Use In Secondary Prevention Research Articles

Aspirin for cardiovascular disease prevention among adults in the United States: Trends, prevalence, and participant characteristics associated with use

ObjectiveAspirin has been widely utilized over several decades for atherosclerotic cardiovascular disease (ASCVD) prevention among adults in the United States. We examined trends in aspirin use among adults aged ≥40 years from 1998 to 2019 and assessed factors associated with its use for primary and secondary ASCVD prevention. MethodsUsing 1998–2019 Behavioral Risk Factor Surveillance System data, we obtained weighted prevalence of aspirin use among adults aged ≥40 years for each year and examined trends in use over this period. Using multivariable logistic regression and utilizing data from 54,388 respondents aged ≥40 years in the 2019 data, we assessed factors associated with aspirin use for secondary prevention and for primary prevention stratified by the number of traditional ASCVD risk factors reported (hypertension, diabetes mellitus, high cholesterol, overweight/obesity, and cigarette smoking). ResultsAspirin use prevalence increased from 29.0%(95%CI, 27.9%-30.2%) in 1998 to 37.5%(36.9%-38.0%) in 2009. However, use has slightly declined over the last decade: 35.6%(34.6%-36.6%) in 2011 to 33.5%(32.5%-34.6%) in 2019. In 2019, among respondents without cardiovascular disease (CVD), 27.5%(26.4%-28.6%) reported primary prevention aspirin use while 69.7%(67.0%-72.2%) of respondents with CVD reported secondary prevention aspirin use. Of concern, 45.6%(43.5%-47.7%) of adults aged ≥70 years without CVD reported primary prevention aspirin use. Additionally, among individuals without any self-reported traditional ASCVD risk factor, males (adjusted odds ratio(aOR):1.60, 95%CI:1.12–2.27), persons aged ≥70 years (aOR:3.22, 95%CI:2.27–4.55), and individuals with healthcare coverage (aOR:2.28, 95%CI:1.17–4.44) had higher odds of primary prevention aspirin use compared to females, persons aged 40–69 years, and individuals without healthcare coverage, respectively. Females were less likely than males to report secondary prevention aspirin use (aOR:0.64, 95%CI:0.50–0.82). ConclusionAspirin use has slightly declined over the last decade. A significant proportion of adults aged ≥70 years reported primary prevention aspirin use in 2019. Since current guidelines do not recommend primary prevention aspirin use among adults aged ≥70 years, such use should be discouraged.

World regional differences in outcomes for patients with peripheral artery disease: Insights from the EUCLID trial

Regional variations exist in the epidemiology of peripheral artery disease (PAD), in comorbidities, use of secondary prevention, and outcomes. Large studies of these variations in worldwide populations are rare. The EUCLID (Examining Use of tiCagreLor In peripheral artery Disease) trial included 13,885 patients with PAD from four geographical regions (Central/South America, Europe, Asia, North America) and compared monotherapy with ticagrelor and clopidogrel. Inclusion criteria were either an ankle–brachial index < 0.80 or a prior revascularization. The primary efficacy endpoint was time to first occurrence of any event in the composite of cardiovascular death, myocardial infarction, or ischemic stroke and did not differ between the study arms. This post hoc analysis of EUCLID confirmed that regional differences occurred in the inclusion criteria with more prior revascularization in North America (73.9%) and Asia (72.5%) compared with Central/South America (34.0%) and Europe (51.6%). The characteristics of patients also differed. Prior amputation at baseline was most frequent in Central/South America (6.3%) compared with other regions (1.6–2.8%). A history of stroke was most common in Asia, coronary heart disease in North America, and diabetes in Central/South America compared with other regions. The incidence of outcomes in patients with PAD varied by region. North America had the highest rate of the primary combined endpoint (5.97 events/100 patient-years). Corresponding rates were 4.80, 3.95, and 3.87 for Asia, Europe, and Central/South America, respectively. Hospitalization for acute limb ischemia (events/100 patient-years) was most frequent in Europe (0.75) and North America (0.74) compared with Asia (0.60) and Central/South America (0.33). Adjustment for inclusion criteria and relevant PAD characteristics did not have a major impact on these regional differences. Further adjustment for concomitant disease, risk factors, and preventive medication modified the regional differences only marginally. In conclusion, substantial regional differences were found in cardiovascular and limb outcomes in patients with PAD and were not explained by variation in the category of included patients, concomitant disease, risk factors, and prevention. Such differences, which may be due to variation in other factors such as background population rates or clinical care, need to be considered when designing and interpreting large international studies (ClinicalTrials.gov Identifier: NCT01732822).

Prognostic effects of cardiovascular rehabilitation: facts and myths.

Since CR was introduced, studies have been carried out to discover the effect of CRHPs on cardiovascular morbidity and mortality and on heart-disease patients' quality of life. The first meta-analyses showed improvement in cardiovascular morbidity and mortality, although the studies were conducted in the coronary pre-reperfusion era, before the generalized use in secondary prevention of drugs such as statins, beta-blockers, or renin-angiotensin-system inhibitors, which have produced a decrease in cardiovascular mortality. In Europe, analyzing 25 studies with more than 200,000 patients. It concluded that, in spite of the great heterogeneity of the programs, CR clearly decreases mortality after ACS. Nevertheless, a strategy of CRHP standardization and evaluation is needed. In 2017, a study was carried out in our hospital to evaluate the effectiveness of multidisciplinary CRHP intervention on cardiovascular morbidity and mortality, recurrence of cardiovascular events, the control of RFCV and lifestyle changes in patients after ACS. A total of 442 patients were included who had presented an acute cardiovascular event in the previous six months; 306 patients from the CR group and 136 others with standard cardiology follow-up were used as controls. 405 patients completed follow-up for a median of 60 months. Compared to the usual treatments in cardiology, the patients who underwent CRHPs presented fewer readmissions for cardiovascular reasons (17% vs. 43.38%, P<0.001), fewer major cardiovascular events (11.9% vs. 27.2%, P<0.001) and new revascularizations (9.3% vs. 21.32%, P=0.001), with lower cardiovascular mortality (0 vs. 2.2%, P=0.014). It also led to better control of the RFCV (66% vs. 19.85%, P<0.001) and favored lifestyle changes in these patients (91% vs. 61%, P<0.001). Therefore, in our setting, the performance of CRHPs was shown to be effective in reducing cardiovascular morbidity and mortality and in the secondary prevention of coronary patients.

Association of Socioeconomic Status With Risk Factor Target Achievements and Use of Secondary Prevention After Myocardial Infarction

Low socioeconomic status (SES) is associated with poor long-term prognosis after myocardial infarction (MI). Plausible underlying mechanisms have received limited study. To assess whether SES is associated with risk factor target achievements or with risk-modifying activities, including cardiac rehabilitation programs, monitoring, and drug therapies, during the first year after MI. This cohort study included a population-based consecutive sample of 30 191 one-year survivors of first-ever MI who were 18 to 76 years of age, resided in the general community in Sweden, were followed up until their routine 11- to 15-month revisit, and were registered in the national registry Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) from 2006 through 2013. Data analyses were performed from January to August 2020. Individual-level SES by proxy disposable income quintile. Secondary exposures were educational level and marital status. Odds ratios (ORs) with 95% CIs for achieved risk factor targets at the 1-year revisit and for use of guideline-recommended secondary prevention activities. The study comprised 30 191 participants (72.9% men) with a mean (SD) age of 63.0 (8.6) years. Overall, higher SES was associated with better target achievements and use of most secondary prevention. The highest (vs lowest) income quintile was associated with achieved smoking cessation (OR, 2.05; 95% CI, 1.78-2.35), target blood pressure levels (OR, 1.17; 95% CI, 1.07-1.27), and glycated hemoglobin levels (OR, 1.57; 95% CI, 1.19-2.06). The highest-income quintile was associated not only with participation in physical training programs (OR, 2.28; 95% CI, 2.11-2.46) and patient educational sessions (OR, 2.29; 95% CI, 2.12-2.47) in cardiac rehabilitation but also with more monitoring of lipid profiles (OR, 1.20; 95% CI, 1.08-1.33) and intensification of statin therapy (OR, 1.22; 95% CI, 1.11-1.35) during the first year after MI. One year after MI, the highest-income quintile was associated with persistent use of statins (OR, 1.26; 95% CI, 1.10-1.45), high-intensity statins (OR, 1.10; 95% CI, 1.00-1.21), and renin-angiotensin-aldosterone system inhibitors (OR, 1.27; 95% CI, 1.08-1.49). Findings indicated that, in a publicly financed health care system, higher SES was associated with better achievement of most risk factor targets, programs aimed at lifestyle change, and evidence-based drug therapies after MI. Observed differences in secondary prevention activity may be a factor in higher long-term risk of recurrent disease among individuals with low SES.

Age-Related Trajectories of Cardiovascular Risk and Use of Aspirin and Statin Among U.S. Adults Aged 50 or Older, 2011-2018.

To examine age-related trajectories of cardiovascular risk and use of aspirin and statin among U.S. adults aged 50 or older. Repeated cross-sectional study using data from 2011 to 2018 National Health and Nutrition Examination Surveys. Nationally representative health interview survey in the United States. Non-institutionalized adults aged 50 years and older (n=11,392 unweighted). Primary prevention was defined as the prevention of a first cardiovascular event including coronary heart disease, angina/angina pectoris, heart attack, or stroke, whereas secondary prevention was defined as those with a history of these clinical conditions. Medication use was determined by self-report; aspirin use included dose and frequency, and statin use included generic names, days of prescription fills, and indications. We examined linear trends between age and each medication use, after controlling for period, sex, and race/ethnicity. Prevalence of those eligible for primary prevention treatment increased with age from 31.8% in ages 50-54 to 52.0% in ages ≥75 (p < 0.001). Similarly, those eligible for secondary prevention treatment increased with age from 2.7% in ages 50-54 to 21.1% in ages ≥75 (p < 0.001). Low-dose daily aspirin use increased with age (p < 0.001), and 45.3% of adults aged ≥75 took low-dose aspirin daily for primary prevention. Statin use also increased with age (p < 0.001), and 56.4% of adults aged ≥75 had long-term statin use for secondary prevention. While adults aged ≥75 do not benefit from the use of aspirin to prevent the first CVD, many continue to take aspirin on a regular basis. In spite of the clear benefit of statin use to prevent a subsequent CVD event, many older adults in this risk category are not taking a statin. Further education and guidance for both healthcare providers and older adults regarding the appropriate use of aspirin and statins to prevent CVD is needed.

Prevalence of Guideline-Directed Medical Therapy for Cardiovascular Disease Among Baltimore City Adults in the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) Study.

Guideline-directed medical therapy (GDMT) has been shown to improve outcomes for people with cardiovascular disease (CVD). Our goal was to assess racial and socioeconomic differences in GDMT use among a diverse population. We examined the cross-sectional association of race and poverty status with GDMT among 441 participants with CVD in a longitudinal cohort of urban-dwelling Black and White adults in Baltimore City, Maryland, using multivariable logistic regression. CVD status and GDMT were self-reported. The participants' mean age was 60.5 (SD 8.5) years, with 61.7% women, 64.4% Black, and 46.9% living below poverty. Of the 126 participants with coronary artery disease (CAD), 37.3%, 54.8%, and 62.7% were on aspirin, antiplatelets, and statins, respectively. Black participants with CAD were less likely to be on aspirin, OR 0.29 (95% CI 0.13-0.67), and on combination GDMT (antiplatelet and statin), OR 0.36 (0.16-0.78) compared to Whites. There were no differences by poverty status in GDMT for CAD. Fully, 222 participants reported atrial fibrillation (AF), but only 10.5% were on anticoagulation with no significant difference by race or poverty status. The use of GDMT for heart failure and stroke was also low overall, but there were no differences by race or poverty status. Among an urban-dwelling population of adults, the use of secondary prevention of CVD was low, with lower aspirin and combination GDMT for Black participants with CAD. Efforts to improve GDMT use at the patient and provider levels may be needed to improve morbidity and mortality and reduce disparities in CVD.

Usefulness of universal beta-blocker therapy in patients after ST-elevation myocardial infarction.

The use of beta-blockers (BB) in the context of ST-segment elevation myocardial infarction (STEMI) was a universal practice in the pre-reperfusion era. Since then, evidence of their use for secondary prevention after STEMI is scarce. Our aim is to determine treatment results associated with BB therapy after a STEMI at 1-year follow-up in a contemporary nationwide cohort.A prospective analysis involving 49 national centers, including patients admitted with STEMI, enrolled between October 2010 and September 2019 was conducted. The primary outcome was defined as the composite of all-cause mortality or hospital re-admission for a cardiovascular (CV) cause in the first year after STEMI. The patients were distributed into 2 groups, depending on whether they received therapy with BB at hospital discharge or not (BB and NB group, respectively).A total of 3145 patients were included in the analysis, of which 2526 (80.3%) in the BB group. A total of 12.2% of patients reached the primary outcome. Regarding the univariate Cox regression analysis, the BB group presented lower mortality or re-admission for CV cause at 1-year follow-up [hazard ratio (HR) 0.69, confidence interval (CI) 95% 0.55-0.87, P = .001]. However, after adjustment for significant covariates, this association was lost (HR 0.73, CI 95% 0.51-1.04, P = .081). In patients with preserved (HR 0.73, CI 95% 0.51-1.04, P = .081) and mid-range (HR 1.01, CI 95% 0.64-1.61, P = .959) left ventricular ejection fraction (LVEF), the primary outcome was similar between the 2 groups, while in patients with reduced LVEF, the BB group presented a better prognosis, with fewer patients reaching the primary outcome (HR 0.431, CI 95% 0.262-0.703, P = .001).BB universal therapy after STEMI has not proved useful, but it seems to be beneficial in patients with reduced LVEF.

Is There a Mortality Benefit of Statin Use for Secondary Prevention of Coronary Artery Disease (CAD) in an Older Population? Insights from the Melbourne Interventional Group (MIG) Registry

Intensive statin therapy reduces death and MACE in patients with CAD, although there is a paucity of evidence within the elderly population. We examined the use of statin therapy and long-term mortality benefits in an elderly population with CAD.

Comparison of second appropriate defibrillator therapy occurrence in patients implanted for primary prevention and secondary prevention - Sub-analysis of the Nippon Storm Study.

BackgroundPatients with implantable cardioverter defibrillator (ICD) use for primary prevention (primary prevention patients) of sudden cardiac death have lower incidence of appropriate ICD therapy (app-Tx) compared with those with ICD use for secondary prevention (secondary prevention patients). However, detail analysis of a second app-Tx after a first app-Tx is still lacking.ObjectiveThis study aimed to compare the incidence of a second app-Tx in primary vs secondary prevention patients.MethodsWe conducted sub-analysis of the Nippon Storm Study, which was a prospective, observational study involving 985 patients with structural heart disease (left ventricular ejection fraction ≤ 50%). Of these, we selected 251 patients (62 ± 14 years old, 82% men) who experienced at least one appropriate ICD therapy, and compared occurrence of a second app-Tx between primary (n = 116) and secondary (n = 135) prevention patients.ResultsThere was no significant difference in the incidence of a second app-Tx between primary and secondary prevention patients (the cumulative incidence for a second app-Tx was 59% at 1 year and 79% at 3 years in primary prevention patients vs the cumulative incidence for the second app-Tx was 59% at 1 year and 75% at 3 years in secondary prevention patients).Additionally, we evaluated the incidence of a second app-Tx according to basal structural disease (ischemic and non-ischemic cardiomyopathy) and found no significant difference between primary and secondary prevention patients.ConclusionOnce app-Tx occurs, primary prevention patients acquire the high risk of subsequent ventricular arrhythmias because there is a comparable incidence of a second app-Tx in secondary prevention patients.

Impact of multimorbidity on risk and outcome of stroke: Lessons from chronic kidney disease.

With both an aging population and greater post-stroke survival, multimorbidity is a growing healthcare challenge, affecting over 40% of stroke patients, and rising rapidly and predictably with increasing age. Commonly defined as the co-occurrence of two or more chronic conditions, multimorbidity burden is a strong adverse prognostic factor, associated with greater short- and long-term stroke mortality, worse rehabilitation outcomes, and reduced use of secondary prevention. Chronic kidney disease can be considered as the archetypal comorbidity, being age-dependent and also affecting about 40% of stroke patients. Chronic kidney disease and stroke share very similar traditional cardiovascular risk factor profiles such as hypertension and diabetes, though novel chronic kidney disease-specific risk factors such as inflammation and oxidative stress have also been proposed. Using chronic kidney disease as an exemplar condition, we explore the mechanisms of risk in multimorbidity, implications for management, impact on stroke severity, and downstream consequences such as post-stroke cognitive impairment and dementia.

Comparison of novel LDL cholesterol equations in myocardial infarction patients: Clinical impact on risk re-classification and lipid treatment goals on secondary prevention

Background and aimsNumerous low-density lipoprotein (LDL) calculating equations for more accurate estimation have emerged. With the present study, we assessed the clinical impact of implementing novel equations in terms of risk reclassification and LDL treatment goals in myocardial infarction (MI) patients. MethodsThis was a post-hoc analysis of a prospective acute MI cohort study. We enrolled 805 consecutive patients presenting with acute MI. Patients with high triglyceride levels (>400 mg/dL) were excluded. In the remaining 773 acute MI patients, LDL cholesterol levels were calculated using 12 different equations including the Friedewald equation. Each patient was categorized into a 5-scale risk strata scheme according to baseline LDL cholesterol levels. Moreover, ΔLDL cholesterol (change in LDL cholesterol levels to achieve the <55 mg/dL LDL treatment goal) was calculated for each patient. ResultsMean levels and distribution of LDL cholesterol were significantly different compared to those derived from the Friedewald equation. Net reclassification improvement (NRI) analysis, as well as heat maps, showed that this re-categorization had no significant impact on prognostic terms (NRI ranged from −6.1% to 5.9% with p values > 0.05 for each comparison). Statistically significant differences were observed in ΔLDL cholesterol levels between each one of the novel equations and the Friedewald equation. ConclusionsNovel LDL cholesterol calculating equations are not associated with a clinically significant risk re-classification in MI patients. In addition, use of these novel equations may have an impact on assessing potency of hypolipidemic therapy use in secondary prevention as far as succeeding lipid treatment goals in MI patients.

Bempedoic acid, an inhibitor of ATP citrate lyase for the treatment of hypercholesterolemia: early indications and potential

ABSTRACT Introduction The lowering of low-density lipoprotein cholesterol (LDL-C), regardless of the method used, results in a reduction of cardiovascular events. Bempedoic acid is a new and until now, the only approved adenosine triphosphate citrate lyase inhibitor that works through the cholesterol-synthesis pathway (similar to statins) that leads to a safe and effective reduction in LDL-C. Areas covered We review clinical phase 2 and 3 studies on bempedoic acid’s lipid-lowering effect and approved indications. Expert opinion In the United States, bempedoic acid is currently approved for use in secondary prevention. In primary prevention, its approval is limited to individuals with heterozygous familial hypercholesterolemia (FH). However, its tolerability and safety profile may warrant its use in primary prevention besides FH. Even though its efficacy appears weaker than high-intensity statins, it may be a useful adjunct in individuals who achieve less than desirable LDL-C reductions with statins or who cannot tolerate statins, where bempedoic acid alone or in combination with ezetimibe may be useful alternatives.

Role of Aspirin for Primary Prevention in Persons with Diabetes Mellitus and in the Elderly.

To review the clinical evidence of the effect of aspirin as primary prevention for patients with diabetes mellitus and in healthy elderly. Two trials were performed to study these two patient populations: ASCEND showed that the use of low-dose aspirin in persons with diabetes, who did not have prior cardiovascular disease, led to a lower risk of cardiovascular events than placebo (8.5% vs 9.6%, rate ratio 0.88, 95% CI 0.79-0.97; p = 0.01). However, it showed a similar magnitude of increased risk of major bleeding among the aspirin group compared with placebo (4.1% vs 3.2%, rate ratio 1.29, 95% CI 1.09-1.52; p = 0.003). ASPREE showed that the use of low-dose aspirin in healthy elderly did not prolong disability-free survival (21.5% vs 21.2%, HR 1.01, 95% CI 0.92-1.11; p = 0.79); however, the rate of major hemorrhage was higher in the aspirin group than in the placebo group (3.8% vs 2.8%, HR 1.38, 95% CI 1.18-1.62; p < 0.001). Additionally, further analyses of secondary end points of death, cardiovascular disease, and major hemorrhage were also studied. Higher all-cause mortality was seen among healthy elderly who received aspirin compared with placebo (12.7% vs 11.1%, HR 1.14, 95% CI 1.01-1.29) and was primarily attributed to cancer-related deaths. Similar risk of cardiovascular disease was seen among elderly who received aspirin compared with placebo (10.7% vs 11.3%, HR 0.95, 95% CI 0.83-1.08) and resulted in a significantly higher risk of major hemorrhage (8.6% vs 6.8%, HR 1.38, 95% CI 1.18-1.62; p < 0.001). These studies show that the use of low-dose aspirin as primary prevention in patients with diabetes and in the elderly does not have overall beneficial effect compared with its use in secondary prevention. In patients with diabetes without prior cardiovascular disease, the benefits of aspirin use were counterbalanced by the bleeding risk. Additionally, in healthy elderly, the use of aspirin did not prolong disability-free survival and instead led to a higher rate of major hemorrhage.

A practical approach to switch from a multiple pill therapeutic strategy to a polypill-based strategy for cardiovascular prevention in patients with hypertension.

: Pharmacological treatment recommended by guidelines for very high-risk patients with established cardiovascular disease (CVD) includes lipid-lowering drugs, antihypertensive agents and antiplatelet therapy. Depending on the associated comorbidities, this baseline regimen has to be complemented with other drugs. Therefore, the number of pills to be taken is usually high and adherence to these multiple pill therapeutic regimens and long-term persistence on treatment is low, being the main factor for insufficient control of cardiovascular risk factors. The CNIC (Centro Nacional de Investigaciones Cardiovasculares, Ministerio de Ciencia e Innovación, España) polypill is the only polypill containing low-dose aspirin approved by the EMA and marketed in Europe, and has demonstrated to improve adherence. For this reason, guidelines recommend its use for secondary prevention of CVD, and also for primary prevention of cardiovascular events in patients with multiple cardiovascular risk factors and advanced atherosclerotic process at high risk of thrombosis and low risk of bleeding. This article pretends to simplify the steps that clinicians may follow to switch from any baseline regimen to the polypill with the use of several algorithms and tables showing the equivalent effective daily doses of different angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and statins to facilitate switching, as well as the steps to be followed depending of the initial levels of BP and LDL-cholesterol values to achieve BP and lipid control with the association to the polypill of other BP-lowering or lipid-lowering drugs whenever needed.

Secondary prevention of cardiovascular disease in China

ObjectiveWe aimed to estimate the current use of secondary prevention drugs and identify its associated individual characteristics among those with established cardiovascular diseases (CVDs) in the communities of China.MethodsWe studied...

Temporal trends in the incidence, treatment patterns, and outcomes of coronary artery disease and peripheral artery disease in the UK, 2006-2015.

Most reports estimating national incidence rates of coronary (CAD) and peripheral arterial disease (PAD) have focused on stable outpatients or acute or elective hospital admissions, but not on the overall burden of disease. In this study, we report the changing trends in the population-level incidence of CAD and PAD, respectively from 2006 to 2015, statin utilization for secondary prevention and survival outcomes using multiple nationally representative data sources from the UK (primary care encounters, hospital admissions, and procedure-level data). A nationally representative study of linked primary and secondary care electronic health records of 4.6 million individuals from the UK. We calculated crude and standardized annual incidence rates separately for CAD and PAD. Statin use for secondary prevention, trends in annual major vascular event rates, and mortality between 2006 and 2015, were estimated for CAD and PAD, respectively. We identified 160376 and 70753 patients with incident CAD and PAD, respectively. The age- and sex-standardized incidence of CAD was similar in 2006 (443 per 100000 person-years) and 2015 [436 per 100000 person-years; adjusted incidence rate ratio (IRR) 0.98, 95% confidence interval (CI) 0.96-1.00]. In contrast, there was a 15% decline in the standardized incidence of PAD (236 per 100000 person-years in 2006 to 202 per 100000 person-years in 2015; adjusted IRR 0.85, 95% CI 0.82-0.88). The proportion of incident CAD and PAD patients prescribed long-term statins, was only 66% and 55%, respectively and was less common amongst women, patients aged >70 years, with heart failure, chronic lung disease, or depression. Cardiovascular mortality declined by 43% for incident CAD (adjusted IRR 0.57, 95% CI 0.50-0.64) between 2006 and 2015 but did not decline for incident PAD (adjusted IRR 0.84, 95% CI 0.70-1.00). In the UK, the standardized incidence of CAD appears stable but mortality rates are falling, whereas the standardized incidence of PAD is falling but mortality rates are not.

Statin Use in the U.S. for Secondary Prevention of Cardiovascular Disease Remains Suboptimal.

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of mortality in the United States. The purpose of this study is to examine the rates of statin use for secondary prevention of ASCVD events in the United States over the last decade and determine whether disparities in the treatment of ASCVD still persist among women and racial/ethnic minorities. We conducted a trend analysis using data from 2008 through 2016 to describe age-adjusted trends in the use of statins for secondary prevention using the Medical Expenditure Panel Survey. We also conducted a multivariable logistic regression analysis to determine whether sociodemographic characteristics are associated with statin use during the 3 years that followed the publication of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline (2014 through 2016). The prevalence of statin use among those with a history of ASCVD remained unchanged from 2008 through 2016. In 2014 to 2016, more than 40% of those aged 40 years and older with a history of ASCVD did not use statins, corresponding to approximately 9.5 million Americans. Increasing age and having been diagnosed with high cholesterol (odds ratio [OR], 6.22; P < .001) were associated with higher odds of statin use while being female (OR, 0.65; P < .001) or Hispanic (OR, 0.69; P = .011) were associated with lower odds of statin use. Our study found there was no increase in the national rates of statin use following the ACC/AHA 2013 secondary prevention guideline and the availability of generic statins. Significant gender and ethnic disparities in ASCVD treatment remained in the United States.

Global Outcome Assessment Life-long after stroke in young adults initiative—the GOAL initiative: study protocol and rationale of a multicentre retrospective individual patient data meta-analysis

IntroductionWorldwide, 2 million patients aged 18–50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis...

Is Anticoagulation Necessary for Severely Disabled Cardioembolic Stroke Survivors?

Background and Objectives: Oral anticoagulants are the hallmark of cardioembolic stroke prevention, but they are frequently underused, especially in elderly patients and patients with paroxysmal atrial fibrillation. In our paper, we analyzed the long-term outcome of severely disabled cardioembolic stroke survivors depending on the prescribed antithrombotic secondary prevention medication. Materials and Methods: In our study, we retrospectively collected data for ischemic stroke (IS) patients treated in P. Stradins Clinical University hospital, Riga, Latvia, from 2014 until 2017. Patients’ clinical data were collected using local stroke registry, including patients’ demographic data, vascular risk factors, clinical findings, and laboratory results. Severely disabled stroke survivors were followed up by phone at 30/90/180/365 days after discharge. Patients’ functional outcomes were assessed using the adapted version of The Rankin Focused Assessment–Ambulation. The collected data were compared in 4 groups according to prescribed secondary prevention medication. Results: A total of 682 (91.42%) patients were followed up and included in data analysis. The median age of patients was 80 (IQR = 75–85) years. Of these patients, 231 (31%) were males and 515 (69%) were females. One-year probability of survival of patients not taking any preventive medication was 53% (IQR = 29–76), while in patients taking antiplatelet agents it was 57% (IQR = 37–78), 78% (IQR = 68–88) of patients on Vitamin K antagonists (VKA) and 81% (IQR = 72–90) in patients on direct oral anticoagulants (DOACs). One year after discharge 73 (31%) had mRS 0–2, 50 (20.9%), 29 (12.1%) were still severely disabled, and 87 (36.4%) had died. Conclusions: Anticoagulant use in secondary prevention predicts better functional outcome and higher survival rate in patients with severe cardioembolic stroke due to non-valvular atrial fibrillation (NVAF), therefore severe neurological deficit must not be a reason of restriction of anticoagulation.

Statins in Older Danes: Factors Associated With Discontinuation Over the First 4 Years of Use.

Use of statins is considerable among older persons. We investigated factors associated with statin discontinuation in new statin users aged 70 years or older within the first 4 years of use. Register-based descriptive drug utilization study using data from 2008 to 2016. All Danish persons, aged 70 years or older, initiating statin treatment. Rates and predictors of statin discontinuation after 1 year (early), 2 years, and 4 years. Predictors of discontinuation were estimated using logistic regression. We included 83 788 statin initiators. At 1 year, 13% had discontinued their treatment, while another 12% and 13% discontinued after 2 and 4 years, respectively. The overall discontinuation rate over 4 years was 32%. Increasing age was associated with discontinuation at all time points (adjusted odds ratio [OR] = 2.06 [95% confidence interval {CI} = 1.35-3.16] at 1 year, adjusted OR = 3.94 [95% CI, 1.83-8.49] at 4 years, comparing those aged >95 years to those aged 70-74 years). Further, higher comorbidity scores and use of more than 10 medications were modestly associated with discontinuation. Use of statins for secondary prevention was associated with decreased odds of discontinuation compared to primary prevention at 1 year (adjusted OR = 0.74; 95% CI, 0.65-0.83) and at 4 years (adjusted OR = 0.83; 95% CI, 0.72-0.95), along with concomitant use of cardiovascular (CV) therapies. The annual proportion of early discontinuers ranged from 14% to 17% for primary prevention and from 9% to 12% for secondary prevention between 2008 and 2015. Statin discontinuation within the first 4 years after initiation appeared to be influenced most strongly by age, and may also be influenced by comorbidity, polypharmacy, use for secondary prevention, and concomitant CV medication use. Future research should clarify reasons for, and discussions about, statin discontinuation and initiation among older persons, to provide additional insight on this topic. J Am Geriatr Soc 67:2050-2057, 2019.