Statin Therapy For Primary Prevention Research Articles

Factors Associated with Discontinuation of Statin Therapy in Patients with Lymphoma Aged 80 Years and Older: A Retrospective Single-Institute Study.

BackgroundThere is little evidence to support or negate the benefits of statin therapy for primary prevention of cardiovascular disease (CVD) in lymphoma patients aged 80 years or older.ObjectiveWe evaluated comprehensive geriatric assessment (CGA) scores and previously reported risk factors for failure of statin therapy discontinuation in lymphoma patients aged 80 years and older with the aim of identifying those in whom discontinuation of statins for primary CVD prevention is indicated.Patients and methodsOur study cohort comprised 50 patients aged 80 years and older treated with chemotherapy for lymphoma at our institute from January 2011 to July 2020. We retrospectively analyzed the associations between CGA, including Geriatric 8, instrumental activities of daily living, and Charlson comorbidity index, and previously reported factors associated with failure of statin therapy discontinuation, defined as reintroduction of statins after their discontinuation, in this patient cohort.ResultsTwenty years or less of statin therapy was an independent predictor of failure of statin therapy discontinuation (hazard ratio 8.240, 95% confidence interval 1.380–49.10). There were significant differences in the rate of failure of statin discontinuation between patients receiving statins for ≥ 20 years versus < 20 years (p = 0.010). Multivariate analysis of CGA-related scores identified no significant risk factors for failure of statin discontinuation.ConclusionsDiscontinuation of statin therapy may be indicated in lymphoma patients aged 80 years and older who have used statins for 20 years or more.

Interactions Between Statins, Exercise, and Health: A Clinical Update

Interactions Between Statins, Exercise, and Health: A Clinical Update

ESC/EAS guidelines for the detection, prevention, and treatment of individuals at risk of a first myocardial infarction: effect of 5 years of updates and the new SCORE2.

The European Society of Cardiology (ESC) has released three consecutive guidelines within 5 years addressing cardiovascular prevention, risk scores, and cholesterol treatment. This study aims to evaluate whether the 2021 ESC guidelines improved the eligibility of individuals for primary prevention statin therapy before their first ST-segment elevation myocardial infarction (STEMI), and for intensive lipid-lowering treatments in secondary prevention. The cardiovascular risk category of 2757 consecutive individuals admitted for a first STEMI was evaluated to assess whether they would have been eligible for primary prevention statins according to 2021 vs. 2019 and 2016 ESC guidelines. Eligibility for intensive lipid-lowering therapy in secondary prevention was assessed according to the real-life follow-up low-density lipoprotein cholesterol (LDL-C) and the expected follow-up LDL-C. More individuals would have been eligible for primary prevention statins according to 2021 and 2019 vs. 2016 guidelines (61.8% vs. 38.7% vs. 23.6%, P&lt;0.01), a finding observed in both men (62.3% vs. 35.0% vs. 24.9%, P&lt;0.01) and women (60.2% vs. 50.7% vs. 19.3%, P=0.18). Only 27% of individuals reached the LDL-C objective of 55mg/L in secondary prevention: using the ESC stepwise approach, 61.7% were eligible for higher doses of statins, 26.2% for ezetimibe, and 12.1% for a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (PCSK9i). Based on expected LDL-C reductions, eligibility for a PCSK9i in secondary prevention was greater with 2021 vs. 2016 guidelines (44.5% vs. 22.5%, P&lt;0.01). The 2021 ESC guidelines improved the detection and treatment of individuals at risk for a first myocardial infarction. In secondary prevention, 70% of patients kept LDL-C levels above 55mg/dL: increasing the statin dose and adding ezetimibe were the most frequently recommended therapeutic actions.

USPSTF issues draft guidance on statins for primary CVD prevention

The US Preventive Services Task Force has issued draft recommendations on statin therapy for primary prevention of cardiovascular disease. Here’s a look at which patients would benefit, based on the evidence.

Beyond 10-Year Risk: A Cost-Effectiveness Analysis of Statins for the Primary Prevention of Cardiovascular Disease.

Background:Cholesterol guidelines typically prioritize primary prevention statin therapy on the basis of 10-year risk of cardiovascular disease. The advent of generic pricing may justify expansion of statin eligibility. Moreover, 10-year risk may not be the optimal approach for statin prioritization. We estimated the cost-effectiveness of expanding preventive statin eligibility and evaluated novel approaches to prioritization from a Scottish health sector perspective.Methods:A computer simulation model predicted long-term health and cost outcomes in Scottish adults ≥40 years of age. Epidemiologic analysis was completed using the Scottish Heart Health Extended Cohort, Scottish Morbidity Records, and National Records of Scotland. A simulation cohort was constructed with data from the Scottish Health Survey 2011 and contemporary population estimates. Treatment and cost inputs were derived from published literature and health service cost data. The main outcome measure was the lifetime incremental cost-effectiveness ratio, evaluated as cost (2020 GBP) per quality-adjusted life-year (QALY) gained. Three approaches to statin prioritization were analyzed: 10-year risk scoring using the ASSIGN score, age-stratified risk thresholds to increase treatment rates in younger individuals, and absolute risk reduction (ARR)–guided therapy to increase treatment rates in individuals with elevated cholesterol levels. For each approach, 2 policies were considered: treating the same number of individuals as those with an ASSIGN score ≥20% (age-stratified risk threshold 20, ARR 20) and treating the same number of individuals as those with an ASSIGN score ≥10% (age-stratified risk threshold 10, ARR 10).Results:Compared with an ASSIGN score ≥20%, reducing the risk threshold for statin initiation to 10% expanded eligibility from 804 000 (32% of adults ≥40 years of age without CVD) to 1 445 500 individuals (58%). This policy would be cost-effective (incremental cost-effectiveness ratio, £12 300/QALY [95% CI, £7690/QALY–£26 500/QALY]). Incremental to an ASSIGN score ≥20%, ARR 20 produced ≈8800 QALYs and was cost-effective (£7050/QALY [95% CI, £4560/QALY–£10 700/QALY]). Incremental to an ASSIGN score ≥10%, ARR 10 produced ≈7950 QALYs and was cost-effective (£11 700/QALY [95% CI, £9250/QALY–£16 900/QALY]). Both age-stratified risk threshold strategies were dominated (ie, more expensive and less effective than alternative treatment strategies).Conclusions:Generic pricing has rendered preventive statin therapy cost-effective for many adults. ARR–guided therapy is more effective than 10-year risk scoring and is cost-effective.

Predictors of Informed People's Preferences for Statin Therapy to Reduce Cardiovascular Disease Risk: an Internet Survey Study.

Guidelines suggest clinicians inform patients about their 10-year cardiovascular disease (CVD) risk; however, little is known about how the risk estimate influences patients' preferences for statin therapy for primary prevention. To define predictors of preference for statin therapy after participants were informed about their individualized benefits and harms. Cross-sectional survey in 2020. Online US survey panel. A national sample of 304 respondents aged 40 to 75 who had not previously taken a statin and who knew their cholesterol levels and blood pressure measurements. Participants entered their risk factors into a calculator which estimated their 10-year CVD risk. They were then provided with an estimate of their absolute risk reduction with a statin and the chance of side effects from meta-analyses. We used a hierarchical model to predict participants' preferences for statin therapy according to their 10-year CVD risk, perceptions of the magnitude of statin benefit (large, medium, small, or almost no benefit), worry about side effects (very worried, somewhat worried, a little worried, not worried at all), and other variables. Participants had a mean age of 55 years (SD = 9.9); 50% were female, 44% were non-white, and 16% had a high school degree or less education. After reviewing their benefits and side effects, 45% of the participants reported they probably or definitely wanted to take a statin. In the full hierarchical model, only perceived benefits of taking a statin was a significant independent predictor of wanting a statin (OR 7.3, 95% CI 4.7, 12.2). Participants were from an internet survey panel and making hypothetical decisions. Participants' perceptions of their benefit from statin therapy predicted wanting to take a statin for primary prevention; neither estimated CVD risk nor worries about statin side effects were independent predictors.

Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data

SummaryBackgroundIn the prevention of cardiovascular disease, a WHO target is that at least 50% of eligible people use statins. Robust evidence is needed to monitor progress towards this target in low-income and middle-income countries (LMICs), where most cardiovascular disease deaths occur. The objectives of this study were to benchmark statin use in LMICs and to investigate country-level and individual-level characteristics associated with statin use.MethodsWe did a cross-sectional analysis of pooled, individual-level data from nationally representative health surveys done in 41 LMICs between 2013 and 2019. Our sample consisted of non-pregnant adults aged 40–69 years. We prioritised WHO Stepwise Approach to Surveillance (STEPS) surveys because these are WHO’s recommended method for population monitoring of non-communicable disease targets. For countries in which no STEPS survey was available, a systematic search was done to identify other surveys. We included surveys that were done in an LMIC as classified by the World Bank in the survey year; were done in 2013 or later; were nationally representative; had individual-level data available; and asked questions on statin use and previous history of cardiovascular disease. Primary outcomes were the proportion of eligible individuals self-reporting use of statins for the primary and secondary prevention of cardiovascular disease. Eligibility for statin therapy for primary prevention was defined among individuals with a history of diagnosed diabetes or a 10-year cardiovascular disease risk of at least 20%. Eligibility for statin therapy for secondary prevention was defined among individuals with a history of self-reported cardiovascular disease. At the country level, we estimated statin use by per-capita health spending, per-capita income, burden of cardiovascular diseases, and commitment to non-communicable disease policy. At the individual level, we used modified Poisson regression models to assess statin use alongside individual-level characteristics of age, sex, education, and rural versus urban residence. Countries were weighted in proportion to their population size in pooled analyses.FindingsThe final pooled sample included 116 449 non-pregnant individuals. 9229 individuals reported a previous history of cardiovascular disease (7.9% [95% CI 7.4–8.3] of the population-weighted sample). Among those without a previous history of cardiovascular disease, 8453 were eligible for a statin for primary prevention of cardiovascular disease (9.7% [95% CI 9.3–10.1] of the population-weighted sample). For primary prevention of cardiovascular disease, statin use was 8.0% (95% CI 6.9–9.3) and for secondary prevention statin use was 21.9% (20.0–24.0). The WHO target that at least 50% of eligible individuals receive statin therapy to prevent cardiovascular disease was achieved by no region or income group. Statin use was less common in countries with lower health spending. At the individual level, there was generally higher statin use among women (primary prevention only, risk ratio [RR] 1.83 [95% CI 1.22–2.76), and individuals who were older (primary prevention, 60–69 years, RR 1.86 [1.04–3.33]; secondary prevention, 50–59 years RR 1.71 [1.35–2.18]; and 60–69 years RR 2.09 [1.65–2.65]), more educated (primary prevention, RR 1.61 [1.09–2.37]; secondary prevention, RR 1.28 [0.97–1.69]), and lived in urban areas (secondary prevention only, RR 0.82 [0.66–1.00]).InterpretationIn a diverse sample of LMICs, statins are used by about one in ten eligible people for the primary prevention of cardiovascular diseases and one in five eligible people for secondary prevention. There is an urgent need to scale up statin use in LMICs to achieve WHO targets. Policies and programmes that facilitate implementation of statins into primary health systems in these settings should be investigated for the future.FundingNational Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy and Innovation, and National Institute of Diabetes and Digestive and Kidney Diseases.

Guideline based eligibility for primary prevention statin therapy – Insights from the North India ST-elevation myocardial infarction registry (NORIN-STEMI)

Current risk scores to estimate atherosclerotic cardiovascular disease (ASCVD) risk and allocate statins in at-risk persons have largely been developed in Western populations; their applicability in India is uncertain. To assess eligibility for primary prevention statin therapy using the 2018 U.S Multisociety Guideline and other contemporary cholesterol guidelines in patients presenting with ST-elevation myocardial infarction (STEMI) in the North India STEMI (NORIN-STEMI) registry. NORIN-STEMI registry prospectively enrolled 3,635 patients at 2 tertiary care centers in Delhi, India from January 2019 to February 2020. Pooled cohort risk equations were used to estimate ASCVD risk at presentation. Patients were evaluated for statin eligibility using the 2018 U.S Multisociety Guideline, United States Preventive Services Task Force (USPSTF), and National Cholesterol Education Program (NCEP) III cholesterol guidelines. A total of 2,551 met the inclusion criteria. The median age was 54 years; 17% were women. The median ASCVD risk was 7.0%. At the time of MI, 54% of patients were eligible for primary prevention statin therapy by Multisociety Guideline, 46% by USPSTF, and 30% by NCEP III guidelines. These findings were applicable in both women and men. Compared with patients aged ≥50 years, those <50 years were less likely to be recommended statin therapy by all the three guidelines. A significant proportion of patients with STEMI in India did not meet the current guideline-based threshold for statin therapy for primary prevention. Novel risk stratification tools are needed to identify patients for primary prevention statin therapy in this population.

Guidelines versus trial-evidence for statin use in primary prevention: The Copenhagen General Population Study

Background and aimsGuideline-recommended use of risk calculators to select for statin therapy in primary prevention has never been tested in a randomized controlled trial (RCT). We determined the extent to which guideline-based statin recommendations from the American College of Cardiology/American Heart Association (ACC/AHA), Canadian Cardiovascular Society(CCS), UK National Institute for Health and Care Excellence (NICE), and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) is supported by available evidence from RCTs. Methods79,171 individuals from the Copenhagen General Population Study who were free of ASCVD and statin use at baseline were included. RCT evidence supporting guideline-recommended statin allocation and the estimated number needed to treat (NNT) to prevent one ASCVD event were assessed. ResultsDuring 8.2 years of follow-up, 4031 ASCVD events occurred. Of individuals eligible for statin therapy with the ACC/AHA, CCS, NICE and ESC/EAS guidelines, 86%, 88%, 88% and 84% had direct RCT evidence of statin efficacy, respectively (guideline-positive&RCT-positive). This group represented 26–37% of all 79,171 individuals, while guideline-positive&RCT-negative individuals represented 5–7%, guideline-negative&RCT-positive individuals 28–39%, and guideline-negative&RCT-negative individuals represented 30–31%. The ASCVD events per 1000 person-years were 11.4–12.7 (guideline-positive&RCT-positive), 6.3–8.0 (guideline-positive&RCT-negative), 4.2–5.2 (guideline-negative&RCT-positive), and 2.3–2.5 (guideline-negative&RCT-negative), respectively, while the corresponding NNT to prevent one event in 10 years using high-intensity statin were 19–21, 30–32, 48–60, and 105–125, respectively. ConclusionsThe far majority of individuals eligible for guideline-recommended primary prevention with statins have direct RCT evidence supporting statin use. Allocating statins based on guideline-criteria is more efficient with lower NNT for preventing ASCVD events than allocating statin therapy based solely on RCT evidence.

Gaps and Disparities in Primary Prevention Statin Prescription During Outpatient Care

The 2018 American College of Cardiology/American Heart Association Guideline on the Management of Blood Cholesterol recommends statin therapy for eligible patients to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). We extracted electronic health record data for patients with at least one primary care or cardiology visit between October 2018 and January 2020 at an urban, academic medical center in New York City. Clinical and demographic data were used to identify patients eligible for primary prevention statin therapy. Statin prescription status was extracted from the electronic health record, and multivariate logistic regression was used to assess the association between statin prescription and age, gender, race, ethnicity, and other clinical and demographic covariables. In 7,550 patients eligible for primary prevention statin therapy, 3,994 (52.9%) were prescribed statins on at least 1 visit. Statin prescription was highest in patients with diabetes mellitus (73.6%) and with a 10-year ASCVD risk ≥20% (60.6%) and was lowest for those with a 10-year ASCVD risk between 5% and 7.5% (18.7%). Compared with those never prescribed statins, patients prescribed statins were less likely to be women, mainly driven by lower statin prescription rates for women with diabetes. In a fully adjusted model, women remained less likely to be prescribed statin therapy (adjusted odds ratios 0.79, 95% confidence interval 0.71 to 0.88). In conclusion, primary prevention statin therapy remains underutilized.

Statin Intolerance and Noncompliance: An Empiric Approach

Statin Intolerance and Noncompliance: An Empiric Approach

Cardiovascular Disease Risk-Based Statin Utilization and Associated Outcomes in a Primary Prevention Cohort: Insights From a Large Health Care Network.

Current American College of Cardiology/American Heart Association guidelines recommend using the 10-year atherosclerotic cardiovascular disease (ASCVD) risk to guide statin therapy for primary prevention. Real-world data on adherence and consequences of nonadherence to the guidelines in primary are limited. We investigated the guideline-directed statin intensity (GDSI) and associated outcomes in a large health care system, stratified by ASCVD risk. Statin prescription in patients without coronary artery disease, peripheral vascular disease, or ischemic stroke were evaluated within a large health care network (2013-2017) using electronic medical health records. Patient categories constructed by the 10-year ASCVD risk were borderline (5%-7.4%), intermediate (7.5%-19.9%), or high (≥20%). The GDSI (before time of first event) was defined as none or any intensity for borderline, and at least moderate for intermediate and high-risk groups. Mean (±SD) time to start/change to GDSI from first interaction in health care and incident rates (per 1000 person-years) for each outcome were calculated. Cox regression models were used to calculate hazard ratios for incident ASCVD and mortality across risk categories stratified by statin utilization. Among 282 298 patients (mean age ≈50 years), 29 134 (10.3%), 63 299 (22.4%), and 26 687 (9.5%) were categorized as borderline, intermediate, and high risk, respectively. Among intermediate and high-risk categories, 27 358 (43%) and 8300 (31%) patients did not receive any statin, respectively. Only 17 519 (65.6%) high-risk patients who were prescribed a statin received GDSI. The mean time to GDSI was ≈2 years among the intermediate and high-risk groups. At a median follow-up of 6 years, there was a graded increase in risk of ASCVD events in intermediate risk (hazard ratio=1.15 [1.07-1.24]) and high risk (hazard ratio=1.27 [1.17-1.37]) when comparing no statin use with GDSI therapy. Similarly, mortality risk among intermediate and high-risk groups was higher in no statin use versus GDSI. In a real-world primary prevention cohort, over one-third of statin-eligible patients were not prescribed statin therapy. Among those receiving a statin, mean time to GDSI was ≈2 years. The consequences of nonadherence to guidelines are illustrated by greater incident ASCVD and mortality events. Further research can develop and optimize health care system strategies for primary prevention.

Implications of the 2019 American College of Cardiology/American Heart Association Primary Prevention Guidelines and potential value of the coronary artery calcium score among South Asians in the US: The Mediators of Atherosclerosis in South Asians Living in America (MASALA) study

Background and aimsSouth Asian (SA) ethnicity is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). However, the implications of considering SA ethnicity as a “risk-enhancing factor” per recent American College of Cardiology/American Heart Association guidelines are not fully understood. MethodsWe used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, a community-based cohort study of individuals of SA ancestry living in the US. The Pooled Cohort Equations were used to estimate 10-year ASCVD risk. Metabolic risk factors and coronary artery calcium (CAC) scores were assessed. ResultsAmong 1114 MASALA participants included (median age 56 years, 48% women), 28% were already using a statin at baseline, 25% had prevalent diabetes, and 59% qualified for 10-year ASCVD risk assessment for statin allocation purposes. The prevalence of low, borderline, intermediate, and high estimated ASCVD risk was 65%, 11%, 20% and 5%, respectively. Among participants at intermediate risk, 30% had CAC = 0 and 37% had CAC>100, while among participants at borderline risk, 54% had CAC = 0 and 13% had CAC>100. Systematic consideration of intermediate and, particularly, of borderline risk individuals as statin candidates would enrich the statin-consideration group with CAC = 0 participants up to 35%. Prediabetes and abdominal obesity were highly prevalent across all estimated risk strata, including among those with CAC = 0. ConclusionsOur findings suggest that systematic consideration of borderline risk SAs as statin candidates might result in considerable overtreatment, and further risk assessment with CAC may help better personalize statin allocation in these individuals. Early, aggressive lifestyle interventions aimed at reducing the risk of incident diabetes should be strongly recommended in US SAs, particularly among those considered candidates for statin therapy for primary prevention. Longitudinal studies are needed to confirm the favorable prognosis of CAC = 0 in SAs.

454 ASSOCIATION BETWEEN STATINS AND MAJOR ADVERSE CARDIAC EVENTS AMONG OLDER ADULTS WITH FRAILTY: A SYSTEMATIC REVIEW

Abstract Background Statins reduce the risk of major adverse cardiovascular events (MACE), however, their clinical benefit for primary and secondary prevention among older adults with frailty is uncertain. This review investigates whether statins prescribed for primary and secondary prevention are associated with reduced MACE among adults aged ≥65 years with frailty. Methods Systematic review of studies published between 01.01.1952 and 01.01.2019 in MEDLINE, Embase, Scopus, Web of Science, Cochrane Library and the International Pharmaceutical Abstracts. Studies that investigated the effect of statins on MACE among adults ≥65 years with a validated frailty assessment were included. Data were extracted from the papers as per a pre-published protocol, PROSPERO: CRD42019127486. Risk of bias was assessed using the Cochrane Risk of Bias in non-randomised studies of interventions. Finding 18794 abstracts were identified for screening. From these, six cohort studies fulfilled the inclusion criteria. There were no randomised clinical trials. Of studies involving statins for primary and secondary prevention (n = 6), one found statins were associated with reduced mortality (hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.37–0.93) and another found they were not (p = 0.73). One study of statins used for secondary prevention found they were associated with reduced mortality (HR 0.28, 95%CI 0.21–0.39). No studies investigated the effect of statins for primary prevention or the effect of statins on the frequency of MACE. Discussion This review summarizes the existing available evidence for decision making for statin prescribing for older adults with frailty. This study identified only observational evidence that, among older people with frailty, statins are associated with reduced mortality when prescribed for secondary prevention, and an absence of evidence evaluating statin therapy for primary prevention. The findings of this study highlight that randomised trial data are urgently needed to better inform the use of statins among older adults living with frailty.

Adherence and prescription of statin therapy in primary prevention in primary care unit

Adherence and prescription of statin therapy in primary prevention in primary care unit

Patient Preference Distribution for Use of Statin Therapy

Thresholds for initiating statin therapy should be informed by patients' preferences. To define the preference distribution for statin therapy across the spectrum of cardiovascular disease (CVD) risk after participants were informed about the benefits and harms of statin therapy. A cross-sectional survey was conducted from May 13 to June 2, 2020. Participants included 304 individuals aged 40 to 75 years drawn from a nonprobability opt-in panel who had not taken a statin or proprotein convertase subtilisin/kexin type 9 inhibitor in the past 3 years and knew the results of their total cholesterol, high-density lipoprotein cholesterol, and blood pressure measurements. Personalized 10-year CVD risk with and without statin therapy and potential harms of statins. The primary outcome was self-reported preference for statin therapy. The 304 participants had a mean (SD) age of 54.8 (9.9) years; 152 were women (50.0%), 130 (42.8%) non-White, 50 (16.6%) had a high school degree or less education, and 153 (50.8%) reported never needing help reading health materials. When asked their preference for using statin therapy after reviewing their benefit and risk information, 45% of the participants reported they would definitely or probably choose statin therapy. As the risk increased, the proportion who would choose statin therapy generally increased (from 31.1% for a risk <5% to 82.6% for a risk >50%). The minimum risk threshold had to increase to 20% before 75% of respondents in that risk group would want statin therapy. For participants with a risk greater than 10%, the desire to use statin therapy decreased as participants' health literacy, subjective numeracy, and knowledge scores increased. In this study, preferences for statin therapy for primary prevention of CVD appeared to vary across the spectrum of 10-year cardiovascular risk, but they were relatively flat at intermediate levels of risk. This preference distribution suggests a broad risk range for shared decision-making.

Cost-Effectiveness of Coronary Artery Calcium Scoring in People With a Family History of Coronary Disease

ObjectivesTo assess the cost effectiveness of coronary artery calcium (CAC) compared with traditional risk factor–based prediction alone in those with an family history of premature coronary artery disease (FHCAD). BackgroundThe use of CAC scoring to guide primary prevention statin therapy in those with a FHCAD is inconsistently recommended in guidelines, and usually not reimbursed by insurance. MethodsA microsimulation model was constructed in TreeAge Healthcare Pro using data from 1,083 participants in the CAUGHT-CAD (Coronary Artery Calcium Score: Use to Guide Management of HerediTary Coronary Artery Disease) trial. Outcomes assessed were quality-adjusted life years (QALYs): cost-effectiveness was assessed over a 15-year time horizon from the perspective of the US health care sector using real-world statin prescribing, accounting for the effect of knowledge of subclinical disease on adherence to guideline-directed therapies. Costs were assessed in 2020 USD, with discounting undertaken at 3%. ResultsStatins were indicated in 45% of the cohort using the CAC strategy and 27% using American College of Cardiology/American Heart Association (2019) treatment strategies. Compared with applying a statin treatment threshold of 7.5%, the CAC strategy was more costly ($145) and more effective (0.0097 QALY) with an incremental cost-effective ratio (ICER) of $15,014/QALY. CAC ICER was driven by CAC acquisition and statin prescription cost and improved with certain patient subgroups: male, age >60 years, and 10-year risk pooled cohort equation risk ≥7.5%. CAC scanning of low-risk patients (10-year risk <5%) or those 40 to 50 years of age was not cost-effective. ConclusionsSystematic CAC screening and treatment of those with FHCAD and subclinical disease was more cost-effective than management using statin treatment thresholds, in the US health care system.

Statin therapy for primary cardiovascular prevention in adults older than 75 years.

Cardiovascular disease (CVD) is a major contributor to morbidity and mortality worldwide. An abundance of research demonstrated that low‑density lipoprotein cholesterol (LDL‑C) is an important risk factor for CVD that can be modified with the drug class hydroxymethylglutaryl‑CoA reductase inhibitors, or statins.Statins have an unequivocal benefit in reducing CVD risk across age groups for secondary prevention. However, the benefit of these drugs for primary prevention in adults older than 75 years of age remains equivocal and controversial. The global population is aging rapidly and primary CVD prevention recommendations to guide statin therapy above the age of 75 years are necessary. However, current trends in statin therapy illustrate that it is underutilized for primary prevention in that age group. Concerns exist regarding the higher incidence of common adverse events from statin use in the older population; however, there are no confirmatory data regarding these associations. In the light of available evidence, it is reasonable to offer statin therapy for primary prevention to all older individuals following a shared decision‑making process that takes life expectancy, polypharmacy, frailty, and potential adverse effects into consideration. Combination therapies with other agents for the management of dyslipidemia should be considered to facilitate the use of tolerable doses of statins. Future investigations of dyslipidemia therapies must appropriately include this at‑risk population to identify optimal drugs and drug combinations that have a high benefit‑to ‑risk ratio for the prevention of CVD in the very old.

Statin Therapy for Primary Prevention in the Elderly and Its Association with New-Onset Diabetes, Cardiovascular Events, and All-Cause Mortality

PurposeThis study assessed associations of the use of statins for primary prevention with cardiovascular outcomes among adults ages ≥70 years. MethodsIn a retrospective population-based cohort study, new users of statins without cardiovascular disease or diabetes mellitus were stratified by ages ≥70 years and <70 years. Using a time-dependent approach, adherence to statins was evaluated according to the proportion of days covered: <25%, 25%-50%, 50%-75%, and ≥75%. We assessed associations of statin therapy with increased risk of new-onset diabetes mellitus and with decreased risks of major adverse cardiovascular events and all-cause mortality. ResultsOf 42,767 new users of statins, 5970 (14%) were ages ≥70 years. The incident rates of major adverse cardiovascular events, all-cause mortality, and new-onset diabetes mellitus in the highest to lowest proportion of days covered categories were 16.9%, 16.7%, and 9.4% and 6.3%, 1.7%, and 9.4%, respectively. For the older group, the adjusted hazard ratios of major adverse cardiovascular events and mortality were significantly decreased for the highest adherence group (proportion of days covered ≥75%): 0.71 (0.57-0.88) and 0.68 (0.54-0.84), respectively. The respective hazard ratios were less favorable for the younger group: 0.80 (0.68-0.93) and 0.74 (0.58-1.03). The risk of new-onset diabetes mellitus was increased for the younger but not the older group. ConclusionsStatin use for primary prevention was associated with cardiovascular benefit in adults ages ≥70 years without a significant risk for the development of diabetes. These data may support the use of statin therapy for primary prevention in the elderly.

Abstract 17321: Guideline Recommended Statin Therapy Implementation and Cardiovascular Outcomes: Insights From a Multi-Site Healthcare Primary Prevention Cohort

Background: The 2013 and 2018 ACC/AHA cholesterol guidelines recommend using the 10-year ASCVD risk to guide statin therapy for primary prevention. Evidence of real-world consequences of non-adherence to these guidelines in primary prevention cohorts is limited. We investigated outcomes based on statin use in a large healthcare system, stratified by 10y ASCVD risk. Methods: Statin prescription practices in patients without CAD or ischemic stroke were evaluated ( 2013-2019). Patient categories constructed per the ASCVD risk were; Borderline (5%-7.4%), Intermediate (7.5%-19.9%) or High (≥20%). Guideline-directed statin intensity (GDSI) , at time of first event, was defined as; “none or any intensity” for borderline , “at least moderate” for Intermediate and high -risk groups. Mean (±SD) time to start/change to GD therapy from first interaction in healthcare, ASCVD incident rates [IR] and mortality were calculated across risk categories stratified by statin utilization. Results: Among 282,298 patients (mean age ~50y), 29,134 (10.3%), 63,299 (22.4%) and 26,687 (9.5%) were borderline, intermediate and high risk, respectively. Within intermediate-risk, 27,358 (43%) and 8,300 (31%) of high-risk never received any statin. Only 17,519 (65.6%) high-risk subjects who were prescribed statin, received GDSI [mean time ~1.8y]. A graded increase in ASCVD and mortality IRs was seen in all risk categories comparing statin versus no statin use (Table). Conclusions: In a multi-site healthcare network, over one-third of statin-eligible patients were not prescribed statin therapy. In eligible patients, who ultimately received statins, mean time to GDSI was ~2yrs. The consequences of non-adherence to guidelines is illustrated with greater incident ASCVD events and mortality among those patients not treated with statin therapy. Further research can define identify barriers and develop healthcare system strategies to optimize preventive therapies.