Use In Secondary Prevention Research Articles

PD47-09 FOLLOW-UP CARE AFTER ED VISITS FOR KIDNEY STONES—A MISSED OPPORTUNITY

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II1 Apr 2016PD47-09 FOLLOW-UP CARE AFTER ED VISITS FOR KIDNEY STONES—A MISSED OPPORTUNITY Amy Luckenbaugh, MD Phyllis Yan, MA J. Stuart Wolf, MD Khurshid Ghani, MBChB, MS Brent Hollenbeck, andMD, MS John HollingsworthMD, MS Amy LuckenbaughAmy Luckenbaugh More articles by this author , Phyllis YanPhyllis Yan More articles by this author , J. Stuart WolfJ. Stuart Wolf More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , Brent HollenbeckBrent Hollenbeck More articles by this author , and John HollingsworthJohn Hollingsworth More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2697AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The emergency department (ED) serves as the entry point for many patients with kidney stones into the healthcare system. When patients with acute renal colic are discharged from the ED, they are typically given instructions for urologic or primary care follow-up. However, data suggest that many do not comply with these recommendations. In doing so, patients may miss an opportunity for secondary stone prevention. To test this hypothesis, we examined patterns of post-ED follow-up care among adults with kidney stones. METHODS We used MarketScan's Commercial Claims and Encounters Database (2003-2006) to identify adults age 18 to 64 years with an ED visit for kidney stones. Next, we determined which patients received post-ED follow-up care, defined as a physician office visit or surgery for kidney stones within 90 days of the index ED claim. We then compared patients who received post-ED follow-up care and those who did not over a variety of sociodemographic characteristics. Finally, we fit multivariable logistic regression models to evaluate the association between receipt of post-ED follow-up care and subsequent secondary stone prevention (i.e., 24-hour urine testing and/or prescription of a preventive pharmacological therapy agent). RESULTS We identified 70,294 patients with an ED visit for kidney stones, of which 53% had follow-up care within 90 days. Among those with post-ED follow-up care, 66% were seen by a urologist. Compared to patients who received follow-up care, those who did not were more likely to be young (P<0.001), have non-salaried employment (P<0.001), and live in a rural area (P<0.001). After controlling for these differences we found that, relative to patients who did not receive follow-up care, those who did were significantly more likely to undergo 24-hour urine testing and be prescribed a preventive pharmacological therapy agent (Figure). Overall, post-ED follow-up care was associated with 36% higher odds of receiving secondary prevention (OR, 1.36; 95% CI, 1.30 to 1.43). CONCLUSIONS A substantial proportion of patients seen acutely in the ED for kidney stones do not have follow-up care for the kidney stone. Given that post-ED follow-up is associated with greater use of secondary prevention, efforts to enhance linkages across settings are needed in order to provide patients with kidney stones more comprehensive care. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1173 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Amy Luckenbaugh More articles by this author Phyllis Yan More articles by this author J. Stuart Wolf More articles by this author Khurshid Ghani More articles by this author Brent Hollenbeck More articles by this author John Hollingsworth More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Falling cholesterol trend at acute coronary syndrome presentation is strongly related to statin use for secondary prevention

BackgroundLifestyle changes are believed responsible for temporal trends of reduced population total cholesterol (TC), but it is uncertain whether this applies to patients with known coronary heart disease (CHD) often prescribed lipid lowering therapy (LLT). We studied temporal TC trends at presentation with acute coronary syndrome (ACS) to determine the contribution of LLT given for secondary prevention. MethodsTC and LLT were obtained in 5592 patients in annual surveys of ACS admissions in Australia between 1999 and 2013, and annual mean trends analysed by linear and segmented regression. ResultsTC declined from 5.13±1.1 to 4.53±1.2mmol/L (p<0.001) and LLT (96% statin) use at presentation increased from 37.4% to 47.5% (p=0.005). TC decline was greater in those on LLT vs. those not on therapy, with LLT contributing to 57% of the TC decline. The decline in TC and increase in LLT use was non-linear and much steeper in those with, than without CHD history, and LLT contributed substantially more to the TC decline (79%, p<0.001 vs. 27%, p=0.06 respectively). The rapid decline in TC and increase in LLT, plateauing after 2005 in those with CHD history differed markedly from trends in recent population studies, while TC trend for those without CHD history was slower, linear and consistent with population trends. ConclusionsDeclining TC level at presentation for ACS was strongly associated with increasing LLT use in those with a history of CHD, indicating that increasing uptake of LLT for secondary prevention has impacted TC changes in the new millennium.

Abstract 12737: Sex and Race/Ethnic Disparities in the Use of High Potency Statins for Patients With Atherosclerotic Cardiovascular Disease

Background: The November 2013 AHA/ACC prevention guidelines recommend the use of a fixed dose high potency statin (HPS) for patients with established atherosclerotic cardiovascular disease (ASCVD), irrespective of low-density lipoprotein cholesterol levels. We sought to determine how these guidelines are being adopted at the Veterans Affairs (VA) Health System and identify treatment gaps in patient groups. Methods: We examined administrative data from the VA 6 months prior to the index dates of 4/1/2013 and 4/1/2014 to identify patients with at least one outpatient visit for a diagnosis of established ASCVD, defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease. Statin use was assessed 6 months following the index date, and HPS was defined as atorvastatin 40mg or 80mg, rosuvasatin 20mg or 40mg, and simvastatin 80mg. Patient and facility-level predictors of statin use for secondary prevention were analyzed using multivariate logistic regressions. Results: Our study sample included 507,072 and 489,754 eligible adults with established ASCVD, in 4/1/2013 and 4/1/2014, respectively. The sample consisted of approximately 190,035 (2%) women and 200,461 (19%) non-white patients. HPS use was lowest in Hispanics and Native Americans, though all groups showed an increase over time (Figure 1). After adjustment for clinical and facility characteristics, there was a 40% increase in the use of HPS during the study period [OR=1.4; 95%CI (1.39-1.42)]. However, the racial differences shown in Figure 1 persisted and women were less likely to receive HPS than men (Odds Ratios [OR]=0.85; 95% CI 0.83-0.87). Conclusion: HPS use has increased following release of the ACC/AHA prevention guideline in the VA, though racial and gender disparities persist. Our findings highlight the continued need for targeted efforts to increase HPS use for women and certain minority groups.

Use of Health Care System-Supplied Aspirin by Veterans With Postoperative Heart Attack or Unstable Angina

Evidence-based guidelines for the use of aspirin in secondary prevention of cardiovascular disease events are well established. Despite this, the prevalence of aspirin use for secondary prevention is suboptimal. The study aimed to determine the prevalence of aspirin use for secondary prevention of cardiovascular disease events when it is dispensed as a prescription, as is performed in the Veterans Affairs (VA) managed care system. VA patients who had undergone major surgery and experienced a postoperative myocardial infarction (MI) or unstable angina between the years 2005 and 2009 were identified from administrative databases. VA pharmacy records were used to determine whether a prescription for aspirin was filled after the postoperative MI or unstable angina. Multivariable logistic regression models estimated odd ratios of filling aspirin prescriptions for the predictors of interest. Of the 321,131 men and women veterans who underwent major surgery, 7,700 experienced a postoperative MI or unstable angina. Among those 7,700, 47% filled an aspirin prescription. Only 59% of veterans with no co-pay filled an aspirin prescription. Aspirin fills were more common in younger veterans, Blacks, Hispanics, males, hypertensive veterans, mentally ill patients, those with no co-pay and those prescribed antiplatelets/anticoagulants in addition to aspirin postoperatively. These findings suggest that the impact of dispensing aspirin as a prescription may not be significant in increasing the appropriate use of aspirin for secondary prevention.

The Number Needed to Treat: 25 Years of Trials and Tribulations in Clinical Research.

The number needed to treat (NNT) is a simple measure of a treatment’s impact, increasingly reported in randomized trials and observational studies, but often incorrectly calculated in studies involving varying follow-up times. We discuss the NNT in these contexts and illustrate the concept using several published studies. While the computation of the NNT is founded on the cumulative incidence of the outcome, several published studies use simple proportions that do not account for varying follow-up times, or use incidence rates per person-time. We show how these approaches can lead to erroneous values of the NNT and misleading interpretations. For example, a trial of 3,845 very elderly hypertensives randomized to a diuretic or placebo reported a NNT of 94 treated for 2 years to prevent one stroke, though the correct approach results in a NNT of 63. Also, meta-analyses involving trials of differing lengths often report a single NNT, such as the meta-analysis of 22 trials of the anticholinergic tiotropium in chronic obstructive pulmonary disease that reported a NNT of 16 patients “over one year,” even if the trials varied in duration from 3 to 48 months, with the actual NNTs varying widely from 15 to 250. Finally, we describe the value of the NNT in assessing benefit–risk, such as low-dose aspirin use in secondary prevention of mortality assessed against the risk of gastrointestinal bleeding. As the “number needed to treat” becomes increasingly used in the comparative effectiveness and safety of therapies, its accurate estimation and interpretation become crucial to avoid distorting clinical, economic, and public health decisions.

Influence of Retirement on Adherence to Statins in the Insurance Medicine All-Sweden Total Population Data Base.

BackgroundRetirement has been suggested to reduce medication adherence, but no evidence is available for statins. We investigated changes in adherence to statins among Swedish adults after retirement.MethodsA prospective cohort study was carried out on all individuals living in Sweden on 31 December 2004, alive in 2010, having purchased statins in the second half of 2005, and retired in 2008 (n=11 718). We used prescription dispensing data in 2006–2010 to determine nonadherence (defined as <80% of days covered by filled prescriptions) before and after old-age or disability retirement. Using multiple repeat measurements of filled statin prescriptions, we calculated the annual prevalence rates of nonadherence for those who continued therapy. Discontinuation was defined as no statin dispensations during a calendar year.ResultsAfter adjustment for age at retirement, the prevalence ratio (PR) of nonadherence after retirement in comparison with those before retirement was 1.23 [95% confidence interval (CI) 1.17–1.29] for the men and 1.19 (95% CI 1.13–1.26) for the women. A post-retirement increase in nonadherence was consistently observed across the strata of age at retirement, marital status, education, income, type of retirement, and participants with and without cardiovascular disease, the largest increases being observed for statin use in secondary prevention (men: PR 1.38, 95% CI 1.26–1.54; women: PR 1.43, 1.18–1.72). For primary prevention, the corresponding prevalence ratios were 1.18 (95% CI 1.13‒1.25) and 1.18 (95% CI 1.11–1.24), respectively.InterpretationRetirement appears to be associated with increased nonadherence to statin therapy among Swedish men and women.

Patients’ and Providers’ Perspectives of a Polypill Strategy to Improve Cardiovascular Prevention in Australian Primary Health Care

This study explores health provider and patient attitudes toward the use of a cardiovascular polypill as a health service strategy to improve cardiovascular prevention. In-depth, semistructured interviews (n=94) were conducted with health providers and patients from Australian general practice, Aboriginal community-controlled and government-run Indigenous Health Services participating in a pragmatic randomized controlled trial evaluating a polypill-based strategy for high-risk primary and secondary cardiovascular disease prevention. Interview topics included polypill strategy acceptability, factors affecting adherence, and trial implementation. Transcribed interview data were analyzed thematically and interpretively. Polypill patients commented frequently on cost-savings, ease, and convenience of a daily-dosing pill. Most providers considered a polypill strategy to facilitate improved patient medication use. Indigenous Health Services providers and indigenous patients thought the strategy acceptable and beneficial for indigenous patients given the high disease burden. Providers noted the inflexibility of the fixed dose regimen, with dosages sometimes inappropriate for patients with complex management considerations. Future polypill formulations with varied strengths and classes of medications may overcome this barrier. Many providers suggested the polypill strategy, in its current formulations, might be more suited to high-risk primary prevention patients. The polypill strategy was generally acceptable to patients and providers in cardiovascular prevention. Limitations to provider acceptability of this particular polypill were revealed, as was a perception it might be more suitable for high-risk primary prevention patients, though future combinations could facilitate its use in secondary prevention. Participants suggested a polypill-based strategy as particularly appropriate for lowering the high cardiovascular burden in indigenous populations. URL: http://www.anzctr.org.au. 12608000583347.

Prevention of Clostridium difficile Infection With Probiotics.

Despite advances in the diagnosis and treatment of Clostridium difficile infection (CDI) and prevention efforts to reduce the spread of C. difficile, CDI remains a significant challenge to healthcare systems worldwide. Further advances in prevention of CDI may need to focus on those who continue to be exposed to the organism and who are susceptible. Interventions directed toward this susceptible population, particularly hospitalized patients who receive antibiotics, may be effective. There is moderate evidence on the effectiveness of probiotics to prevent primary CDI, but there are few data to support use in secondary prevention of recurrent CDI. This review discusses the literature available on the use of probiotics to prevent primary and secondary CDI.

Closing the mortality gap after a myocardial infarction in people with and without chronic obstructive pulmonary disease

ObjectivePatients with chronic obstructive pulmonary disease (COPD) have increased mortality following myocardial infarction (MI) compared with patients without COPD. We investigated the extent to which differences in recognition and management...

Use of Low-Dose Aspirin as Secondary Prevention of Atherosclerotic Cardiovascular Disease in US Adults (from the National Health Interview Survey, 2012)

Current guidelines recommend that adults with atherosclerotic cardiovascular disease take low-dose aspirin or other antiplatelet medications as secondary prevention of recurrent cardiovascular events. Yet, no national level assessment of low-dose aspirin use for secondary prevention of cardiovascular disease has been reported in a community-based population. Using data from the 2012 National Health Interview Survey, we assessed low-dose aspirin use in those with atherosclerotic cardiovascular disease. We estimated the prevalence ratios of low-dose aspirin use, adjusting for sociodemographic status, health insurance, and cardiovascular risk factors. In those with atherosclerotic cardiovascular disease (n = 3,068), 76% had been instructed to take aspirin and 88% of those were following this advice. Of those not advised, 11% took aspirin on their own. Overall, 70% were taking aspirin (including those who followed their health care provider's advice and those who were not advised but took aspirin on their own). Logistic regression models showed that women, non-Hispanic blacks and Hispanics, those aged 40 to 64 years, with a high school education or with some college, or with fewer cardiovascular disease risk factors were less likely to take aspirin than men, non-Hispanic whites, those aged ≥65 years, with a college education or higher, or with all 4 selected cardiovascular disease risk factors, respectively. Additional analyses conducted in those with coronary heart disease only (n = 2,007) showed similar patterns. In conclusion, use of low-dose aspirin for secondary prevention was 70%, with high reported adherence to health care providers' advice to take low-dose aspirin (88%) and significant variability within subgroups.

A systematic review of aspirin in primary prevention: is it time for a new approach?

Background and ObjectivesWhile evidence in support of aspirin use in secondary prevention is well documented, the role of aspirin in primary prevention remains unclear. We conducted a systematic literature review to evaluate aspirin use in cardiovascular disease (CVD) and cancer primary prevention, and consider whether aspirin’s role is set to become more clearly defined based on past and prospective studies.Data SourcesUtilizing PubMed, the reviewers identified appropriate Medical Subject Headings (MeSH) terms to establish CVD-based studies, cancer-based studies, and studies on adherence.Study Eligibility CriteriaDate restrictions of May 31, 2008 to May 31, 2013 were applied to capture the most robust meta-analyses and randomized controlled trials. Websites of relevant EU and US scientific societies were used to identify the key guidelines for aspirin use in primary prevention of CVD, and ClinicalTrials.gov was used to establish future or ongoing trials.ResultsEvidence in support of aspirin prophylaxis is conflicting, though some meta-analyses have underlined potential benefit in reducing cardiovascular events. Despite this apparent benefit, bleeding risk with aspirin is consistently higher versus control, and remains a concern. A reduction of cancer incidence and mortality after a least 3 and 5 years treatment, respectively, is also apparent with aspirin.ConclusionAvailable data on aspirin in primary prevention suggest a modest benefit for patients at high risk of CVD, and a promising benefit for those at risk of cancer. Future studies should help to elucidate whether the benefit of aspirin outweighs risk in appropriate patient groups.

Is it Time to Repair a Fairly Fast SAAB Convertible? Testing an Evidence-based Mnemonic for the Secondary Prevention of Cardiovascular Disease

Optimising secondary prevention of cardiovascular disease has the greatest potential to reduce recurrent events, yet despite major guidelines there are ongoing treatment gaps. FFSAABC (Fish oils, Fibrates, Statins, Aspirin, Angiotensin converting enzyme inhibitors or angiotensin 2 receptor antagonists, Beta blockers and Clopidogrel) is one mnemonic previously adopted to assist clinicians in remembering medications for use in secondary prevention. The aim of this narrative review is to examine the current evidence base for medications recommended for patients with established cardiovascular disease and the current applicability of this, or a revised mnemonic for their use. Randomised controlled trials and systematic reviews were sought examining Fish oils, Fibrates, Statins, Aspirin, Angiotensin converting enzyme inhibitors or angiotensin 2 receptor antagonists, Beta blockers or Clopidogrel vs placebo in secondary prevention. The emerging evidence base for other contemporary therapies including the P2Y12 inhibitors (ticagrelor and prasugrel) and aldosterone antagonists was also reviewed. Definitive evidence supports the use of statins, aspirin, angiotensin converting enzyme inhibitors or angiotensin 2 receptor antagonists, and P2Y12 antagonists (clopidogrel, ticagrelor or prasugrel) for the secondary prevention of cardiovascular disease. Aldosterone antagonists have strong evidence in the presence of systolic heart failure. There is a weaker evidence base for the routine use of omega-3 fatty acid supplementation although this therapy carries minimal harms. Fenofibrate reduces cardiovascular events in dyslipidaemic patients, with additional benefits in patients with diabetes. Mnemonic upgrading from a Fairly Fast SAAB Convertible to a Fairly Fast SA(2)A(2)B (Fish oils, Fibrate, Statin, Antiplatelets (Aspirin+Other), ACE/ARB, Aldosterone Antagonist, Beta-blocker) may help to ensure patients receive best practice evidence-based pharmacotherapies for the secondary prevention of cardiovascular disease.

S107 Explaining The Mortality Gap In Copd Patients After Myocardial Infarction: Data From The Uk Myocardial Ischaemia National Audit Project (minap)

Introduction COPD patients are at increased risk of myocardial infarction (MI) and have increased mortality after an MI. Although some of this increased risk may be due to COPD itself, differences in management after an MI may play a role.1 We therefore investigated whether the increased in-hospital and 180 day mortality for COPD patients could be explained by differences in in-hospital and discharge treatment. Methods Patients with a first MI between 2003–2013 were identified from the UK MINAP database. COPD patients had a record of obstructive airway disease, smoking history and were aged >35 years. Logistic regression was used to compare mortality in-hospital and at 180 days post-discharge between COPD and non-COPD patients. All models were adjusted for age, sex, smoking, previous cardiovascular disease, renal failure, diabetes and cardiovascular drugs used on admission. Variables relating to in-hospital management (delay in diagnosis, use of reperfusion and time to reperfusion/use of angiography in-hospital) and use of secondary prevention on discharge were then sequentially added to models to assess the extent to which they explained the mortality difference. Results 300,146 patients with a first MI were identified. 34,027 (11.3%) had COPD. In-hospital mortality was greater for COPD patients after a STEMI (see [Table 1][1]), this difference was reduced after adjusting for in-hospital factors. Mortality was also greater for COPD patients at 180 days; this was not reduced after adjustment for in-hospital factors, but was reduced after adjusting for use of secondary prevention. In-hospital mortality was also greater for COPD patients after a non-STEMI, this was reduced after adjusting for in-hospital factors. Mortality at 180-days after a non-STEMI was greater for COPD patients, this was reduced after adjusting for in-hospital factors, but not after adjusting for use of secondary prevention. Conclusions Improved recognition and timely use of reperfusion treatments after a STEMI may significantly reduce the in-hospital mortality for COPD patients. Longer term mortality in COPD patients after a STEMI may be improved by increased use of secondary prevention drugs. Increased use of timely angiography may improve mortality for COPD patients after a non-STEMI. Reference 1. Quint, JK et al . BMJ . 2013;347:f6650 View this table: Abstract S107 Table 1 Differences in mortality after an MI between COPD and non-COPD patients. All odds ratios compare COPD to non-COPD patients [1]: #T1

Impact of chronic kidney disease on use of evidence-based therapy in stable coronary artery disease: a prospective analysis of 22,272 patients.

PurposeTo assess the frequency of chronic kidney disease (CKD), define the associated demographics, and evaluate its association with use of evidence-based drug therapy in a contemporary global study of patients with stable coronary artery disease.Methods22,272 patients from the ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease (CLARIFY) were included. Baseline estimated glomerular filtration rate (eGFR) was calculated (CKD-Epidemiology Collaboration formula) and patients categorised according to CKD stage: >89, 60–89, 45–59 and <45 mL/min/1.73 m2.ResultsMean (SD) age was 63.9±10.4 years, 77.3% were male, 61.8% had a history of myocardial infarction, 71.9% hypertension, 30.4% diabetes and 75.4% dyslipidaemia. Chronic kidney disease (eGFR<60 mL/min/1.73 m2) was seen in 22.1% of the cohort (6.9% with eGFR<45 mL/min/1.73 m2); lower eGFR was associated with increasing age, female sex, cardiovascular risk factors, overt vascular disease, other comorbidities and higher systolic but lower diastolic blood pressure. High use of secondary prevention was seen across all CKD stages (overall 93.4% lipid-lowering drugs, 95.3% antiplatelets, 75.9% beta-blockers). The proportion of patients taking statins was lower in patients with CKD. Antiplatelet use was significantly lower in patients with CKD whereas oral anticoagulant use was higher. Angiotensin-converting enzyme inhibitor use was lower (52.0% overall) and inversely related to declining eGFR, whereas angiotensin-receptor blockers were more frequently prescribed in patients with reduced eGFR.ConclusionsChronic kidney disease is common in patients with stable coronary artery disease and is associated with comorbidities. Whilst use of individual evidence-based medications for secondary prevention was high across all CKD categories, there remains an opportunity to improve the proportion who take all three classes of preventive therapies. Angiotensin-converting enzyme inhibitors were used less frequently in lower eGRF categories. Surprisingly the reverse was seen for angiotensin-receptor blockers. Further evaluation is required to fully understand these associations. The CLARIFY (ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) Registry is registered in the ISRCTN registry of clinical trials with the number ISRCTN43070564. http://www.controlled-trials.com/ISRCTN43070564.

Abstract 385: The Impact of Aspirin Primary Prevention Treatment Guidelines: Temporal Trends in Aspirin Use for Primary vs Secondary Prevention, 2005-2013

Background: Current national prevention guidelines recommend use of low dose aspirin (ASA) for both the primary prevention (PP) and secondary prevention (SP) of heart attack and stroke. ASA use for SP has been documented to have increased over the past decade. Since the publication of the 2009 United States Preventative Services Task Force (USPSTF) recommendations for PP ASA use, data describing the trends in PP ASA use in primary care are sparse. This study evaluates trends in PP and SP ASA use in primary care clinics from a large, regional health system over an 8 year period (2005-2013). Methods: A bi-annual cross-sectional electronic medical record (EMR) chart extraction was performed from 2005 to 2013 to evaluate documented ASA use for all patient encounters within primary care clinics in the Fairview Health System (Minnesota). Primary prevention candidates were defined as individuals within the USPSTF guideline age and sex target populations (men aged 45-79, and women aged 55-79 years) with no documented history of an atherosclerotic syndrome or contraindication to ASA use (aspirin allergy, peptic ulcer disease, or concurrent antithrombotic therapy). Secondary prevention candidates were defined as adults within the same age and gender range with a history of coronary artery disease, peripheral artery disease or ischemic stroke. The ASA treatment to candidacy ratio was calculated for the PP and SP populations. Results: Over 225,000 unique encounters at 66 primary care clinics were analyzed over the 8 year study period. The PP population was younger (60.4±8.7 vs. 66.2±8.3 years), with lower prevalence of hypertension (49 vs. 79%), hyperlipidemia (54 vs. 84%), and diabetes (17 vs. 35%) compared to the SP cohort. The mean SP ASA use of 86% was high, concordant with national trends, and did not change over this period. In contrast, PP ASA average use was 44% with no increase after publication of the 2009 USPSTF guideline. Documented contraindications to ASA use were uncommon (ASA allergy, 2.1 and 2.8%; peptic ulcer disease, 3.2 and 7.2%; and use of other antithrombotic medications, 4.6 and 32.6% in PP and SP populations respectively). Conclusion: Secondary prevention ASA use in primary care settings remains high, but ASA use for primary prevention of cardiovascular events is low. Despite creation of national guidelines, aspirin use in the PP population is half the rate of ASA use for secondary prevention. Additional methods to safely and effectively disseminate this primary prevention aspirin use recommendation, targeting both the public and health care providers, are warranted.

Geographic Variation in Statin Use for Complex Acute Myocardial Infarction Patients

Despite strong evidence to designate statin use for secondary prevention of cardiovascular disease (CVD) as "effective care," observational studies show that many patients with CVD do not receive statins. This suggests that statin prescribing decisions for complex CVD patients are preference sensitive. The aim of this study was to evaluate local area variation in statin prescribing for subsets of complex patients after acute myocardial infarction (AMI) to assess whether current statin prescribing patterns fit profiles of either "effective care" or "preference-sensitive care." This was a retrospective cohort study of 124,618 Medicare patients with fee-for-service parts A, B, and D benefits who were hospitalized with AMI in 2008 or 2009 with no evidence of AMI in the past 12 months. Patient complexity was defined by the presence of diabetes, heart failure, and chronic kidney disease in the year before AMI admission. Local area practice styles for "no statin," "lower-intensity statins," and "high-intensity statins" were measured using the driving area for clinical care method. Statin prescribing rates for complex patient subsets were contrasted across patients grouped by local areas practice styles. Lower statin treatment rates were observed for patients with complex conditions, especially among those with heart failure. However, substantial local area variation in statin prescribing is observed across all complex patient groups. Despite guidelines promoting the use of statins for secondary prevention for CVD patients, substantial local area variation suggests that patient and provider beliefs and preferences weigh heavily in statin prescribing decisions.

Abstract 64: The Use of Oral Anticoagulation After Ischemic Stroke Increases, Users Have Fewer Recurrences, and Are Increasingly Likely to Survive. A Nationwide Study From Finland

Background and Purpose: Oral anticoagulation (OAC) is an effective secondary preventive therapy after atrial fibrillation related cardioembolic ischemic stroke. We explored the use of OAC after ischemic stroke in Finland, the country with the most rapidly aging population in Europe. Methods: Data from 1999 to 2010 were extracted from the PERFECT Stroke registry, a nationwide database of all incident stroke patients hospitalized in Finland. Purchase of warfarin, the only OAC available during the study period in Finland, was registered in all pharmacies in a national database. Recurrence was defined as re-hospitalization with new acute stroke diagnosis through an emergency department. Survival was tracked from the national death registry with 100% follow-up. Results: Among the 99,677 incident ischemic stroke cases over the study period, there were 24,327 cases surviving their initial hospitalization and using OAC for secondary prevention. This represented 24.4% of all ischemic stroke patients, increasing from 20.3% in 1999 to 26.7% in 2010. In these OAC users, 1-year recurrence rate of ischemic stroke decreased from 20.1% in 1999 to 12.5% in 2010, while 1-year hemorrhagic stroke rate remained unchanged at 0.4%. Increases in the secondary preventive use of blood pressure medications (from 83.5% to 92.7%), statins (from 32.8% to 73.5%), and a combination of these (from 28.2% to 69.0%) were observed from 1999 to 2010. One-year case-fatality of patients surviving to go home was 4.2% when no recurrences occurred. When secondary prevention failed, patients who experienced a new ischemic stroke had 11.3% likelihood of dying within a year, increasing to 42.0% after a hemorrhagic stroke. After adjusting for age, sex, and comorbidities with a logistic regression model, the odds of 1-year case-fatality decreased over time (OR 0.97; 95% CI 0.95-0.99 per year). Conclusion: As the population ages, the proportion of ischemic stroke patients that require oral anticoagulation increases, in our data from 20% to 27% over a period of 12 years. Secondary prevention of stroke in OAC users improved, which could be due to increased use of antihypertensives and statins, and reflected on survival. The risk of hemorrhagic stroke due to anticoagulation for ischemic stroke remains small.

Aspirin therapy: Evaluating benefits and risks

The prevalence of OTC aspirin use is unknown, but with all the publicity about its potential benefit for cardiovascular health and cancer prevention, it's wise to assume many of your patients are using it. Recent data regarding aspirin therapy reinforce the need to evaluate potential benefits and risks in each patient. A recent study evaluated the overall benefit of aspirin use for primary prevention of cardiovascular events.1.JAMA. 2012;307(21):2286–94.Google Scholar Data for patients with and without diabetes who were taking placebo or aspirin were evaluated to determine the incidence of hospitalization for major bleeds (cerebral hemorrhage or gastrointestinal bleeds). The aspirin dose was less than 300 mg daily, and patient data were collected for a period of approximately 6 years. The researchers found that those taking aspirin and those with diabetes (regardless of aspirin use) had a significantly higher incidence of one of the adverse outcomes. These data reinforce the opportunities for pharmacists to counsel patients on the use of aspirin and potential risks to keep in mind. The data also suggest that individuals with diabetes, regardless of aspirin use, might benefit from a brief conversation about watching for increased risk of bleeding. The most recent guidelines for aspirin use from the American Diabetes Association suggested using low-dose aspirin (75–162 mg) as primary prevention for cardiovascular disease (CVD) in individuals with type 1 or type 2 diabetes and a 10-year cardiovascular risk greater than 10%.2.http://care.diabetesjournals.orgcontent/36/Supplement_1/S4.full.Google Scholar This would include most men older than 50 years and women older than 60 years with at least one additional risk factor (e.g., dyslipidemia, hypertension). Clinical judgment regarding the use of aspirin is recommended for those with a 10-year cardiovascular risk of 5% to 10%. Low-dose aspirin for secondary prevention also is recommended in patients with diabetes who have a history of CVD. Often the only evidence of aspirin's antiplatelet activity is increased bruising or bleeding. A recent evaluation was completed to determine if enteric coating/absorption affected response.3.Circulation. 2013;127(3):377–85Google Scholar A total of 400 patients took 325 mg aspirin in either immediate-release (IR) or enteric-coated (EC) formulation. Cyclooxygenase-1 activity was measured to evaluate response. Approximately 50% of patients taking 325 mg EC aspirin appeared to have aspirin resistance compared with no resistance among those taking the IR product. However, subsequent analysis revealed that rather than resistance, the issue was related to the type of aspirin used and the timing of administration. This study suggested that the IR formulation should be used to ensure absorption, and ultimately therapeutic benefit of antiplatelet activity, especially in patients using aspirin for secondary prevention only. CVD is the leading cause of death in women; thus, many are told to take aspirin for either primary or secondary prevention. In 2004 (survey 1) and 2009 (survey 2), women from 127 facilities were assessed for health attributes, including CVD risk factors and aspirin use.4.J Womens Health (Larchmt). 2012;21(4):379–87Google Scholar Slightly more than 218,000 women responded to the surveys, and 29,701 were told by their health care provider to take aspirin based on their profile and guidelines. The results showed that 41% of women who met criteria for primary prevention were taking aspirin as recommended, while 48% who met criteria for secondary prevention were taking aspirin as recommended. From survey 1 to survey 2, a significant increase was seen in use for primary prevention, but no change was seen in use for secondary prevention. These data suggest that pharmacists have an opportunity to identify women who should be using aspirin and educate those for whom aspirin therapy is recommended.

Persisting gender differences and attenuating age differences in cardiovascular drug use for prevention and treatment of coronary heart disease, 1998–2010

Evidence on recent time trends in age-gender differences in cardiovascular drug use is scarce. We studied time trends in age-gender-specific cardiovascular drug use for primary prevention, secondary prevention, and in-hospital treatment of coronary heart disease. The PHARMO database was used for record linkage of drug dispensing, hospitalization, and population data to identify drug use between 1998 and 2010 in 1 203 290 persons ≥25 years eligible for primary prevention, 84 621 persons hospitalized for an acute coronary syndrome (ACS), and 15 651 persons eligible for secondary prevention. The use of cardiovascular drugs increased over time in all three settings. In primary prevention, the proportion of women that used lipid-lowering drugs was lower than men between 2003 and 2010 (5.7 vs. 7.3% in 2010). The higher proportion of women that used blood pressure-lowering drugs for primary prevention, compared with men, attenuated over time (15.1 vs. 13.8% in 2010). During hospital admission for an ACS, the proportion of women that used cardiovascular drugs was lower than men. In secondary prevention (36 months after hospital discharge), drug use was lowest in young women. The proportion receiving lipid-lowering drugs declined after the age of 75 in all three settings. This age difference attenuated over time. Age differences in drug use tended to attenuate over time, whereas gender differences persisted. Areas potentially for improvement are in the hospital treatment of ACS in young women, in secondary prevention among young women and the elderly, and in the continuity of drug use in secondary prevention.

Population trends in aspirin use for cardiovascular disease prevention 1980-2009

Background: Aspirin (ASA) is an established therapy for secondary prevention of cardiovascular disease (CVD). More recently the use of ASA for primary CVD prevention was confirmed in large prospective randomized clinical trials and is recommended by the United States Preventive Services Taskforce and other professional organizations for those at increased CVD risk. However, little is known about the prevalence of ASA use for primary or secondary CVD prevention in the general population. The Minnesota Heart Survey (MHS) describes population trends in CVD risk and therapies over the past 30 years. Data regarding ASA use for primary and secondary CVD prevention were collected from 1980 to 2009. Methods: Adult residents, ages 25-74 from the Minneapolis/St. Paul, USA metropolitan area (2.8 million, 2010 census) were randomly selected at five-year intervals from 1980-82 to 2007-09. In each of six cross-sectional surveys, interviewers collected data on medication use, risk factors, health history and demographics. Questions on regular ASA use were segregated according to primary and secondary prevention groups based on the question: "Have you ever been hospitalized for a heart attack (AMI) or stroke?" and "Are you taking aspirin regularly to avoid an AMI or stroke?" Individuals defined to be within the primary prevention cohort were asked: "Are you taking aspirin regularly to avoid an AMI or stroke?" Mixed model regression analysis estimated the age-adjusted trends for aspirin used in men and women. Results: 12,281 men and 14,258 women ages 25-74 were included in six surveys. Of those, 547 (4%) men and 280 (2%) women reported a previous AMI and/or stroke. Among men, trends in ASA use for secondary CVD prevention rose progressively from 14% in 1980-82 to 77% in 2007-09. Among women, ASA use for secondary prevention increased from 6% to 60% over the same period. Among men, trends in ASA use for primary CVD prevention rose progressively from 1% in 1980-82 to 29% in 2007-09. Among women, ASA use for primary prevention increased from 0.5% to 15% over the same period. ASA use for primary prevention also increased with age from 1% among 25-34 year olds to 37% among those 65-74 years in 2007-09. The use of ASA for CVD prevention was also positively associated with education, hypertension and hypercholesterolemia but negatively associated with smoking. Conclusions: Population use of ASA for primary and secondary prevention of CVD has substantially increased becoming widespread over the past 30 years. Men are more likely than women to use ASA. Those who are older and at increased risk are more likely to use ASA.