Statins For Secondary Prevention Research Articles

Statin Therapy for the Prevention of Atrial Fibrillation: A Meta‐analysis of Randomized Controlled Trials

To assess the efficacy of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) for primary and secondary prevention of atrial fibrillation, and to evaluate the efficacy of individual statins and their dosages. Meta-analysis of 20 randomized controlled trials. A total of 32,311 patients who received either a statin (16,203 patients) or a placebo or active control regimen (16,108 patients) for either primary or secondary prevention of atrial fibrillation as part of a research study. A systemic literature search of MEDLINE, EMBASE, and the Cochrane Controlled Trials Register was performed to identify randomized controlled trials involving the prevention of atrial fibrillation with statin therapy. Effect size was expressed as odds ratio (OR) with 95% confidence interval (CI). Subgroup analysis was performed to explore the reasons for heterogeneity. Of the 20 trials, atorvastatin was studied in 11, pravastatin in five, rosuvastatin in three, and simvastatin in one. Overall, among the 32,311 patients in these trials, the risk of atrial fibrillation was significantly reduced by statins (OR 0.59, 95% CI 0.45-0.76), and the drugs were effective for both primary prevention (OR 0.67, 95% CI 0.51-0.88) and secondary prevention (OR 0.40, 95% CI 0.20-0.83). Secondary prevention was not superior to primary prevention, however. A significant benefit was observed in the atorvastatin-treated subgroup (OR 0.43, 95% CI 0.27-0.66), especially in the dose range of 10-40 mg/day (OR 0.29, 95% CI 0.19-0.45). No protective effect was observed in the pravastatin subgroup (OR 1.03, 95% CI 0.77-1.37). This meta-analysis suggests that statin therapy is useful for the prevention of atrial fibrillation. The benefit of statins in secondary prevention was significant but not superior to primary prevention. Atorvastatin was more effective than pravastatin, and its effects were dose related, with lower doses being more effective. The number of trials focusing on individual drugs is still insufficient, and more randomized controlled trials are necessary to further support these conclusions.

Abstract P132: QUICC: Quality Initiative to Improve Cholesterol Care

Background: An initial quality audit identified areas of improvement in cholesterol management for diabetic patients. The goal of this project was to assess the success of targeted quality improvement (QI) initiatives regarding evidence based cholesterol management in this population. Methods: Following an initial QI audit the following actions were initiated (~01/2008): clinician education, clinical notes added to disease management database, and electronic medical records critical alerts placed on diabetic patient records regarding cholesterol treatment (prescribing and goal attainment). Eighteen months following the implementation of these initiatives, a retrospective chart review was conducted with identical methodology as the initial QI audit. Inclusion criteria were: diabetic patients aged 18 - 89 years seen in a comprehensive lipid clinic within the past year. Objectives included the change in percent of patients receiving cholesterol medication according to ADA guidelines and change in percent of patients at LDL goal, per NCEP guidelines. T-test was used to analyze data. Results: Fifty-six patients included in this analysis were compared to 134 patients from the baseline analysis. Average age of this population was 66 ± 11 years, 54% (30/56) were male, and 77% (43/56) had coronary disease. There were no differences in demographics between groups. Results of the current data demonstrate cholesterol prescribing according to guidelines was seen in 98% (55/56) of patients overall; 98% (47/48) of patients receiving statins for secondary prevention, and 100% (8/8) of patients receiving statins for primary prevention. These results are significantly higher compared to baseline data where 81% (109/134), 84% (86/102), and 72% (23/32) of patients, respectively, received medication according to guidelines, p<0.05 for all comparisons. In addition, a significantly higher percent of patients achieved LDL goal < 100 mg/dL (71%; 40/56) in this analysis compared to the baseline analysis (61%; 82/134), p<0.05. Conclusions: These data demonstrate that QI initiatives, including education, electronic database management, and clinical alerts positively impacts evidence-based prescribing and cholesterol goal attainment in diabetic patients.

Current status of statin therapy for stroke prevention

Stroke is a leading cause of mortality and long-term disability in the Western world. Lipid abnormalities are a key risk factor for stroke, elevated LDL-cholesterol being the most common abnormality. No clear association has been demonstrated between elevated LDL-cholesterol and stroke incidence, possibly due to the lack of appropriate etiopathophysiological classification of stroke in most studies. Nonetheless, statin therapy is associated with significant reduction in first and recurrent stroke, and there remains a net benefit despite a significant but small increase in hemorrhagic stroke. Following a stroke, indirect evidence supports continuation of prestroke statin therapy while the impact of de novo statin therapy in acute stroke remains uncertain. International guidelines advise an objective assessment of cardiovascular risk to determine the appropriateness of statins for primary prevention and near universal use of statins for secondary prevention after the acute phase of ischemic stroke. There is lack of consensus with regard to the choice of agent, timing of initiation, dose and duration of therapy. Some guidelines advocate high-dose atorvastatin while others suggest the use of simvastatin owing to generic availability and low cost. While the benefits of preventive interventions for stroke are well established and clearly outlined in international guidelines, there is poor application of such measures in clinical practice. This article summarizes the current understanding of the role of statins in stroke prevention and early studies of potential interventions to overcome the barriers to effective statin therapy for secondary prevention. There is a clear need for further research into identifying deficiencies in long-term management, barriers to optimal secondary prevention and novel interventions to overcome these barriers.

Gender-Specific Aspects in Primary and Secondary Prevention of Cardiovascular Disease

Gender differences in biological substrates of disease determine different clinical manifestations of CV disease with important implications for prevention, diagnosis and therapy in the two sexes. In women, the activity of sex hormones reduces the influence of CV risk factors during the reproductive age, and delays the onset of CHD of 2 decades compared to men. However, women as men suffer from CV events, and in women mortality from all CV causes and have greater than the sum of the others 7 causes of death together. Women are more likely than men to die of a first myocardial infarction a probability of developing heart failure or a second infarction than their male counterparts. The levels of lipid components vary in different ages of life and in the two genders. TC and LDL increase in men between 35 and 50 years of age. On the contrary LDL levels do not change significantly in fertile women in which they have a lower predictive value for CHD than in men, HDL levels are higher in premenopausal women than in men of the same age and their role in predicting CHD is considerably higher in women. High triglycerides and Lp(a) are more important as a risk factor in women than in men. Because of the greater incidence of cardiovascular diseases in men until the early 80s, the information about the importance of risk factors associated with an increased risk of cardiovascular events has been gathered mainly in men and transferred to women. Most studies on lipid-lowering therapy did not have the adequate statistical power to show significant reductions in CV events in women. Regarding the indications for use of statins in daily practice, current data suggest that in secondary prevention statins are equally effective in both genders while in primary prevention the CV benefits of lipid-lowering therapy in women are less clear than in men and therefore should be used according to the degree of risk calculated from the available score systems.

Statins utilisation pattern: a retrospective evaluation in a tertiary care hospital in Thailand

To determine statin usage pattern and evaluate whether new generation statins are actually needed by the patients receiving them. This retrospective cohort included patients receiving first-time statins at a tertiary care hospital in Thailand. Using electronic medical records from 2005, its indication was determined based on history of coronary heart disease (CHD) and CHD-risk equivalents. The lipid profiles tested within 30 days prior to the first date of statins prescription were analysed. Each patient was assessed as to whether statin was needed based on low-density lipoprotein cholesterol (LDL-C) reduction capacity and lipid goals. A total of 2479 first-time statin users was included. Ninety percent of the users received simvastatin, while 8% and 2% received atorvastatin and pravastatin respectively. More than half (58.0%) used statins for primary prevention, although all usage of atorvastatin was considered not needed. Considering the use of statin for secondary prevention to achieve the LDL-C goal of <130mg/dl (3.37mmol/l), more than 80% of atorvastatin users could be switched to simvastatin. Only 8% of simvastatin usage would not be able to achieve this target. When the LDL-C goal was <70mg/dl (1.81mmol/l), 40.2% simvastatin users was considered appropriate, while 58.6% needed atorvastatin to be prescribed. A substantial proportion of patients did not need statins therapy, particularly for primary prevention. In addition, atorvastatin use is mostly not needed except in patients requiring statins for secondary prevention to achieve the LDL-C goal of <70mg/dl (1.81mmol/l). The findings should prompt hospital policy makers to develop measures to ensure the proper use of statins in their clinical settings.

Statins for secondary prevention: might less in fact be more?

Statin therapy following myocardial infarction is a pillar of the secondary prevention approach. However, defining a maximally beneficial dosing strategy requires attention to both cardiovascular outcomes and to the potentially unsavory clinical adverse effects of high-dose therapy.

Use of high-intensity statin therapy with simvastatin 80 mg and atorvastatin 80 mg in primary care

Cardiovascular disease (CVD) is the most common cause of death worldwide. Pharmaceutical risk reduction with high-intensity statin therapy is advisable for high-risk patients. Clinicians face a conflict between prescribing for cost (simvastatin 80 mg) or for efficacy (atorvastatin 80 mg). The aim of this audit was to examine the use, efficacy and tolerability of high intensity statin treatment (simvastatin 80 mg; atorvastatin 80 mg) in primary care. Electronic medical records were examined from two general practitioners' surgeries. Analyses involved Mann-Whitney U and χ(2) tests. A total of 116 patients had taken simvastatin 80 mg or atorvastatin 80 mg. Patients were similar between treatment groups: mostly men (62.9%), over 60 years old (68.1%), non-smokers (81.0%) taking statins for secondary prevention (56.9%). More patients on simvastatin withdrew from treatment as a result of inefficacy (49.3% vs. 23.2%, p=0.025) compared with the atorvastatin group. Furthermore, patients on simvastatin were more likely to be failing conventional targets of lipid control, compared with patients on atorvastatin 80 mg (43.5% vs. 21.3%, p=0.006). Tolerability was similar between the two groups. UK guidelines recommend simvastatin 80 mg as an economic choice, despite scant evidence at this dose and recent safety concerns. Conversely, robust evidence exists for atorvastatin 80 mg. Head-to-head clinical trials or clinical studies comparing these agents are lacking. The present study suggests that atorvastatin 80 mg compares favourably to simvastatin in terms of efficacy and has a similar tolerability profile. This retrospective observational study suggests that despite national guidelines, atorvastatin 80 mg is used in clinical practice and is more effective and at least as well tolerated as simvastatin 80 mg.

E0297 Treatment of statins in secondary prevention of high risk coronary heart disease in Chinese—BRIG study

PurposeTo determine in patients with established coronary heart disease (CHD) whether the guidelines recommendations on secondary prevention of CHD are being followed.Methods64 hospitals across 31 provinces of China, including 32...

Impacts of stroke clinics on the utilization of statins for secondary prevention of ischemic stroke

To describe the impact of stroke clinic on the usage of statins for secondary prevention of ischemic stroke. Data about the demography, social economic status, personal histories, blood lipid profiles, and the status of the usage of statins from 568 serial ischemic stroke patients were retrospectively analysed. A total of 51.3% patients followed up in stroke clinic (306 patients) and 7.6% patients followed up in general clinic (262 patients) were treated with statins. 71.6% patients with and 44.8% patients without hyperlipidemia in stroke clinics were taking statins, which were higher than that patients in the general clinics (27.1% and 2.0% respectively). The patients in the stroke clinics with high LDL-C level (>3.4 mmol/L) were more likely to be treated with statins than those with lower level (25.6% vs 14.7%, P=0.017). The rate of statins usage is extremely low in stroke patients followed up in a general clinic, but it can been improved greatly in a stroke clinic. Stroke clinic can narrow the gap between the clinical practice and the guideline for secondary prevention of ischemic stroke.

What the Saskatchewan Roughriders Have Taught Me about Pharmacy

JCPH – Vol. 63, n 2 – mars–avril 2010 184 many fans were “looking for blood”, the coach’s actions calmed us down and reinstated our faith in the team. Similarly, in pharmacist practice, we must all take responsibility for our actions. This attitude helps to ensure that we maintain the respect of our patients and other health care professionals. Little Plays Make a Difference: Whether it is conceding a single point in a football game or suggesting a statin for secondary prevention, little plays can add up significantly over time. We need to make the most of every situation. Attention to Detail: Whether counting players on the field or noticing trends in potassium levels, paying attention to detail is vitally important. Pride, Passion, and Inspiration: The Rider Nation can make a difference to players’ morale with hats made of real watermelons, green Rider jerseys, a 6-foot gopher, flags, and face paint. In pharmacy, with all of us supporting and advocating for our profession by showing our “professional colours”, we can make a difference to our profession and our patients! As I anticipate what lies ahead for our profession, I am overcome with excitement. Perhaps the dawn of a “Pharmacist Nation” is on the horizon. I wonder . . . what food should we wear on our heads?

Lipid reduction in acute coronary syndrome: How much, when, and how?

The use of statins for secondary prevention after acute coronary syndrome is well established. In recent years, trials have investigated the dose of statins used and timing of administration. Initiation of statin therapy as early as 1 day after an acute coronary syndrome event has been shown to be effective in reducing major adverse cardiovascular events. The benefit of early statin use is linked to reduction in inflammation and increased compliance with therapy. In addition, intensive therapy further reduces events and inflammation, as reflected by decreased C-reactive protein. Given the findings of these recent studies, early and intensive lipid-lowering therapy with a statin is justified and safe.

Evidence-based medicine within a budget - where should we spend our money?

Evidence-based medicine within a budget - where should we spend our money?

Statins in primary prevention:should we ignore the zealots?

AbstractDr Stephen Banham warns of the potential dangers of extending the known benefits of using statins in secondary prevention of cardiovascular disease to widespread primary prevention. Copyright © 2009 Wiley Interface Ltd

Cost-Effectiveness of Treatments Reducing Coronary Heart Disease Mortality in Ireland, 2000 to 2010

Objective Coronary heart disease (CHD) is associated with a large burden of disease in Ireland and is responsible for more than 6000 deaths annually. This study examined the cost-effectiveness of specific CHD treatments in Ireland. Methods Irish epidemiological data on patient numbers and median survival in specific groups, plus the uptake, effectiveness, and costs of specific interventions, all stratified by age and sex, were incorporated into a previously validated CHD mortality model, the IMPACT model. This model calculates the number of life-years gained (LYGs) by specific cardiology interventions to generate incremental cost-effectiveness ratios (ICERs) per LYG for each intervention. Results In 2000, medical and surgical treatments together prevented or postponed approximately 1885 CHD deaths in patients aged 25 to 84 years, and thus generated approximately 14,505 extra life-years (minimum 7270, maximum 22,475). In general, all the cardiac interventions investigated were highly cost-effective in the Irish setting. Aspirin, beta-blockers, ACE inhibitors, spironolactone, and warfarin for specific conditions were the most cost-effective interventions (<€3000/LYG), followed by the statins for secondary prevention (<€6500/LYG). Revascularization for chronic angina and primary angioplasty for myocardial infarction, although still cost-effective, had the highest ICER (between €12,000 and €20,000/LYG). Conclusions Using a comprehensive standardized methodology, cost-effectiveness ratios in this study clearly favored simple medical treatments for myocardial infarction, secondary prevention, angina, and heart failure.

Targeted versus global approaches to the management of hypercholesterolaemia

The role of statins in secondary prevention of cardiovascular disease is well established. However, there is debate about the most effective approach to primary prevention. This study simulated the effects of directed versus global approaches for intervention on coronary heart disease (CHD) event rates. A primary prevention population was generated by computer simulation derived from data from the National Health Survey for England. The efficacy of reductions in cholesterol, treatment to cardiovascular risk targets and effects of phytosterols or statins were assessed. A 0.5 mmol/L reduction in population total cholesterol would result in a 10.4% reduction in CHD events, while 1.0 mmol/L, 1.5 mmol/L and 2.0 mmol/L reductions would achieve 21.0%, 30.6% and 41.9% reductions respectively. In statin-based cardiovascular risk targeted strategies, use of simvastatin 40 mg would result in 1.8% reduction by UK National Service Framework targets of 30%/decade CHD risk and 7.2% reduction in events for a 20%/decade target assuming perfect adherence. Similarly, aggressive primary prevention with 40 mg atorvastatin would result in a 2.5% or 10% reduction in events. Universal use of 10 mg simvastatin following an over-the-counter approach would result in a 25% reduction in CHD events. In contrast, whole population consumption of sitostanol/sitosterol products would result in 11.8% reduction. Targeting and treating high-risk individuals may be beneficial for them and rewarding for medical practitioners. However, this approach has minimal effects on the population burden of atherosclerotic disease. This study suggests that universal therapy with phytosterols and/or wider availability of statins has the potential to dramatically decrease rates of CHD.

Statins for Secondary Prevention in Elderly Patients: A Hierarchial Bayesian Meta-Analysis

Statins for Secondary Prevention in Elderly Patients: A Hierarchial Bayesian Meta-Analysis

Statins for Secondary Prevention in Elderly Patients: A Hierarchical Bayesian Meta-Analysis

This study was designed to determine whether statins reduce all-cause mortality in elderly patients with coronary heart disease. Statins continue to be underutilized in elderly patients because evidence has not consistently shown that they reduce mortality. We searched 5 electronic databases, the Internet, and conference proceedings to identify relevant trials. In addition, we obtained unpublished data for the elderly patient subgroups from 4 trials and for the secondary prevention subgroup from the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) trial. Inclusion criteria were randomized allocation to statin or placebo, documented coronary heart disease, > or =50 elderly patients (defined as age > or =65 years), and > or =6 months of follow-up. Data were analyzed with hierarchical Bayesian modeling. We included 9 trials encompassing 19,569 patients with an age range of 65 to 82 years. Pooled rates of all-cause mortality were 15.6% with statins and 18.7% with placebo. We estimated a relative risk reduction of 22% over 5 years (relative risk [RR] 0.78; 95% credible interval [CI] 0.65 to 0.89). Furthermore, statins reduced coronary heart disease mortality by 30% (RR 0.70; 95% CI 0.53 to 0.83), nonfatal myocardial infarction by 26% (RR 0.74; 95% CI 0.60 to 0.89), need for revascularization by 30% (RR 0.70; 95% CI 0.53 to 0.83), and stroke by 25% (RR 0.75; 95% CI 0.56 to 0.94). The posterior median estimate of the number needed to treat to save 1 life was 28 (95% CI 15 to 56). Statins reduce all-cause mortality in elderly patients and the magnitude of this effect is substantially larger than had been previously estimated.

Statins After Recent Stroke or TIA

Should patients with recent stroke or transient ischemic attack (TIA) receive statins for secondary prevention? In a randomized trial comparing 80

Statins in secondary prevention in hypertensive patients with coronary artery disease

Statins in secondary prevention in hypertensive patients with coronary artery disease

Survival Bias Associated with Time-to-Treatment Initiation in Drug Effectiveness Evaluation: A Comparison of Methods

The authors compared five methods of studying survival bias associated with time-to-treatment initiation in a drug effectiveness study using medical administrative databases (1996-2002) from Quebec, Canada. The first two methods illustrated how survival bias could be introduced. Three additional methods were considered to control for this bias. Methods were compared in the context of evaluating statins for secondary prevention in elderly patients post-acute myocardial infarction who initiated statins within 90 days after discharge and those who did not. Method 1 that classified patients into users and nonusers at discharge resulted in an overestimation of the benefit (38% relative risk reduction at 1 year). In method 2, following users from the time of the first prescription and nonusers from a randomly selected time between 0 and 90 days attenuated the effect toward the null (10% relative risk reduction). Method 3 controlled for survival bias by following patients from the end of the 90-day time window; however, it suffered a major loss of statistical efficiency and precision. Method 4 matched prescription time distribution between users and nonusers at cohort entry. Method 5 used a time-dependent variable for treatment initiation. Methods 4 and 5 better controlled for survival bias and yielded similar results, suggesting a 20% risk reduction of recurrent myocardial infarction or death events.