assessed the hypothesis that there would be a significant difference in appropriate prescription of statins for primary ASCVD prevention between male and female patients. This analysis did not show evidence of a statistically significant difference between the rates of untreated elevated-risk men versus women in this patient population. Though a single-institution study, these findings may signal increasing awareness of women's heart disease risk among primary care physicians.

Educational level differences in the primary and secondary prevention of stroke

The aim of this study is to estimate the educational level differences in the primary and secondary prevention of stroke among the Chinese population. Data were obtained from the China Kadoorie Biobank (CKB) survey of 512,891 people aged 30–79 years in 10 geographic regions of China, which was conducted from 2002 to 2008. The Prediction for Atherosclerotic Cardiovascular Disease Risk in China model was used to identify individuals with a high estimated 10-year stroke risk. A total of 8884 participants (1.7%) had established stroke and 218,972 (42.7%) had a high stroke risk. In both primary and secondary prevention, the participants' educational level was positively associated with the control of smoking, blood pressure, consuming a healthy diet, and the use of antiplatelet, BP-lowering medications but negatively associated with higher physical activity levels (all Ptrend < 0.001). In addition, the positive associations were observed with the control of drinking and use of anti-hyperglycaemia medication for primary prevention (all Ptrend < 0.001) and with the use of lipid-lowering medication for secondary prevention (Ptrend = 0.019). The results of the interaction between education level and prevention level showed that, compared with participants in primary prevention, educational level disparities in those with secondary prevention had significantly higher use of antiplatelets and lipid-lowering drugs, achieving the physical activity goal and non-current drinker (all Pfor interaction < 0.05). A higher education level was associated with an increased acceptance of primary and secondary prevention strategies (not smoking or drinking, consuming a healthier diet) except for engaging in a suitable level of physical activity.

Long-term trends in the epidemiology of cardiovascular diseases in the UK: insights from the British Heart Foundation statistical compendium.

The British Heart Foundation's (BHF) annual statistical compendium is a comprehensive source of accessible epidemiological data in relation to cardiovascular disease (CVD) in the UK. Using datasets with multiple years of data from the compendium we have analysed trends in mortality, morbidity, and treatment for CVD within the UK. CVD mortality in the UK has consistently declined over recent decades, from 1045 deaths per 100 000 in 1969, shortly after the BHF was founded, to 255 per 100 000 in 2019. Despite this remarkable improvement, inequalities in CVD mortality persist in the UK nations, for example in 2019 the death rate in Scotland was 326 deaths per 100 000 compared with 246 per 100 000 in England. Improvements in CVD mortality have been paralleled by increased use of primary prevention medications (anti-hypertensives and statins) and interventional procedures. In recent years, progress in mortality outcomes has stalled, probably due to a combination of factors including a rise in risk factors such as obesity and diabetes. In terms of morbidity, CVD remains a significant burden in the UK, accounting for at least 1.18 million hospital admissions and reflects the enormous economic burden of CVD, estimated at £19bn in the UK. Our results highlight the importance of accessible and comprehensive statistics in relation to the burden of CVD and the value of the BHF's annual compendium in drawing out conclusions and opportunities for future research. One key area is to improve the data on which estimation of prevalence is based. There is also a need for ongoing work to better understand the root causes of disparity between socio-economic groups in relation to CVD. One important way to address this will be to improve the consistency of reporting of CVD health data across all nations of the UK. Understanding the causes will inform UK healthcare planning in addition to providing analytical insights that will be applicable in other countries.

Role of Coronary Artery Calcium Testing for Risk Assessment in Primary Prevention of Atherosclerotic Cardiovascular Disease

Current guidelines recommend a few different approaches to the use of coronary artery calcium (CAC) testing as a tool for risk assessment and decision-making regarding drug therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD). Coronary artery calcium testing is not recommended for universal screening, particularly in patients at very low or high predicted risk for ASCVD, where its yield and utility for altering clinical decisions are limited. Use of CAC testing appears to be optimal when used in selected patients who are at intermediate or borderline risk of ASCVD as a sequential decision aid after initial quantitative risk assessment and consideration of individual patient risk-enhancing factors (eg, strong family history of premature ASCVD, chronic kidney disease). Although convincing clinical trials have not been completed, observational studies strongly suggest that, in those at intermediate risk, CAC testing can meaningfully reclassify risk and can support improved targeting of drug therapy to patients most likely to benefit. This narrative review summarizes the evidence available about the appropriate role of CAC testing for ASCVD risk assessment. Coronary artery calcium testing should be used selectively in patients who are at intermediate risk of ASCVD, when there is persistent uncertainty after performing standard risk assessment using traditional risk factors in a risk score, and after consideration of additional individual risk-enhancing factors. In these situations, the result of the CAC test can be helpful to clarify whether the patient's true risk is high enough to justify initiation of primary prevention medications, such as statins or aspirin.

Coronary Heart Disease Risk Associated with Primary Isolated Hypertriglyceridemia; a Population-Based Study.

BackgroundHypertriglyceridemia is associated with increased risk of coronary heart disease but the association is often attributed to concomitant metabolic abnormalities. We investigated the epidemiology of primary isolated hypertriglyceridemia (PIH) and associated cardiovascular risk in a population‐based setting.Methods and ResultsWe identified adults with at least one triglyceride level ≥500 mg/dL between 1998 and 2015 in Olmsted County, Minnesota. We also identified age‐ and sex‐matched controls with triglyceride levels <150 mg/dL. There were 3329 individuals with elevated triglyceride levels; after excluding those with concomitant hypercholesterolemia, a secondary cause of high triglycerides, age <18 years or an incomplete record, 517 patients (49.4±14.0 years, 72.0% men) had PIH (triglyceride 627.6±183.6 mg/dL). The age‐ and sex‐adjusted prevalence of PIH in adults was 0.80% (0.72–0.87); the diagnosis was recorded in 60%, 46% were on a lipid‐lowering medication for primary prevention and a triglyceride level <150 mg/dL was achieved in 24.1%. The association of PIH with coronary heart disease was attenuated but remained significant after adjustment for demographic, socioeconomic, and conventional cardiovascular risk factors (hazard ratio [HR], 1.53; 95% CI, 1.06‐2.20; P= 0.022). There was no statistically significant association between PIH and cerebrovascular disease (HR, 1.06; 95% CI, 0.65‐1.73, P= 0.813), peripheral artery disease (HR, 1.27; 95% CI, 0.43‐3.75; P= 0.668), or the composite end point of all 3 (HR, 1.28; 95% CI, 0.92‐1.80; P=0.148) in adjusted models.ConclusionsPIH was associated with incident coronary heart disease events (although there was attenuation after adjustment for conventional risk factors), supporting a causal role for triglycerides in coronary heart disease. The condition is relatively prevalent but awareness and control are low.

Abstract P685: Primary Care Utilization for Primary Prevention Continues to Be Lacking in Patients With Stroke

Introduction: Primary care plays an essential role in stroke prevention. Yet still, for many stroke patients, a relationship with a primary care provider (PCP) is not established until after stroke. Our goal was to determine if lack of PCP and the consequential differences in management affects stroke severity. Methods: Data was obtained from our Institutional Review Board approved stroke admission database from 2017 to November 2019 of all stroke subtypes (ischemic stroke, transient ischemic attack, subarachnoid and intracerebral hemorrhages). Non-parametric Mann Whitney t-test and regression analysis was used to identify significant differences in medications, stroke risk factors and stroke severity. Results: A total of 559 patients were included, median age 67 (interquartile range (IQR) 58-76), 49% woman, 32% established care with a PCP, 36% on medications for diabetes mellitus (DM), 42% hyperlipidemia, 66% anti-hypertensives, 39% anti-platelet agents, and 10% anticoagulation. More patients with PCP were taking anti-hypertensive medications (80% versus (vs) 60%, p value &lt; 0.0001), DM medications (56% vs 30%, p value &lt; 0.0001), anti-platelet agents (46% vs 35%, p value = 0.0149), and medications for hyperlipidemia (49% vs 39%, p value = 0.0426). Admission NIHSS was lower in patients with a PCP median 6 (IQR 3-11) vs median 9 (IQR 4 -15), p value= 0.0016, and median hemoglobin A1c was higher in patients with a PCP 8 (IQR 5.7- 9.3) vs patients without a PCP prior to their stroke 6 (IQR 5.4 - 8.5), p value= 0.0002. Admitting systolic blood pressure was similar 155 (137-177) vs 152 (134-171). After correcting for age and gender, regression analysis demonstrated a significant association between whether a patient had PCP and antihypertensive medication use (odds ratio (OR) 2.413, 95% confidence interval 1.511 - 3.914) and hemoglobin A1c (OR 1.122, 95% CI 1.037 - 1.215). Also, patients with a PCP were more likely to have a lower NIHSS on admission (OR 0.9679, 95% CI 0.9423 - 0.9930). Conclusions: These result show that patients not followed by a PCP prior to stroke are less likely to be on medications for primary prevention of stroke, contributing to an increased stroke severity on admission. More research is needed to identify barriers to patients establishing care with PCP.

Coronary artery calcium scoring and cardiovascular risk reclassification in patients undergoing coronary computed tomography angiography

IntroductionCoronary artery calcium (CAC) scoring is used for both cardiovascular risk reclassification and as a gatekeeper for coronary computed tomography angiography (CCTA). The aims of this study were to assess to what extent CAC score results can reclassify the cardiovascular risk of patients without obstructive coronary artery disease (CAD) on CCTA, and to measure the proportion of these patients whose primary prevention medication is changed after the exam. MethodsIn a retrospective analysis of a multicenter registry of individuals who underwent CCTA for suspected CAD during a two-year period, the Systematic COronary Risk Evaluation (SCORE) and Multi-Ethnic Study of Atherosclerosis (MESA) risk scores were calculated for each individual. In a subset of 184 patients, we also assessed the prescription of statins and antiplatelet agents before and after the test. ResultsA total of 467 patients (248 women, mean age 60±9.10 years) were included. Median CAC score was 0 (interquartile range 0-40). Overall, 249 patients (53%) and 159 (34%) were classified as being of moderate/intermediate risk according to the SCORE and MESA risk scores, respectively. Among these, 29 (12%) and 30 (19%) patients had CAC score >100 AU, making them eligible for statin therapy. The inclusion of CAC scoring in the MESA score resulted in the reclassification of 215 patients (46%). The proportion of patients who were prescribed statins or antiplatelet agents did not change significantly after the test. ConclusionCAC scoring can reclassify cardiovascular risk in a significant proportion of patients undergoing CCTA. Despite this, little change was seen in the prescription of statins and antiplatelet agents.

Assessing the effectiveness of statin therapy for alleviating cerebral small vessel disease progression in people \u226575\u2009years of age

BackgroundStatins have been recommended by several guidelines as the primary prevention medication for cardiovascular diseases. However, the benefits of statin therapy for cerebral small vessel disease (CSVD), particularly in adults ≥75 years of age, have not been fully evaluated.MethodsWe analyzed the data from a prospective population-based cohort study and a randomized, double-blind, placebo-controlled clinical trial to determine whether statin therapy might aid in slowing the progression of CSVD in adults ≥75 years of age. For the cohort study, 827 participants were considered eligible and were included in the baseline analysis. Subsequently, 781 participants were included in follow-up analysis. For the clinical trial, 227 participants were considered eligible and were used in the baseline and follow-up analyses.ResultsThe white matter hyperintensities (WMH) volume, the WMH-to-intracranial volume (ICV) ratio, the prevalence of a Fazekas scale score ≥ 2, lacunes, enlarged perivascular spaces (EPVS), and microbleeds were significantly lower in the statin group than the non-statin group at baseline in the cohort study (all P < 0.05). During the follow-up period, in both the cohort and clinical trial studies, the WMH volume and WMH-to-ICV ratio were significantly lower in the statin/rosuvastatin group than the non-statin/placebo group (all P < 0.001). Statin therapy was associated with lower risk of WMH, lacunes, and EPVS progression than the non-statin therapy group after adjustment for confounders (all P < 0.05). There was no statistically significant difference in the risk of microbleeds between the statin and non-statin therapy groups (all, P > 0.05).ConclusionsOur findings indicated that statin therapy alleviated the progression of WMH, lacunes, and EPVS without elevating the risk of microbleeds. On the basis of the observed results, we concluded that statin therapy is an efficient and safe intervention for CSVD in adults ≥75 years of age.Trial registrationChictr.org.cn: ChiCTR-IOR-17013557, date of trial retrospective registration November 27, 2017 and ChiCTR-EOC-017013598, date of trial retrospective registration November 29, 2017.

Prior Use of Medication for Primary Prevention in Patients with Coronary Syndrome

Background: Cardiovascular disease, especially coronary disease, represents one of the main causes of morbidity and mortality. Objective: To determine the drug prescription profile for primary cardiovascular prevention prior to a first acute coronary syndrome event. Methods: Cross-sectional study. We included adult patients of any sex affiliated with one healthcare insurer of the Colombian Health System, with a diagnosis of a first episode of acute coronary syndrome that occurred during the period of 2015 to 2016. Sociodemographic, clinical and pharmacological variables were evaluated from clinical records. The cardiovascular risk score prior to the event was calculated, and the need for the use of statins and aspirin in primary prevention was defined according to the recommendations of clinical practice guidelines. Results: Clinical records of 322 patients were reviewed with mean age of 61.9 ± 10.8 years, and 77.3% were men. The most frequent comorbidities were dyslipidemia (64.3%), arterial hypertension (62.7%) and diabetes mellitus (30.1%); 22% of the patients were obese, and 33.5% were smokers. The cardiovascular risk score was calculated in 211 patients (65.5%) who had the necessary variables complete. The median 10-year risk according to Framingham risk score was 21.4%, and it was 16.3% according to the American Heart Association. From the 211 patients with risk scores, there were 179 (84.8%) who needed statins (175 of high intensity, 97.8%), and 88 (27.3%) required aspirin as a primary prevention; however, 56 of these patients (31.3%) did not receive any statins, 127 (72.6%) did not receive the high intensity statin they needed, and 38 (43.2% of those with indication) lacked aspirin. Conclusion: Real-life data show that among a group of patients with high cardiovascular risk, a substantial proportion were not receiving medications for primary prevention necessary to reduce their risk and finally suffered an acute coronary event.

Budget impact analysis of osteoporosis medications for primary prevention of fractures in Taiwan.

Taiwan's national health insurance currently only covers the use of osteoporosis drugs for the secondary prevention of fractures and does not provide coverage for primary prevention. The purpose of this study is to develop a model for analyzing the budgetary impact of the use of osteoporosis medications of primary prevention. The budget impact model in this study is the "actual medication cost" minus the "medical expenses for all types of fractures that can be avoided by taking osteoporosis medications." We developed six possible insurance payment plans for primary prevention based on the age of the patients and T-scores and performed eleven steps to estimate the budget impact of each payment plan. The results of this study indicated that there may be 71,220 (T-score ≤ - 3.0, 75 + y/o) to 157,515 (T-score ≤ - 2.5, 65 + y/o) people using the drugs, and the budget impact may be US$26.28-58.98 million in 2019. However, the payment plans may avoid 492-766 fracture events and save medical expenditures for fracture treatment by US$1.30-2.02 million. The average costs for primary prevention within a year will be US$53,386-77,006. The budget impact of using osteoporosis medications to primary prevention of fractures is significant, but it can be compensated due to savings in fracture treatment costs.

Multimorbidity, polypharmacy and primary prevention in community-dwelling adults in Quebec: a cross-sectional study.

Polypharmacy carries the risk of adverse events, especially in people with multimorbidity. To investigate the prevalence of polypharmacy in community-dwelling adults, the association of multimorbidity with polypharmacy and the use of medications for primary prevention. Cross-sectional analysis of the follow-up data from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Multimorbidity was defined as the presence of three or more chronic diseases and polypharmacy as self-reported concurrent use of five or more medications. Primary prevention was conceptualized as the use of statin or low-dose antiplatelets without a reported diagnostic of cardiovascular disease. Mean age 56.7 ± 11.6, 62.5% female, 30.3% had multimorbidity, 31.9% had polypharmacy (n = 971). The most common drugs used were statins, renin-angiotensin system inhibitors and psychotropics. Compared to participants without any chronic disease, the adjusted odds ratios (ORs) for having polypharmacy were 2.78 [95% confidence interval (CI): 1.23-6.28] in those with one chronic disease, 8.88 (95% CI: 4.06-19.20) in those with two chronic diseases and 25.31 (95% CI: 11.77-54.41) in those with three or more chronic diseases, P < 0.001. In participants without history of cardiovascular diseases, 16.2% were using antiplatelets and 28.5% were using statins. Multimorbidity was associated with increased likelihood of using antiplatelets (adjusted OR: 2.98, 95% CI: 1.98-4.48, P < 0.001) and statins (adjusted OR: 3.76, 95% CI: 2.63-5.37, P < 0.001) for primary prevention. There was a high prevalence of polypharmacy in community-dwelling adults in Quebec and a strong association with multimorbidity. The use of medications for primary prevention may contribute to polypharmacy and raise questions about safety.

Primary Prevention Using Cholesterol-Lowering Medications in Patients Meeting New Treatment Guidelines: A Retrospective Cohort Analysis.

The American College of Cardiology and American Heart Association (ACC/AHA) issued new cholesterol treatment guidelines in 2013. Two of the groups designated for primary prevention were analyzed: patients with a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg per dL and diabetic patients aged 40-75 years. To estimate the effects of primary prevention as specified in the 2013 guidelines on cardiovascular event risk and cost. Primary prevention patients were identified using laboratory and diagnostic data for Humana members from 2007 to 2013. Potential study patients were classified into 3 risk groups: elevated LDL-C, diabetes, and elevated LDL-C and diabetes. Patients receiving cholesterol-lowering medications before their index date were excluded. Eligible patients were divided into 2 treatment groups: (1) primary prevention patients who initiated treatment before experiencing any cardiovascular disease (CVD)-related event, and (2) patients who either did not initiate treatment until after experiencing a CVD event or never initiated treatment. The associations between initiating cholesterol-lowering medications for primary prevention and the risk for acute myocardial infarction, stroke, coronary angioplasty, or coronary artery bypass graft surgery were estimated using Cox proportional hazards models. The effect of primary prevention on health care costs was estimated using generalized linear models. 91,066 patients met study selection criteria. Primary prevention rates were the lowest in diabetic patients (35%), who were newly designated for treatment in the 2013 guidelines. Primary prevention rates were higher for patients designated for treatment under earlier guidelines: 65% for patients with elevated LDL-C and 78% for the combined LDL-C and diabetes group. Primary prevention treatment was associated with significant reductions in cardiovascular event risk (up to 37%) and lower total all-cause costs (by $673) in the first post-index year. Initiating cholesterol-lowering medications for primary prevention, as specified in the ACC/AHA 2013 guidelines, for patients with high LDL-C and diabetes is associated with reduced CVD event risks and lower health care costs. No outside funding supported this study. Han received fellowship support from the Pharmaceutical Research and Manufacturers Association Foundation (PhRMA) during the conduct of this study. Dougherty is employed by PhRMA. The authors have nothing to disclose.

Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults.

Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults.

Current status and the consistency analysis of using two criteria for decision making of aspirin use for the primary prevention of ischemic cardiovascular disease in outpatients

Objective: To compare the consistency and accuracy of using 2 criteria for decision making of aspirin use for the primary prevention of ischemic cardiovascular disease (ISCVD) and explore the current status and related factors of aspirin use for the primary prevention of ISCVD in Chinese outpatients. Methods: This cross-sectional study enrolled 3 018 outpatients with hypertension, diabetes, or hypercholesterolemia, who visited the General Practice (GP) clinics of Anzhen hospital in Beijing from September to December 2015 were enrolled in. The information of risk factors for ISCVD and use of aspirin was collected. Both quantitative and qualitative criteria were used to make the decision of aspirin use for primary prevention of ISCVD in this patient cohort. Quantitative criteria were derived from the 2011 Chinese guideline of cardiovascular disease prevention: aspirin use for primary cardiovascular disease prevention in population with risk of ISCVD in the next 10 years≥10%. Qualitative criteria were derived from the Chinese expert consensus on the aspirin use issued in 2013: aspirin should be given for the purpose of primary ISCVD in population with≥3 risk factors:(1) men aged ≥50 years or postmenopausal women; (2) hypertensive subjects with blood pressure ≤150/90 mmHg(1 mmHg=0.133 kPa);(3) diabetes; (4) hypocholesteremia; (5) obesity with body mass index (BMI)≥28 kg/m(2); (6) Smokers;(7) with familiar premature ISCVD history (male<55 years, female<65 years). Demographic data of participants were obtained by questionnaire, on-site measurements or screening previous medical records. Results: 67.1% participants (n=2 024) should be recommended to take aspirin as primary prevention medication using 10-year risk of ISCVD≥10% as the criteria, and 77.9% participants (n=2 350) should be recommended to take aspirin as primary prevention medication using number of risk factors≥3 as the criteria. With 10-year risk of ISCVD≥10% as the gold standard and risk factors≥3 as the evaluation criteria, the sensitivity was 97%, specificity was 61%, the consistency rate was 85%, Kappa value was 0.628 (U=35.824, P<0.001) , indicating that the consistency of the 2 criteria was good. The percentage of real-world aspirin use for primary prevention of ISCVD in this cohort was significantly higher for participants evaluated with the 10-year risk of ISCVD≥10% than that evaluated with 3 risk factors (53.1% vs. 49.2%, χ(2)=6.523, P=0.011). 12.7% participants with 10-year risk of ISCVD<10% and 6.6% participants with<3 risk factors took aspirin for the primary prevention of ISCVD in this cohort. Age, smoking, hypertension, diabetes and hypercholesterolemia were significantly related to the aspirin use in this cohort, relative ORs were 1.047 (95%CI 1.035-1.060) , 1.969 (95%CI 1.403-2.762) , 2.065 (95%CI 1.623-3.629) , 3.493 (95%CI 2.726-4.475, and 1.344 (95%CI 1.109-1.628) , respectively. Obesity and familial history of premature ISCVD were not related to the aspirin use, relative ORs were 1.137 (95%CI 0.828-1.562) and 0.986 (95%CI 0.767-1.266) . Conclusions: The consistency of the 2 criteria for decision making of aspirin use for the primary prevention of ISCVD is good and about 50% participants who should be recommended to the use of aspirin for the primary prevention of ISCVD took the aspirin in the real-world scenario. The use of aspirin as primary prevention strategy for ISCVD in the real-world scenario is related to age, smoking, hypertension, diabetes and hypercholesterolemia.

Abstract TP173: Does Cancer Chemotherapy Predispose to Stroke? A Systematic Literature Review

Although the mechanisms are not entirely understood, cancer chemotherapy seems to increase the incidence of stroke and other thromboembolic events. We evaluated stroke incidence among cancer patients that undergo chemotherapy treatment, by conducting a systematic literature review. Studies were identified from Medline and EMBASE. A protocol was developed with a search strategy based on population, intervention, comparators, outcome, and study design criteria (PICOS), where the intervention was cancer chemotherapy and the outcomes included stroke. Quality was assessed using the critical appraisal skills (CASP) guidelines, the majority of studies included were of a cohort design. From 1089 titles, 57 full text articles were assessed for eligibility. After duplicate abstract review, at the end of the screening process 24 studies were identified, and data from 50,613 included participants extracted. The majority of patients were older than 65 years (35,153 participants). One study included all types of cancers, the other studies included only one type of cancer (12 types of cancer in all). Breast (5 studies) and testicular (4 studies) malignancies were the most prevalent. Any drug classified as cancer chemotherapy was included. Some studies clearly named individual drugs while others simply defined the intervention as chemotherapy. Seven studies used platinum-based drugs. Quality assessment using CASP suggested most studies were valid and of good quality. The risk of stroke was reported in 12 studies as a hazard ratio, with values ranging from 0.73 to 2.84 - five of these showed a statistically increased risk of stroke. For studies that reported the outcome as incidence, the values range from 0.14% to 11%. One study reported an odds ratio of 2.3 while another reported a standardised incidence ratio of 1.5. Due to study heterogeneity, a meta-analysis was not performed. Based on the results of individual studies, the evidence supports an increased risk of stroke in cancer patients treated by chemotherapy. Further exploration to identify which agents most increase stroke risk, and to look at other factors (such as primary prevention medication) influencing stroke incidence and outcome in cancer patients will help inform patient choice and clinician practice.