Non-cardiovascular Hospitalizations Research Articles

Use Of Rate And Rhythm Control Drugs In Patients Younger Than 65 Years With Atrial Fibrillation.

Little is known about the use of pharmacologic rhythm or rate control in younger atrial fibrillation (AF) patients in clinical practice. Using commercial health data from 2006 through 2010, patients aged <65 years with an initial AF encounter were categorized as receiving pharmacologic rhythm- or rate-control treatment. Factors associated with each treatment were determined. Cox models with inverse propensity-weighted estimators were used to compare times to AF, heart failure, cardiovascular, non-cardiovascular, and any-cause hospitalizations. Of 79,232 patients meeting the study criteria, 12,408 (16%) received a rhythm-control drug and 66,824 (84%) received only rate-controlling drugs. Only 2% and 0.1%, respectively, received electrical cardioversion and AF ablation during the initial AF encounter. Patients who were men (OR 1.10, 95% CI 1.06-1.15), had index encounters in later years (2010 versus 2006: OR 1.34, 95% CI 1.23-1.45), were in the southern United States, and had other cardiac comorbidities were more likely to receive a rhythm-control drug. There was a greater risk of AF (HR 1.40, 95% CI 1.31-1.50), cardiovascular (HR 1.26, 95% CI 1.20-1.33), and all-cause (HR 1.11, 95% CI 1.07-1.16) hospitalizations in the rhythm-control group, but there was no difference between groups in heart failure (HR 1.01, 95% CI 0.88-1.17) or non-cardiovascular (HR 1.04, 95% CI 0.99-1.09) hospitalizations. Among younger AF patients receiving initial pharmacologic treatment, antiarrhythmic drugs were used less frequently than only rate-controlling drugs, and were associated with a higher risk of subsequent hospitalization.

Cardiovascular polypharmacy is not associated with unplanned hospitalisation: evidence from a retrospective cohort study

BackgroundPolypharmacy is often considered suggestive of suboptimal prescribing, and is associated with adverse outcomes. It is particularly common in the context of cardiovascular disease, but it is unclear whether prescribing of multiple cardiovascular medicines, which may be entirely appropriate and consistent with clinical guidance, is associated with adverse outcome. The aim of this study was to assess the relationship between number of prescribed cardiovascular medicines and unplanned non-cardiovascular hospital admissions.MethodsA retrospective cohort analysis of 180,815 adult patients was conducted using Scottish primary care data linked to hospital discharge data. Patients were followed up for one year for the outcome of unplanned non-cardiovascular hospital admission. The association between number of prescribed cardiovascular medicines and hospitalisation was modelled using logistic regression, adjusting for key confounding factors including cardiovascular and non-cardiovascular morbidity and non-cardiovascular prescribing.Results25.4% patients were prescribed ≥1 cardiovascular medicine, and 5.7% were prescribed ≥5. At least one unplanned non-cardiovascular admission was experienced by 4.2% of patients. Admissions were more common in patients receiving multiple cardiovascular medicines (6.4% of patients prescribed 5 or 6 cardiovascular medicines) compared with those prescribed none (3.5%). However, after adjusting for key confounders, cardiovascular prescribing was associated with fewer non-cardiovascular admissions (OR 0.66 for 5 or 6 vs. no cardiovascular medicines, 95% CI 0.57-0.75).ConclusionsWe found no evidence that increasing numbers of cardiovascular medicines were associated with an increased risk of unplanned non-cardiovascular hospitalisation, following adjustment for confounding. Assumptions that polypharmacy is hazardous and represents poor care should be moderated in the context of cardiovascular disease.

Rate-control versus Rhythm-control Strategies and Outcomes in Septuagenarians with Atrial Fibrillation

BackgroundThe prevalence of atrial fibrillation substantially increases after 70 years of age. However, the effect of rate-control versus rhythm-control strategies on outcomes in these patients remains unclear. MethodsIn the randomized Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 4060 patients (mean age 70 years, range 49-80 years) with paroxysmal and persistent atrial fibrillation were randomized to rate-control versus rhythm-control strategies. Of these, 2248 were 70-80 years, of whom 1118 were in the rate-control group. Propensity scores for rate-control strategy were estimated for each of the 2248 patients and were used to assemble a cohort of 937 pairs of patients receiving rate-control versus rhythm-control strategies, balanced on 45 baseline characteristics. ResultsMatched patients had a mean age of 75 years; 45% were women, 7% were nonwhite, and 47% had prior hospitalizations due to arrhythmias. During 3.4 years of mean follow-up, all-cause mortality occurred in 18% and 23% of matched patients in the rate-control and rhythm-control groups, respectively (hazard ratio [HR] associated with rate control, 0.77; 95% confidence interval [CI], 0.63-0.94; P = .010). HRs (95% CIs) for cardiovascular and noncardiovascular mortality associated with rate control were 0.88 (0.65-1.18) and 0.62 (0.46-0.84), respectively. All-cause hospitalization occurred in 61% and 68% of rate-control and rhythm-control patients, respectively (HR 0.76; 95% CI, 0.68-0.86). HRs (95% CIs) for cardiovascular and noncardiovascular hospitalization were 0.66 (0.56-0.77) and 1.07 (0.91-1.27), respectively. ConclusionIn septuagenarian patients with atrial fibrillation, compared with rhythm-control, a rate-control strategy was associated with significantly lower mortality and hospitalization.

The effects of apixaban on hospitalizations in patients with different types of atrial fibrillation: insights from the AVERROES trial

The aim of this study was to evaluate the effects of apixaban, a novel oral factor Xa inhibitor, on the need for cardiovascular hospitalization. Our analysis is based on data from AVERROES, a randomized double-blind trial testing the efficacy and safety of apixaban against aspirin for the prevention of thrombo-embolism in 5599 atrial fibrillation (AF) patients unsuitable for vitamin K antagonist therapy. Hospitalizations were captured by dedicated case report forms and the outcome variable was time from randomization to the first hospitalization. Effects of treatment with apixaban on the rates of cardiovascular and non-cardiovascular hospitalizations were assessed using Cox proportional hazards regression models. During a mean follow-up of 1.1 years, 800 patients were hospitalized at least once for cardiovascular reasons, 442 (15.4%/year) in the aspirin group, 358 (12.3%) in the apixaban group [hazard ratio (HR) 0.80, 95% confidence interval (CI) 0.69-0.92; P = 0.002]. The reduction in cardiovascular hospitalization in the apixaban arm was predominantly due to a reduction in hospitalization for strokes, but there were also fewer hospitalizations for other cardiovascular causes. Patients with paroxysmal AF were significantly more likely to be hospitalized for AF treatment, whereas more heart failure admissions occurred in patients with permanent AF. Assignment to apixaban was the only independent predictor for a reduction in hospitalization. Cardiovascular hospitalization was the strongest independent predictor of subsequent mortality (HR: 3.95, 95% CI: 3.06-5.09; P < 0.001). In AVERROES, patients on apixaban therapy were less likely to be hospitalized. This may have important consequences for patients' well-being and for healthcare resources. This trial is registered underClinicalTrials.gov number, NCT00496769.

Long-term impact on healthcare resource utilization of statin treatment, and its cost effectiveness in the primary prevention of cardiovascular disease: a record linkage study

AimsTo assess the impact on healthcare resource utilization, costs, and quality of life over 15 years from 5 years of statin use in men without a history of myocardial infarction in the West of Scotland Coronary Prevention Study (WOSCOPS).MethodsSix thousand five hundred and ninety-five participants aged 45–54 years were randomized to 5 years treatment with pravastatin (40 mg) or placebo. Linkage to routinely collected health records extended follow-up for secondary healthcare resource utilization to 15 years. The following new results are reported: cause-specific first and recurrent cardiovascular hospital admissions including myocardial infarction, heart failure, stroke, coronary revascularization and angiography; non-cardiovascular hospitalization; days in hospital; quality-adjusted life years (QALYs); costs of pravastatin treatment, treatment safety monitoring, and hospital admissions.ResultsFive years treatment of 1000 patients with pravastatin (40 mg/day) saved the NHS £710 000 (P < 0.001), including the cost of pravastatin and lipid and safety monitoring, and gained 136 QALYs (P = 0.017) over the 15-year period. Benefits per 1000 subjects, attributable to prevention of cardiovascular events, included 163 fewer admissions and a saving of 1836 days in hospital, with fewer admissions for myocardial infarction, stroke, heart failure and coronary revascularization. There was no excess in non-cardiovascular admissions or costs (or in admissions associated with diabetes or its complications) and no evidence of heterogeneity of effect over sub-groups defined by baseline cardiovascular risk.ConclusionFive years' primary prevention treatment of middle-aged men with a statin significantly reduces healthcare resource utilization, is cost saving, and increases QALYs. Treatment of even younger, lower risk individuals is likely to be cost-effective.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Cardiovascular and non-cardiovascular hospital admissions associated with atrial fibrillation: a Danish nationwide, retrospective cohort study

ObjectiveTo examine the excess risk of hospitalisation in patients with incident atrial fibrillation (AF).DesignA nationwide, retrospective cohort study.SettingDenmark.ParticipantsData on all admissions in Denmark from 1997 to 2009 were collected from...

Abstract P205: Comorbities Predict Future Hospitalization Risk in Incident Myocardial Infarction Survivors

Background: Patients are surviving longer after myocardial infarction (MI), but little is known about the occurrence and predictors of subsequent hospitalizations. Methods: We identified all Olmsted Count residents with incident MI from 1987-2008 and evaluated Olmsted County hospitalizations through 2009. ICD-9 codes were used to determine the primary reason for hospitalization. To account for repeated events, Andersen-Gill models were used to examine the predictors of hospitalization post-MI. Patients were censored at death or last follow-up. Results: A total of 2617 patients (mean 67 years, 41% female, 32% with ST-elevation MI) were diagnosed with incident MI from 1987-2007 and survived MI hospitalization. Over a mean follow-up of 7.1 years, 10116 hospitalizations occurred equating to a median of 3 (range 0 to 43) per person. Only 37.5% (n=3793) of hospitalizations were due to cardiovascular causes, and of these, most were due to ischemic heart disease (n= 1865, 49.2%) and heart failure (n= 733, 19.3%). The proportion of non-cardiovascular hospitalizations increased over time and was higher in women than men, but did not differ by ST-segment status. Several factors were associated with the risk of hospitalization after adjusting for year of diagnosis and sex (Figure). Biomarker levels were not predictors of hospitalization risk. Conclusions: Two-thirds of hospitalizations among incident MI survivors in the community are for non-cardiovascular reasons, and this proportion has increased. Comorbidities are important predictors of recurrent hospitalizations. Therapies focused solely on MI management may be insufficient to prevent the majority of future admissions.

Home-based telemanagement in chronic heart failure: an 8-year single-site experience

During an eight-year period, 358 patients with chronic heart failure (CHF) were enrolled in a six-month home-based telemanagement (HBT) programme. The efficacy of the programme was evaluated in two four-year periods, based on changes in clinical, functional, Quality of Life (QoL) status and rate of hospital readmission. The New York Heart Association (NYHA) class and the number of patients with comorbidities increased significantly in the second period, while the number of patients with beta-blockers decreased significantly (P < 0.01). Following the HBT programme, non-cardiovascular hospital readmission rate and all-cause readmission rate increased by 11% (P < 0.03) and 13% (P < 0.05), respectively. On re-evaluation after six months (238 patients) there was a general improvement in clinical, functional and QoL status and a significant increase in the mean daily dosage of beta-blockers prescribed. Our experience confirms that HBT for patients with CHF is associated with favourable effects on hospital readmission for cardiovascular reasons and on QoL. However, a more comprehensive multidisciplinary approach will probably be required to obtain favourable effects on total morbidity.

Left ventricular dysfunction as a risk factor for cardiovascular and noncardiovascular hospitalizations in African Americans

A substantial portion of the public health burden of heart failure is due to hospitalizations, many of which are for causes other than cardiovascular disease. We assessed whether left ventricular (LV) systolic dysfunction was associated with increased risk of both cardiovascular and noncardiovascular hospitalizations in a community sample of African Americans. African American participants from the Jackson, MS, site of the Atherosclerosis Risk in Communities (ARIC) study who underwent echocardiography were followed for 12 years. Hospitalization rates among individuals with and without LV systolic dysfunction were compared using negative binomial regression. Among 2,416 participants with echocardiograms, LV systolic dysfunction was found in 61 (2.5%). Participants with LV dysfunction experienced 366 hospitalizations, a rate of 1.27 per person-year, compared with 0.25 per person-year among individuals without LV dysfunction. The incidence rate ratio adjusted for demographics, comorbidities, and other risk factors was 3.11 (95% CI 2.22-4.35). The adjusted rate ratios were 4.76 (95% CI 2.90-7.20) for cardiovascular and 2.67 (95% CI 1.82-3.90) for noncardiovascular diagnoses, with similar findings in the subset of individuals with asymptomatic LV dysfunction. The percentage attributable risks for hospitalizations were 87% and 74% for cardiovascular and noncardiovascular causes (79% and 63% after adjustment). African American individuals with LV dysfunction are at an increased risk of hospitalization due to a wide range of causes, with noncardiovascular hospitalizations accounting for nearly half the increased risk. To the extent that estimates of risk focus on cardiovascular morbidity, they may underestimate the true health burden of LV dysfunction.

Transatlantic similarities and differences in major natural history endpoints of heart failure after acute myocardial infarction: A propensity-matched study of the EPHESUS trial

Background Transatlantic differences in outcomes in heart failure after acute myocardial infarction (AMI) have not been examined in propensity-matched studies. Methods In the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS), there were significant imbalances in baseline characteristics between patients from North America ( n = 858) and Europe ( n = 4646). Propensity scores for North America, calculated for each patient using 64 baseline characteristics, were used to assemble 298 pairs of patients who were well balanced on all measured baseline characteristics. Matched Cox regression models were used to estimate transatlantic differences in outcomes. Results There was no transatlantic difference in all-cause mortality during 16 months of mean follow-up of (matched hazard ratio {HR}, 1.00; 95% confidence interval {CI}, 0.64–1.57; P = 1.000). All-cause hospitalization occurred in 175 (rate, 8974/10,000 person-years) and 137 (rate, 5249/10,000 person-years) patients respectively from North America and Europe (matched HR when North America was compared with Europe, 1.89; 95% CI, 1.41–2.52; P < 0.0001). Matched HRs (95% CIs) for cardiovascular and non-cardiovascular hospitalization for North America were respectively 1.35 (0.92–1.97; P = 0.125) and 1.89 (1.31–2.72; P < 0.0001). Among 5504 pre-match patients, unadjusted, multivariable-adjusted, and propensity-adjusted HRs for all-cause hospitalization for North America were 1.52 (95% CI, 1.38–1.68; P < 0.0001), 1.16 (95% CI, 1.02–1.31; P = 0.020), 1.41 (95% CI, 1.17–1.70; P < 0.0001). Conclusion Despite major transatlantic differences in baseline characteristics, there was no difference in post-AMI mortality. The increased non-cardiovascular hospitalization in North America may in part be due to transatlantic differences in patient preferences and access to care.

Abstract 4101: The Effect of Dronaderone on Hospitalizations in Patients with Atrial Fibrillation. Results from the ATHENA Study

The ATHENA study has demonstrated that dronaderone reduces a combined endpoint of cardiovascular hospitalizations and cardiovascular death in patients with paroxysmal or persistent atrial fibrillation or flutter (AF). Two previous studies have demonstrated dronaderone to reduce risk of AF recurrence. Here we examine the impact of dronaderone on hospitalizations. ATHENA is a double-blind, placebo controlled parallel group study. Eligible patients needed to have documented AF as well as documented sinus rhythm within 6 months year prior to randomization. Patients further needed to document increased risk by an age above 75 years or an age above 70 years and additionally either diabetes, prior stroke, hypertension, reduced left ventricular function or an enlarged left atrium. New York heart association class IV was an exclusion criterion. Randomized patients received dronaderone 400 mig bid or matching placebo. Mean follow-up was 21 months. The primary outcome was cardiovascular hospitalization or death. Cardiovascular hospitalization was a secondary outcome. There were 675 first cardiovascular hospitalizations on dronaderone and 859 on placebo, hazard ratio 0.75 (95% cl 0.67– 0.82, p&lt;0.001). The main reasons for first hospitalization on dronaderone/placebo were: AF 296/457, ischemic heart disease 93/102, heart failure 78/92. Overall there were 438/511 cardiovascular hospitalizations not related to AF/AFL, hazard ratio 0.86 (0.75– 0.97, p=0.02). There were 516/533 non-cardiovascular hospitalizations, hazard ratio 0.98 (0.87–1.11, p=0.8). Examining total hospitalization burden (cardiovascular and non-cardiovascular) there were 9995 nights in hospital on dronaderone and 13986 on placebo, a reduction of 28% (p&lt;0.001). For cardiovascular hospitalizations the number of nights were 5875/9073, a reduction of 35% (p&lt;0.001). In patients with paroxysmal or persistent AF dronaderone substantially reduces the risk of cardiovascular hospitalization and substantially reduces total hospitalization burden.

Candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) and resource utilization and costs in Italy

Chronic heart failure (HF) is a major cause of morbidity and mortality particularly in the elderly and a growing healthcare burden in Italy. The objective was to assess the cost-effectiveness of candesartan cilexetil, an angiotensin II type 1 receptor blocker (ARB) for the treatment of HF. A pre-specified economic evaluation was conducted on resource utilization (cardiovascular drug treatment, cardiovascular and non-cardiovascular hospital admission, cardiovascular procedures/operations) prospectively collected alongside the CHARM program, a series of parallel randomized clinical trials comparing candesartan with placebo (standard therapy) in patients with NYHA Class II-IV HF: CHARM-Alternative (LVEF < or =40% patients not receiving ACE inhibitors because of previous intolerance); CHARM-Added (LVEF < or =40% patients currently receiving ACE inhibitors); or CHARM-Preserved (LVEF > or =40% patients). The primary outcome for the component trials was the composite of cardiovascular death or worsening hospital admission for HF and of the overall program all-cause mortality. Adjunctive treatment with candesartan in CHARM-Alternative and CHARM-Added led to clinical benefits and to either cost-savings or a small additional cost, depending on the trial. The less certain clinical benefit in CHARM-Preserved was obtained at modest extra cost. The incremental cost-effectiveness ratios (ICERs) were estimated to range from euro713 per life year gained for CHARM-Alternative to dominant for CHARM-Added and the pooled reduced LVEF trials.

Clinical, Neurohormonal, and Inflammatory Markers and Overall Prognostic Role of Chronic Obstructive Pulmonary Disease in Patients With Heart Failure: Data From the Val-HeFT Heart Failure Trial

Background Chronic obstructive pulmonary disease (COPD) and heart failure are major causes of death and disability. Because little information is available about the population of patients with both syndromes, we assessed the characteristics and the independent contribution of COPD to outcomes in patients with stable chronic heart failure. Methods The clinical, neurohormonal, and echocardiographic characteristics of the 5010 patients enrolled in the Valsartan Heart Failure Trial were compared in patients with or without COPD. The prognostic value of COPD was tested by multivariate Cox proportional hazard models. Results Patients with COPD were older, more symptomatic, and less likely to be receiving beta-blocker therapy, and had a higher mortality (27.4% vs. 18.4%, P < .0001). Echocardiographic parameters were not different, and brain natriuretic peptide was only minimally increased. Norepinephrine, inflammatory markers, cardiac troponin T, and creatinine values were significantly higher. After adjustment, COPD no longer predicted all-cause mortality but remained predictive of noncardiovascular mortality (hazard ratio 2.50; 95% confidence interval: 1.58–3.96; P < .0001) and hospitalizations, especially noncardiovascular (hazard ratio 1.71; 95% confidence interval; 1.43–2.06; P < .0001). Conclusions Patients with COPD are more symptomatic and have worse outcomes that are not explained by poorer left ventricular function. After adjustment for demographic, clinical, biohumoral, and treatment variables, COPD is a weak predictor of all-cause mortality but a strong predictor of noncardiovascular events. Awareness and optimized treatment of heart failure and COPD may reduce the clinical burden of these patients.

Association of Diastolic Dysfunction and Outcomes in Ambulatory Older Adults With Chronic Heart Failure

Studies of patients with heart failure and preserved systolic function report variable outcomes compared with those of patients with impaired systolic function. To study outcomes of diastolic (vs systolic) heart failure in older adults with chronic heart failure. Patients were ambulatory chronic heart failure patients 65 years and older (N = 3984) who participated in the Digitalis Investigation Group trial. Of these, 3405 had systolic heart failure (ejection fraction < or =45%) and 579 had diastolic heart failure (ejection fraction >45%). By using a 1:1 match by age, sex, and race, 571 diastolic heart failure patients were matched with 571 systolic heart failure patients. Kaplan-Meier survival analyses and multivariable Cox proportional hazard analyses were used to estimate the risk of various outcomes between the groups. During the 1044 mean days of follow up, compared with 41% of systolic heart failure patients, 27% of diastolic heart failure patients died (p <.001). Presence of diastolic heart failure was independently associated with a 27% decreased risk of all-cause death (adjusted hazard ratio [HR] = 0.73; 95% confidence interval [CI], 0.58-0.91) and a 32% reduction in risk of hospitalization due to heart failure (adjusted HR = 0.68; 95% CI, 0.52-0.88). There was no difference in overall hospitalization between the groups. However, compared with systolic heart failure patients, diastolic heart failure patients were more likely to be hospitalized due to noncardiovascular causes (adjusted HR = 1.38; 95% CI, 1.02-1.88). Older adults with diastolic heart failure had lower risk of all-cause mortality and heart failure-related hospitalizations, but higher risk of noncardiovascular hospitalization.

Low-dose carvedilol improves left ventricular function and reduces cardiovascular hospitalization in Japanese patients with chronic heart failure: the Multicenter Carvedilol Heart Failure Dose Assessment (MUCHA) trial

Background The efficacy and optimum dose of β-blockers have not been established in Japanese patients with chronic heart failure (CHF). The efficacy and safety of two doses of carvedilol, a β-blocker with vasodilator and antioxidant actions, were investigated in Japanese patients with CHF. Methods After screening and a carvedilol challenge phase, 174 patients with mild to moderate CHF were randomly assigned (double-blinded) to placebo, 2.5 mg of carvedilol twice daily, or 10 mg of carvedilol twice daily. After a 2- to 4-week uptitration phase, maintenance treatment was continued for 24 to 48 weeks. The primary end point was improvement of the global assessment of CHF by the attending physician. Secondary end points were death or hospitalization for cardiovascular disease, cardiovascular hospitalization, hospitalization for heart failure, change of left ventricular ejection fraction, and change in New York Heart Association class. Results Carvedilol therapy achieved dose-dependent improvement of all end points ( P for linear trend, range .002 to <.001). Both carvedilol groups showed marked risk reduction (71% to 91%) for cardiovascular and CHF hospitalization and for death or cardiovascular hospitalization ( P range, .024 to <.001 for pairwise comparisons with placebo). No significant differences were observed for noncardiovascular hospitalization or adverse events. Conclusions In Japanese patients with mild or moderate CHF, carvedilol achieved dose-related improvement of CHF and left ventricular ejection fraction; cardiovascular hospitalization was markedly reduced. At 5 mg/d, carvedilol conferred an important patient benefit, less than at 20 mg/d.

Health care resource utilization among patients starting ACEI and ARB therapy

Medical and pharmacy claims from a database containing more than 2.5 million covered lives were examined to evaluate the costs of outpatient laboratory and physician visits, hospitalizations, and ER visits among patients initiating angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), ACEI-diuretic combination, and ARB-diuretic combination. Continuously enrolled members (1/1/97 to 8/30/99) with at least one ICD-9 diagnosis code for hypertension, no claims for antihpertensive drug in 1997, and at least one claim for an ACEI, ACEI-diuretic, ARB, ARB-diuretic therapy filled between Jan 1, 1998 and August 30, 1999 were followed for 12 months after initial prescription fill. Patient demographics, cardiovascular comorbid conditions and costs of health care utilization (outpatient laboratory and physician visits, hospitalizations, and ER visits) were assessed. There were 3,725 ACEI patients, 426 ACEI-diuretic patients, 1,112 ARB patients, and 302 ARB-diuretic patients identified. The average age of patients in all groups was similar (57-59). The majority of patients starting ACEI and ARB were males (51% and 56%, respectively). Patients starting ACEI-diuretic and ARB-diuretic were mainly females (56% and 53%, respectively). Except for diabetes, baseline cardiovascular comorbid conditions were similar for all drug classes. Diabetes (17.4%) was more prevalent with ACEI patients than were ARB patients (10.8%) and similarly for ACEI-diuretic (12.2%) and ARB-diuretic (5.6%) patients. The average annual total costs of health care utilization per patient were $2551 for ACEI versus $2329 for ARB and $1665 for ACEI-diuretic versus $1411 for ARB-diuretic. Lower cardiovascular and non-cardiovascular hospitalizations contributed to the lower total health care costs associated with ARB therapy. When averaged over all groups, hospitalization accounted for 71.8%; outpatient physician visits accounted for 21.3%; ER visits accounted for 2.4%; and outpatient laboratory accounted for 4.5% of the total costs. This analysis suggests that patients initiating ARB therapy had lower total health care resource utilization costs one year following initiation of therapy.

The effects of pravastatin on hospital admission in hypercholesterolemic middle-aged men : West of Scotland Coronary Prevention Study

OBJECTIVESThe purpose of the study was to assess the effect of lipid reduction with pravastatin on hospital admissions in middle-aged men with hypercholesterolemia in the West of Scotland Coronary Prevention Study.BACKGROUNDA prospective, randomized controlled trial was undertaken in primary care centers in the West of Scotland.METHODSA total of 6,595 participants randomized to receive pravastatin 40 mg or placebo daily were followed up for a mean of 4.9 years (range 3.5 to 6.1 years). Analysis of hospital admissions was undertaken according to the “intention to treat” principle both for cardiovascular diseases and noncardiovascular diseases (including malignant neoplasms, psychiatric diagnoses, trauma and other causes). A secondary analysis of hospitalization in patients who were ≥75% compliant was performed.RESULTSDuring the trial, 2,198 (33%) of the 6,595 men were admitted to hospital on 4,333 occasions, of which 1,234 (28%) were for cardiovascular causes. Pravastatin reduced the number of subjects requiring hospital admission for cardiovascular causes by 21% (95% CI [confidence interval] 9 to 31, p = 0.0008) overall, and by 27% (95% CI 15 to 38) in compliant participants. The number of admissions per 1,000 subject-years for cardiovascular disease was reduced by 10.8 (95% CI 4 to 17.4, p = 0.0013) in all subjects, and by 15.6 (95% CI 8.3 to 23, p < 0.0001) in compliant participants. Pravastatin had no significant influence on hospital admission for any noncardiovascular diagnostic category. There were 13.4 fewer admissions per 1,000 subject-years for all causes in the pravastatin-treated group (95% CI −0.4 to 27.3, p = 0.076). No significant difference in duration of hospital stay was found between the pravastatin and placebo patients in any diagnostic group.CONCLUSIONSPravastatin therapy reduced the burden of hospital admissions for cardiovascular disease, without any adverse effect on noncardiovascular hospitalization.