Use Of Evidence-based Medications Research Articles

Randomized Evaluation of a Remote Management Program to Improve Guideline-directed Medical Therapy: The Diabetes Remote Intervention to Improve Use of Evidence-based Medications (DRIVE) Trial.

Several sodium-glucose transport protein 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) reduce cardiovascular (CV) events and improve kidney outcomes in patients with type 2 diabetes (T2D); however, utilization remains low despite guideline recommendations. A randomized, remote implementation trial in the Mass General Brigham network enrolled patients with T2D at high CV and /or kidney risk. Patients eligible for, but not prescribed, SGLT2i or GLP-1 RA were randomly assigned to simultaneous virtual patient education with concurrent prescription of SGLT2i or GLP-1 RA ("simultaneous") or two months of virtual education followed by medication prescription ("education-first") delivered by a multi-disciplinary team driven by non-licensed navigators and clinical pharmacists who prescribed SGLT2i or GLP-1 RA using a standardized treatment algorithm. The primary outcome was the proportion of patients with prescriptions for either SGLT2i or GLP-1 RA by 6 months. Between March 2021 and December 2022, 200 patients were randomized. Mean age was 66.5 years, 36.5% were female, 22.0% were non-White. Overall, 30.0% had cardiovascular CV disease, 5.0% had cerebrovascular disease, and 1.5% had both. Mean estimated glomerular filtration rate (eGFR) 77.9 mL/min/1.73m2 and mean urine/albumin creatinine ratio (UACR) 88.6mg/g. After two months, 69/200 (34.5%) patients received a new prescription for either SGLT2i or GLP-1 RA: 53.4% of patients in the simultaneous arm vs. 8.3% of patients were in the education-first arm (p<0.001). After six months, 128/200 (64.0%) received a new prescription: 69.8 % of patients in the simultaneous arm vs. 56.0% of patients in education-first (p<0.001). Patient self-report of taking SGLT2i or GLP-1 RA within six months of trial entry was similarly higher in the simultaneous versus education-first arm (69 /116; 59.5% vs 37/84; 44.0%; p<0.001) Median time to first prescription was 24 (IQR 13, 50) vs 85 days (IQR 65, 106), respectively (p<0.001). In this randomized trial, a remote team-based program that identifies patients with T2D and high CV or kidney risk, provides virtual education, and prescribes SGLT2i or GLP-1 RA improves GDMT. These findings support greater utilization of virtual team-based approaches to optimize chronic disease management.

Disparity in initiation of checkpoint inhibitors among commercially insured and Medicare Advantage patients with metastatic melanoma.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced melanoma, but racial disparities in melanoma outcomes continue. These inequities are not fully explained by individual factors. OBJECTIVE: To investigate the associations of neighborhood factors with the use of ICIs in metastatic melanoma. METHODS: We conducted a retrospective cohort study of commercially insured US adults with metastatic melanoma diagnosed between January 2011 and December 2020. We examined the associations between the county-level percentage of population from racial and ethnic minority groups and the time from metastatic melanoma diagnosis to initiating ICIs using Cox proportional hazards models adjusting for patient characteristics. RESULTS: We identified 4,052 patients with metastatic melanoma, of which 49% used ICIs. We found that the adoption of ICIs in a county declined with increasing minority quintile (quintile 1: 52.4%, quintile 2: 50.4%, quintile 3: 50.1%, quintile 4: 45.8%, and quintile 5: 44.7%). The delay in ICI initiation also went up as the percentage of minorities in a county increased (log-rank test P = 0.03). Compared with the lowest quintile, the adjusted hazard ratio of ICI initiation of the second, third, fourth, and highest minority quintile was 0.94 (95% CI = 0.81-1.08), 0.88 (95% CI = 0.76-1.02), 0.81 (95% CI = 0.68-0.97), and 0.77 (95% CI = 0.66-0.91), respectively. Secondary analysis revealed that the slower initiation was driven by the counties with the highest percentage of Hispanic population (hazard ratio = 0.74; 95% CI = 0.61-0.89) in both Cox models and sensitivity analyses. High-minority counties correlated with metro areas, higher poverty levels, and a greater number of medical oncologists. CONCLUSIONS: We found that patients with metastatic melanoma living in counties with higher proportion of minorities, particularly of Hispanic origin, are more likely to experience delays in ICI treatment. This study provides important population-level data on neighborhood-level disparity in medication use. More research is needed on the underlying provider- and system-level factors that directly contributed to the lower use of cancer medicines in high-minority areas, which can help inform the development of evidence-based medication use strategies that can improve health outcomes and equity.

1359-P: Gaps in the Use of Evidence-Based Diabetes Medications for NASH

Patients with type 2 diabetes (T2D) and nonalcoholic steatohepatitis (NASH) are at exceedingly high risk of NASH progression to cirrhosis and end-stage liver disease. T2D medications shown to improve histologic features of NASH, such as GLP-1 receptor agonists and pioglitazone, should be considered for use in all patients with T2D and NASH, unless contraindications exist. However, utilization of T2D medications that benefit NASH are poorly understood. Our objective was to address this gap by examining their use in patients with T2D and NASH engaged with Primary and/or Endocrinology care in the Duke University Healthcare System between 1/1/2019 and 1/1/2021. T2D and NASH were defined by ICD-10 codes, E11.xx and K75.81, respectively and 848 patients were included in the analyses. Mean age of our cohort was 60 (SD 12) years, 62% were female (n=525), 13% (n=110) were Black race and 4.7% (n=40) were Hispanic ethnicity. The mean HbA1c was 7.5% (SD 1.5), and the majority followed with Endocrinology (58.5%, n=496) and used insulin (62.4%, n=529). Only 26.3% (n=223) had an appointment with Duke Hepatology during the study period (either new consultation or follow-up visit). The use of evidence-based T2D medications for NASH was low (34.8%, n=295), with only 31.3% (n=265) and 6.5% (n=55) of patients having been prescribed a GLP-1 receptor agonist or pioglitazone during the study period, respectively. Prescriptions of these medications did not significantly vary by race (Black vs. White unadjusted OR 1.08, 95% CI 0.71, 1.64) or Hispanic ethnicity (unadjusted OR, 1.46, 95% CI 0.77, 2.79). In summary, we observed a large gap between recommended and current use of evidence-based medications for NASH in patients with T2D. Use of pioglitazone was particularly low, despite its low cost and longstanding evidence for use in NASH. Future studies should explore reasons for underuse of these evidence-based T2D medications in NASH, and whether this is changing over time with growing evidence supporting their use in NASH. Disclosure A. Alexopoulos: None. A. Parish: None. M. Olsen: None. B. Batch: Advisory Panel; LLENA (AI). C.A. Moylan: Advisory Panel; Boehringer Ingelheim Inc. Research Support; GlaxoSmithKline plc. M.J. Crowley: None. Funding National Institutes of Health (KL2TR002554)

Is Use of Evidence-Based Medications One Year After an Acute Coronary Syndrome Related to the Severity of Left Ventricular Systolic Dysfunction?

Beta blockers (BB), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), and mineralocorticoid receptor antagonists (MRA) improve outcomes following an acute coronary syndrome (ACS) in patients with a reduced left ventricular ejection fraction (LVEF). Treatment benefits are greater with lower LVEF and higher dose. Dispensing of BB, ACEi/ARB, and MRA, and the number (%) taking ≥50% of the recommended dose at one year were audited in 1,444 ACS patients admitted to three New Zealand hospitals between 2015 and 2019, who had a predischarge LVEF <50%, and were alive at 12 months. Results are summarised in the Table.TableMedication dispensedLVEF <30% n=159LVEF 30%–40% n=606LVEF 41%–<50% n=679Beta blockerDischarge143 (90%)503 (83%)563 (83%)One year119 (75%)478 (79%)533 (78%)Dose ≥50% recommended48 (30%)131 (22%)119 (18%)ACEi or ARBDischarge137 (86%)483 (80%)561 (83%)One year108 (68%)471 (77%)535 (79%)Dose ≥50% recommended27 (17%)127 (21%)131 (19%)MRADischarge52 (33%)87 (14%)26 (4%)One year49 (31%)97 (16%)34 (5%)Dose ≥50% recommended27 (17%)60 (10%)21 (3%) Open table in a new tab In ACS patients with a reduced LVEF, evidence-based medications were poorly targeted to those with the lowest LVEF, often stopped after discharge, and the dose seldom increased. Strategies are needed to improve long-term use of evidence-based medications, especially in high-risk patients. This study is consistent with other large registries.

Predictors of Evidence-Based Medication Use Among Black Patients With Hypertension and CKD

Predictors of Evidence-Based Medication Use Among Black Patients With Hypertension and CKD

Prevalence of standard modifiable cardiovascular risk factors in patients with ST segment elevation myocardial infarction and its relation with outcomes

Abstract Background It has been recently suggested that more than 15% of patients with ST-segment–elevation myocardial infarction (STEMI) lack any of the standard modifiable risk factors (cigarette smoking, diabetes, hyperlipidemia, and hypertension -SMuRFs). This claim implies that other factors play a significant role in development of STEMI and has led to considerable interest in genetic causes of coronary heart disease including family history (FHx) Purpose To investigate whether FHx may be a significant driver for STEMI in patients without SMuRFs. Methods We analyzed 11,840 patients with ACSs, without evidence of prior cardiovascular disease (CVD) enrolled in the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry between January 2010 to January 2021. Main outcome measures were the adjusted rates of STEMI and 30-day mortality from STEMI using multivariable logistic regression models. Patients presenting with non-ST elevation acute coronary syndromes served as controls. Results Among patients with STEMI, at least 1 of the 4 conventional risk factors was present in 88.1% of women and 86.7% of men. Overall, 3,194 patients (27.0%) self-reported a FHx of CV disease, defined as a first-degree relative with premature CV events (men, age &amp;lt;55 years; women, age &amp;lt;65 years). There were 261 (8.2%) patients with FHx but without SMuRFs and 2,933 (91.8%) patients with FHx and SMuRFs. After adjusting for age, and standard risk factors, FHx was associated with a significantly lower incidence of STEMI in patients with SMuRFs, but not in those without SMuRFs (ORs: 0.87; 95% Cl: 0.79 to 0.97 vs 0.80; 95% Cl: 0.58 to 1.12). Prior use of evidence-based medications (aspirin, beta-blockers, ACE inhibitors/ARBs and statins) did not consistently change prior estimates on FHx and SMuRFs (OR: 0.82 95% Cl: 0.71 to 0.96 and OR 0.89 95% CI: 0.54–1.47). Patients who presented with STEMI had a 46% excess risk of 30-day mortality (OR: 1.46; 95% CI: 1.11 to 1.91; p&amp;lt;0.001) compared with controls Conclusions In direct contrast with recent findings, almost 90% of patients with STEMI have SMuRFs. Self-reported FHx is not a significant risk factor for development of STEMI and related high rate of CV mortality in patients without SMuRFs. Although research on genetic causes of heart disease is important, public health policies, and research efforts should place significant emphasis on the 4 SMuRFs and the lifestyle behaviors causing them to reduce the epidemic of STEMI. Funding Acknowledgement Type of funding sources: None.

A Unique Multi- and Interdisciplinary Cardiology-Renal-Endocrine Clinic: A Description and Assessment of Outcomes.

Background:Patients with diabetes and co-existing chronic kidney disease and/or cardiovascular disease have complex medical needs with multiple indications for different guideline-directed medical therapies and require high health care resource utilization. The Cardiac and Renal Endocrine Clinic (C.a.R.E. Clinic) is a multi- and interdisciplinary clinic offering a unique care model to this population to overcome barriers to optimal care.Objective:To describe the patient characteristics and clinical data of consecutive patients seen in the C.a.R.E. Clinic between 2014 and 2020, with a focus on the feasibility, strengths, and challenges of this outpatient care model.Design:Single-center retrospective cohort study.Setting:The C.a.R.E. Clinic is a multi- and interdisciplinary clinic at Toronto General Hospital in Toronto, Canada.Patients:We reviewed the charts of all 118 patients who had been referred to the C.a.R.E. Clinic with type 2 diabetes mellitus, co-existing renal disease, and/or cardiovascular disease.Measurements:Demographic data, medication data, clinic blood pressure measurements, and laboratory data were assessed at the first and last available clinic visit.Methods:Data were extracted via manual chart review of paper and electronic medical records.Results:First and last attended clinic visit data were available for descriptive analysis in 74 patients. There was a significant improvement in low-density lipoprotein (LDL) cholesterol (1.9 mmol/L vs 1.5 mmol/L, P < .01), hemoglobin A1C (7.5% vs 7.1%, P = .02), and the proportion of patients with blood pressure at target (52.7% vs 36.5%, P = .04), but not body mass index (29.7 kg/m² vs 29.6 kg/m², P = .15) between the last and first available clinic visits. There was higher uptake in evidence-based medication use including statins (93.2% vs 81.1%, P = .01), SGLT-2i (35.1% vs 4.1%, P < .01), and GLP-1 receptor agonists (13.5% vs 4.1%, P = .02), while RAAS inhibitor use was already high at baseline (81.8% vs 78.4%, P = .56). There remains a significant opportunity for therapy with sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists.Limitations:This is a retrospective chart review lacking a control group, therefore clinical improvements cannot be causally attributed to the clinic alone. New evidence and changes to guideline-recommended therapies also contributed to practice changes during this time period.Conclusions:A multi- and interdisciplinary clinic is a feasible and potentially effective way to improve evidence-based and patient-centered care for patients with diabetes, kidney, and cardiovascular disease.

Atherothrombotic residual risk in coronary and peripheral artery disease patients on guideline-recommended antiplatelet monotherapy: baseline preliminary results from the RESRISK study

Abstract Introduction Greater recognition of a multi-factorial approach to risk factor control and use of guideline-recommended evidence-based therapies, including antiplatelets, have led to a decline in recurrent cardiovascular (CV) events among those with atherosclerotic CV disease (ASCVD). While residual risk still persists, recent evidence-based therapies have emerged which could further attenuate CV risk in these individuals, including novel drugs adjunct to antiplatelet therapies. Purpose The RESRISK study aims to quantify the residual atherothrombotic risk among a routine care cohort with ASCVD on guideline-recommended antiplatelet monotherapy (APMT). As a first step, we assessed the characteristics of participants at entry in the study, including risk factor burden, comorbidities and use of evidence-based medications. Methods A retrospective (2010–18) cohort of 758,325 patients with coronary (CAD) or peripheral artery disease (PAD) aged ≥18 years was derived from the UK Clinical Practice Research Datalink. Patients were selected if they were on recommended APMT according to ESC guidelines and NICE (aspirin for CAD; clopidogrel for PAD), were diagnosed with CAD/PAD prior to initiating APMT, and had ≥1 year of baseline data prior to index date (date of first APMT prescription). History of atrial fibrillation and haemorrhagic stroke led to exclusion. Results 174,210 patients with CAD (and no prior history of PAD) and 11,050 patients with PAD (and no prior history of CAD) met the inclusion criteria. Within the selection process for the PAD cohort, 51,114 patients were excluded due to being prescribed aspirin instead of clopidogrel. Baseline characteristics are shown in Table. Mean age was ∼70 years for both cohorts. While prevalence of hypertension was similar in both cohorts, presence of diabetes was 1.6 times higher in PAD patients. Stroke was 2.5 times more prevalent among PAD patients. The proportion of patients with systolic/diastolic blood pressure ≤130/≤85 mmHg were 41.6%/84.5% for CAD and 32.2%/80.6% for PAD (corresponding numbers for ≤140/≤90 mmHg were 67.8%/93.4% for CAD, and 58.8%/91.1% for PAD). Mean LDL-C was 2.4±0.9 and 2.6±1.1 mmol/L in CAD and PAD patients, with 10.7% and 9.5% of them, respectively, having an LDL-C &amp;lt;1.4 mmol/L (25.1% and 22.6% for LDL-C &amp;lt;1.8). Conclusions Among a contemporary cohort with ASCVD on guideline-recommended APMT, risk factor burden is high and attainment of guideline-recommended targets remains largely suboptimal. Prevalence of diabetes among PAD patients is particularly high. A large gap exists between guideline recommendations and guideline-recommended goal attainment. Greater attention to risk factor control and use of appropriate evidence-based therapy is required to reduce the potential risk of recurrent events among this high-risk population. Subsequent follow-up analysis with linkage to outcomes will provide quantification of the consequences of current practice on residual risk. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): All financial support for this research has been provided by Bayer plc. Table 1

Greater burden of risk factors and less effect of cardiac rehabilitation in elderly with low educational attainment: The Eu-CaRE study.

Socioeconomic status is a strong predictor of cardiovascular health. The aim of this study was to describe the immediate and long-term effects of cardiac rehabilitation (CR) across socioeconomic strata in elderly cardiac patients in Europe. The observational EU-CaRE study is a prospective study with eight CR sites in seven European countries. Patients ≥65 years with coronary heart disease or heart valve surgery participating in CR were consecutively included. Data were obtained at baseline, end of CR and at one-year follow up. Educational level as a marker for socioeconomic status was divided into basic, intermediate and high. The primary endpoint was exercise capacity (peak oxygen consumption (VO2peak)). Secondary endpoints were cardiovascular risk factors, medical treatment and scores for depression, anxiety and quality of life (QoL). A total of 1626 patients were included; 28% had basic, 48% intermediate and 24% high education. A total of 1515 and 1448 patients were available for follow-up analyses at end of CR and one-year, respectively. Patients with basic education were older and more often female. At baseline we found a socioeconomic gradient in VO2peak, lifestyle-related cardiovascular risk factors, anxiety, depression and QoL. The socioeconomic gap in VO2peak increased following CR (p for interaction <0.001). The socioeconomic gap in secondary outcomes was unaffected by CR. The use of evidence-based medication was good in all socioeconomic groups. We found a strong socioeconomic gradient in VO2peak and cardiovascular risk factors that was unaffected or worsened after CR. To address inequity in cardiovascular health, the individual adaption of CR according to socioeconomic needs should be considered.

Usefulness of a personalized algorithm-based discharge checklist in patients hospitalized for acute heart failure.

AimsThe aim of this study is to evaluate the usefulness of a personalized discharge checklist (PCL) based on simple baseline characteristics on mortality, readmission for heart failure (HF), and quality of care in patients hospitalized for acute HF.Methods and resultsWe designed an algorithm to generate PCL, based on 2016 HF European Society of Cardiology Guidelines and the screening of common comorbidities in elderly HF patients. We prospectively included 139 patients hospitalized for HF from May 2018 to October 2018. A PCL was fulfilled for each patient at admission and 24 to 48 hours before the planned discharge. A control cohort of 182 consecutive patients was retrospectively included from May 2017 to October 2017. The primary composite endpoint was mortality or readmission for HF at 6 months. The secondary endpoints were mortality, readmission for HF, and quality of care (evidence‐based medications, management of HF comorbidities, and planned care plan). There was no difference among baseline characteristics between PCL and control cohorts; mean age was 78.1 ± 12.2 vs. 79.0 ± 12.5 years old (P = 0.46) and 61 patients (43.9%) vs. 63 (34.6%) had HF with left ventricular ejection fraction (LVEF) <40% (P = 0.24). During the 6 month follow‐up period, 59 patients (42.4%) reached the primary endpoint in the PCL cohort vs. 92 patients (50.5%) in the control cohort [hazard ratio (HR): 0.79, 95% confidence interval (CI) (0.57–1.09), P = 0.15]. Subgroup analysis including only patients with either altered (<40%) or mid‐range or preserved (≥40%) LVEF showed no significant difference among groups. There was a non‐significant trend toward a reduction in HF readmission rate in the PCL group [38 patients (27.3%) vs. 64 patients (35.2%), HR: 0.73, 95%CI (0.49–1.09), P = 0.13]. There was no difference regarding survival or the use of evidence‐based medications. A higher proportion of patients were screened and treated for iron and vitamin D deficiencies (53.2% vs. 35.7%, P < 0.01 and 73.4% vs. 29.7%, P < 0.01, respectively), as well as malnutrition supplemented in the PCL group. There was a higher referral to HF follow‐up programme in the PCL group but not to telemedicine or cardiac rehabilitation programs.ConclusionsIn this preliminary study, the use of a PCL did not improve outcomes at 6 months in patients hospitalized for acute HF. There was a non‐significant trend towards a reduction in HF readmission rate in the PCL group. In addition, the management of HF comorbidities was significantly improved by PCL with a better referral to follow‐up programme. A multicentre study is warranted to assess the usefulness of a simple costless personalized checklist in a large HF patients' population.

P764A quality improvement program for heart failure involving structured patient data, diagnosis and organization of care - results from the 4D heart failure project

Abstract Background Heart failure (HF) management is suboptimal in Sweden despite available evidence-based treatments. Purpose We hypothesized that a comprehensive organizational improvement programme could improve HF management, treatment and outcome. Methods Between 2012 and 2017 a HF improvement programme (the 4D Heart Failure project) was conducted in an urban region in Sweden (&gt;2.2 million inhabitants). The steering committee led working groups 2012–17 including all health care providers with 250 primary care centers to build a standardized care process. HF outpatient care was centralized at five hospital-based HF clinics and included multidisciplinary health care teams. The outcomes were: 1) prescription withdrawals of HF medication (RAS-inhibitors and beta-blockers, MRA) per year, expressed as percentage (%), 2) one-year all-cause mortality or heart failure readmission by multivariable Cox regression, 3) total number of admitted HF patients, subdivided by new-onset and previously known HF, per million inhabitants and year. Results Between 2012 and 2017, yearly visits to the five HF clinics increased 3.5 times from 3200 to 11700, to a total of 47400 visits or 15800 patients (average 3 visits/patient). Prescription withdrawals of MRAs for readmitted HF patients increased from 37% to 60%, of beta-blockers and RAS-inhibitors from 80 to 90%. Similar increases were noted for all admitted patients. One-year mortality or HF readmission was 48% (n=17124/35880) over the period and decreased significantly (adjusted HR 0.98 per year, 95% CI 0.97–0.99, p&lt;0.001). Number of admitted HF patients, new-onset or readmitted HF patients decreased by 16%, 13% and 20%, respectively (p&lt;0.0001, Figure). Numbers of admitted patients 2012-2017 Conclusion A comprehensive standardized care HF management programme in an urban region substantially increased access to multidisciplinary hospital-based HF clinics, and increased use of evidence-based medications. HF admissions and readmissions were reduced, as was the risk of one-year mortality or HF rehospitalization. Acknowledgement/Funding County of Stockholm and the Karolinska Institute

P2509Less effect of cardiac rehabilitation for elderly cardiac patients with lower educational attainment

Abstract Background Previous analyses from EU-CaRE study have shown that elderly cardiac patients with basic education have a greater burden of cardiovascular risk factors and a lower exercise capacity at baseline of cardiac rehabilitation (CR). We hypothesize that participation in CR will diminish this socioeconomic gap. Purpose To describe if educational level predicts the benefits of CR in an elderly population in Europe. Methods The observational EU-CaRE study is a prospective study with eight participating CR centers in seven countries (Denmark, France, Germany, the Netherlands, Italy, Spain and Switzerland). Consecutive patients age 65 or older with coronary heart disease or valve surgery participating in CR were included. Data were obtained at baseline (T0) and at the end of CR (T1) and include risk factors for cardiovascular disease, clinical and psychological assessment, medical treatment and exercise capacity. Patients were divided into basic, intermediate and higher educational levels. We compared changes from T0-T1 by multiple regression models. Results A total of 1621 (99% of included) patients were eligible for follow-up analyses. At baseline patients with basic education had more diabetes, higher BMI, lower exercise capacity (VO2 peak) and higher scores for depression (GAD) and anxiety (PHQ-9). At T1 they had improved significantly less on these parameters. The results were not affected by adjustment for gender, age, country and baseline value of the variable. Use of evidence-based medication did not differ by level of education. Difference between T0 and T1 Factor High Intermediate Basic p-value* N total 1621 N=386 N=775 N=460 BMI, mean (SD) −0.16 (0.71) −0.08 (0.82) −0.26 (0.95) 0.794 LDL (mmol/L), mean (SD) −0.07 (0.63) −0.11 (0.62) −0.04 (0.58) 0.978 HbA1c (mmol/mol), mean (SD) 0.23 (3.70) 0.52 (4.39) 0.04 (5.79) 0.021 GAD score, mean (SD) −0.92 (2.72) −0.76 (3.07) −0.13 (3.47) 0.003 PHQ-9 score, mean (SD) −1.45 (3.21) −1.16 (3.36) −0.93 (4.49) &lt;0.001 Diet score, mean (SD) 0.57 (1.72) 0.63 (1.90) 0.23 (1.81) 0.003 VO2 peak (ml/kg/min), mean (SD) 2.47 (2.90) 1.95 (2.78) 1.75 (2.56) 0.016 *Adjusted for gender, age, country and baseline value. Difference in VO2peak, GAD and PHQ score Conclusions In this large European study with high-quality data from 7 CR centers we found an increased gap disfavoring the lower educated elderly patients participating in CR. These results indicate that “one-size cardiac rehabilitation” does not fit all and indicate that a more personalized CR with attention to the different needs of some patient groups is appropriate. Acknowledgement/Funding Horizon2020

Twenty-year trends in profile, management and outcomes of patients with ST-segment elevation myocardial infarction according to use of reperfusion therapy: Data from the FAST-MI program 1995-2015

We used data from 5 one-month French nationwide registries, conducted 5 years apart from 2005 to 2015, including 8579 STEMI patients (67% with and 33% without reperfusion therapy) admitted to cardiac intensive care units in France. Use of reperfusion therapy increased from 49% in 1995 to 82% in 2015, with a shift from fibrinolysis (37.5% to 6%) to pPCI (12% to 76%). Early use of evidence-based medications gradually increased over the period in both patients with and without reperfusion therapy, although it remained lower at all times in those without reperfusion therapy. One-year mortality decreased in patients with reperfusion therapy (from 11.9% in 1995 to 5.9% in 2010 and 2015, hazard ratio [HR] adjusted on baseline profile 0.40; 95% CI: 0.29-0.54, P < .001) and in those without reperfusion therapy (from 25.0% to 18.2% in 2010 and 8.1% in 2015, HR: 0.33; 95% CI: 0.24-0.47, P < .001). In STEMI patients, one-year mortality continues to decline, both related to increased use of reperfusion therapy and progress in overall patient management. In patients with reperfusion therapy, mortality has remained stable since 2010, while it has continued to decline in patients without reperfusion therapy.

Assessing suitability for sacubitril-valsartan therapy in an Irish cohort: challenges and opportunities

Sacubitril-valsartan has been shown by the PARADIGM-HF trial to decrease hospital admissions and improve mortality in patients with heart failure with reduced ejection fraction. The PARADIGM trial had stringent exclusion criteria. It is not known how applicable these trial criteria are to real-life practice. In this study, we sought to determine the percentage of patients eligible for sacubitril-valsartan therapy in a level 3 hospital without a dedicated heart failure service. All patients discharged from our service with a diagnosis of congestive cardiac using our hospital in-patient enquiry (HIPE) system underwent hierarchal analysis. In order to be deemed eligible for sacubitril-valsartan therapy, patients had to meet PARADIGM-HF inclusion criteria. Our 143 patients represented a more clinically unwell, elderly cohort than the PARADIGM trial study population. Only 24 patients (16.66%) had an ejection fraction of 40% or less. Our results indicate that only 4/143 patients in a real-world setting (2.79%) were eligible for sacubitril-valsartan therapy at the point of discharge as per the PARADIGM-HF study criteria. This is primarily due to the higher than expected percentage of patients in our cohort with an ejection fraction of over 40% (n = 120) and the low percentage of patients on therapeutic doses of ACEI/ARB (n = 15). Our study showed that a smaller than expected proportion of our patients in real-world practice are suitable for sacubitril-valsartan therapy at discharge. Most patients were in the HFPEF cohort which does not currently have evidence for treatment with sacubitril-valsartan. Low rates of prescribing of basic heart failure medicatons and the absence of dedicated heart failure services in a non-tertiary centre may explain the poor compliance observed. Improving guideline adherence and increasing awareness of evidence-based medication use at primary and secondary care levels would be of benefit to Irish heart failure patients.

Osteoporosis Medication Use: A Comparison of Elderly Females Living in Long-term Care Facilities Versus Community Dwellers.

OBJECTIVE: This study compares patterns of evidence-based osteoporosis medication use among females in community and long-term care settings enrolled in Medicare Part D.<br/> DESIGN: Pooled cross-sectional study.<br/> SETTING: Medicare beneficiaries enrolled in Medicare Parts A and B, and Part D stand-alone prescription drug plans from January 1, 2006, through December 31, 2008, or death.<br/> PARTICIPANTS: Female Medicare Part D enrollees 70 years of age and older with osteoporosis or prior hip fracture.<br/> INTERVENTIONS: NA.<br/> MAIN OUTCOME MEASUREMENTS: Use of bisphosphonates, calcitonin, teriparatide, and raloxifene was tracked by residential status over the three-year period.<br/> RESULTS: The study sample comprised 96,408 female Part D enrollees with osteoporosis. Prevalence of evidence-based medication use was 42.3% in 2006 and dropped slightly to 40.4% in 2008. In unadjusted comparisons, long-term care residents were significantly less likely to use any osteoporosis medication compared with community dwellers (40.6% vs. 53.1%). After adjustment for differences in individual characteristics, utilization was still lower among long-term care residents (relative risk [RR] = 0.89, 95% confidence interval [CI] 0.87-0.91). Bisphosphonates were the top choice among medication users, but were prescribed much less often to long-term care residents (RR = 0.79, 95% CI 0.75-0.83) compared with community residents.<br/> CONCLUSION: Prevalence of evidence-based osteoporosis medication use is low in older women enrolled in Part D whether community-dwelling or long-term care residents, but long-term nursing facility residents are more likely to be treated with nonbisphosphonates. Many events that may affect osteoporosis medication use occurred after 2008; therefore, future studies using more recent data are warranted to examine osteoporosis medication use after 2008.

Osteoporosis Medication Use: A Comparison of Elderly Females Living in Long-term Care Facilities Versus Community Dwellers

OBJECTIVE: This study compares patterns of evidence-based osteoporosis medication use among females in community and long-term care settings enrolled in Medicare Part D.<br/> DESIGN: Pooled cross-sectional study.<br/> SETTING: Medicare beneficiaries enrolled in Medicare Parts A and B, and Part D stand-alone prescription drug plans from January 1, 2006, through December 31, 2008, or death.<br/> PARTICIPANTS: Female Medicare Part D enrollees 70 years of age and older with osteoporosis or prior hip fracture.<br/> INTERVENTIONS: NA.<br/> MAIN OUTCOME MEASUREMENTS: Use of bisphosphonates, calcitonin, teriparatide, and raloxifene was tracked by residential status over the three-year period.<br/> RESULTS: The study sample comprised 96,408 female Part D enrollees with osteoporosis. Prevalence of evidence-based medication use was 42.3% in 2006 and dropped slightly to 40.4% in 2008. In unadjusted comparisons, long-term care residents were significantly less likely to use any osteoporosis medication compared with community dwellers (40.6% vs. 53.1%). After adjustment for differences in individual characteristics, utilization was still lower among long-term care residents (relative risk [RR] = 0.89, 95% confidence interval [CI] 0.87-0.91). Bisphosphonates were the top choice among medication users, but were prescribed much less often to long-term care residents (RR = 0.79, 95% CI 0.75-0.83) compared with community residents.<br/> CONCLUSION: Prevalence of evidence-based osteoporosis medication use is low in older women enrolled in Part D whether community-dwelling or long-term care residents, but long-term nursing facility residents are more likely to be treated with nonbisphosphonates. Many events that may affect osteoporosis medication use occurred after 2008; therefore, future studies using more recent data are warranted to examine osteoporosis medication use after 2008.

Medication Use in Women and Men With Sudden Unexpected Death.

In Wake County, NC, sudden unexpected death accounts for 10% to 15% of all natural deaths in individuals 18 to 64 years old. Medications such as aspirin, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins, and β-blockers are recommended in guidelines to reduce cardiovascular events and even sudden death (β-blockers). However, guidelines are often underpracticed, even in high-risk patients, with noted disparities in women. We assessed the relation between prescription of evidence-based medications and sudden unexpected death in Wake County, NC. We analyzed 399 cases of sudden unexpected death for the time period March 1, 2013 to February 28, 2015 in Wake County, NC. Medications were assessed from available medical examiner reports and medical records and grouped using the third level of the Anatomical Therapeutic Chemical Classification System (ATC) codes. This study was reviewed and exempt by the University of North Carolina's institutional review board. Among 126 female and 273 male victims, women were prescribed more medications overall than men (6.5 vs 4.3, P = 0.001); however, the use of guideline-directed therapies was not different between genders in the chronic conditions associated with sudden death. Overall, there was remarkably low use of evidence-based medications. Our findings highlight the need to improve prescribing of evidence-based medications and to further explore the relationship between undertreatment and sudden unexpected death.

Physician follow-up and long-term use of evidence-based medication for patients with hypertension who were discharged from an emergency department: a prospective cohort study.

More than 25% of the population has hypertension. The number of patients seeking care for hypertension in emergency departments has increased by more than 60% in the last decade, with less than 10% of these patients subsequently admitted to hospital. Managing physicians recommend early follow-up to patients who are discharged from the emergency department, but there is a paucity of literature assessing the impact or timing of follow-up on patient outcomes. Using a population-based cohort design, we included patients more than 65 years of age who were discharged from an Ontario emergency department with a primary diagnosis of hypertension between 2007 and 2014. We identified 2 cohorts: an incident cohort, and a cohort in which patients were on no more than 1 class of evidence-based antihypertensive medication at the time of presentation. Using logistic regression, we assessed the association of early follow-up care (within 7 d) and basic care (8-30 d), compared with no care within 30 days, on patient use of a new evidence-based antihypertensive medication 1 year later. Our study included 2088 patients with a new diagnosis of hypertension (the first cohort), and 6420 patients in the second cohort. Of patients with new diagnoses, 48.2% and 30.2% obtained early and basic follow-up care, respectively, compared with 50.0% and 30.9% of patients in the second cohort. Compared with patients without follow-up care within 30 days, the adjusted odds of filling an evidence-based antihypertensive medication prescription 1 year later in the incident group were 2.36 (95% confidence interval [CI] 1.86-2.99) for those who received early care, and 2.00 (95% CI 1.55-2.58) for those who received basic care. The adjusted odds in the second cohort were 2.12 (95% CI 1.84-2.43) and 1.96 (95% CI 1.69-2.27), respectively. Early follow-up care after leaving an emergency department with a diagnosis of hypertension was associated with improved long-term use of evidence-based antihypertensive medication. As patients increasingly present to the emergency department for hypertension, a formal, timely follow-up care system could improve patient use of evidence-based antihypertensive medication.

Time Trends in Lifestyle, Risk Factor Control, and Use of Evidence-Based Medications in Patients With Coronary Heart Disease in Europe: Results From 3 EUROASPIRE Surveys, 1999-2013.

The EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) cross-sectional surveys describe time trends in lifestyle and risk factor control among coronary patients between 1999 and 2013 in Belgium, Czech Republic, Finland, France, Ireland, the Netherlands, Poland, Slovenia, and the United Kingdom as part of the EuroObservational Research Programme under the auspices of European Society of Cardiology. This study sought to describe time trends in lifestyle, risk factor control, and the use of evidence-based medication in coronary patients across Europe. The EUROASPIRE II (1999 to 2000), III (2006 to 2007), and IV (2012 to 13) surveys were conducted in the same geographical areas and selected hospitals in each country. Consecutive patients (≤70 years) after coronary artery bypass graft, percutaneous coronary intervention, or an acute coronary syndrome identified from hospital records were interviewed and examined ≥6 months later with standardized methods. Of 12,775 identified coronary patients, 8,456 (66.2%) were interviewed. Proportion of current smokers was similar across the 3 surveys. Prevalence of obesity increased by 7%. The prevalence of raised blood pressure (≥140/90 mm Hg or ≥140/80 mm Hg with diabetes) dropped by 8% from EUROASPIRE III to IV, and therapeutic control of blood pressure improved with 55% of patients below target in IV. The prevalence of low-density lipoprotein cholesterol ≥2.5 mmol/l decreased by 44%. In EUROASPIRE IV, 75% were above the target low-density lipoprotein cholesterol <1.8 mmol/l. The prevalence of self-reported diabetes increased by 9%. The use of evidence-based medications increased between the EUROASPIRE II and III surveys, but did not change between the III and IV surveys. Lifestyle habits have deteriorated over time with increases in obesity, central obesity, and diabetes and stagnating rates of persistent smoking. Although blood pressure and lipid management improved, they are still not optimally controlled and the use of evidence-based medications appears to have stalled apart from the increased use of high-intensity statins. These results underline the importance of offering coronary patients access to modern preventive cardiology programs.

The impact of medication adherence on clinical outcomes of coronary artery disease: A meta-analysis.

Background Long-term use of evidence-based medications is recommended by international guidelines for the management of stable coronary artery disease, however, non-adherence to medications is common. This meta-analysis aims to systematically evaluate the impact of medication adherence on clinical outcomes in patients with stable coronary artery disease. Methods Articles from January 1960-December 2015 were retrieved from the MEDLINE and EMBASE databases without any language restriction. A meta-analysis was performed to investigate the risk ratios of all-cause mortality, cardiovascular mortality, and myocardial infarction/hospitalization between groups with good medication adherence and poor medication adherence. Studies were independently reviewed by two investigators. Data from eligible studies were extracted, and the meta-analysis was performed using R Version 3.1.0 software. Results A total of 10 studies were included in the analysis, with a total of 106,002 coronary artery disease patients. The results showed that good adherence to evidence-based medication regimens, including β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antiplatelet drugs, and statins, was related to a lower risk of all-cause mortality(risk ratio 0.56; 95% confidence interval: 0.45-0.69), cardiovascular mortality(risk ratio 0.66; 95% confidence interval: 0.51-0.87), and cardiovascular hospitalization/myocardial infarction(risk ratio 0.61; 95% confidence interval: 0.45-0.82). Conclusions This meta-analysis confirms the significant impact of good medication adherence on clinical outcomes in patients with stable coronary artery disease. More strategy and planning are needed to improve medication adherence.