Whom are we treating with lipid-lowering drugs? Are we following the guidelines? Evidence from a population-based study: the Troms� study 2001

Clinical and Genetic Risk Factors for Adverse Metabolic Outcomes in North American Testicular Cancer Survivors

Background: Testicular cancer survivors (TCS) are at significantly increased risk for cardiovascular disease (CVD), with metabolic syndrome (MetS) an established risk factor. No study has addressed clinical and genetic MetS risk factors in North American TCS. Patients and Methods: TCS were aged <55 years at diagnosis and received first-line chemotherapy. Patients underwent physical examination, and had lipid panels, testosterone, and soluble cell adhesion molecule-1 (sICAM-1) evaluated. A single nucleotide polymorphism in rs523349 (5-α-reductase gene, SRD5A2), recently implicated in MetS risk, was genotyped. Using standard criteria, MetS was defined as ≥3 of the following: hypertension, abdominal obesity, hypertriglyceridemia, decreased high-density lipoprotein (HDL) cholesterol level, and diabetes. Matched controls were derived from the National Health and Nutrition Examination Survey. Results: We evaluated 486 TCS (median age, 38.1 years). TCS had a higher prevalence of hypertension versus controls (43.2% vs 30.7%; P<.001) but were less likely to have decreased HDL levels (23.7% vs 34.8%; P<.001) or abdominal obesity (28.2% vs 40.1%; P<.001). Overall MetS frequency was similar in TCS and controls (21.0% vs 22.4%; P=.59), did not differ by treatment (P=.20), and was not related to rs523349 (P=.61). For other CVD risk factors, TCS were significantly more likely to have elevated low-density lipoprotein (LDL) cholesterol levels (17.7% vs 9.3%; P<.001), total cholesterol levels (26.3% vs 11.1%; P<.001), and body mass index ≥25 kg/m² (75.1% vs 69.1%; P=.04). On multivariate analysis, age at evaluation (P<.001), testosterone level ≤3.0 ng/mL (odds ratio [OR], 2.06; P=.005), and elevated sICAM-1 level (OR_{highest vs lowest quartile}, 3.58; P=.001) were significantly associated with MetS. Conclusions and Recommendations: Metabolic abnormalities in TCS are characterized by hypertension and increased LDL and total cholesterol levels but lower rates of decreased HDL levels and abdominal obesity, signifying possible shifts in fat distribution and fat metabolism. These changes are accompanied by hypogonadism and inflammation. TCS have a high prevalence of CVD risk factors that may not be entirely captured by standard MetS criteria. Cancer treatment-associated MetS requires further characterization.

Time trends of persistent organic pollutants in 30 year olds sampled in 1986, 1994, 2001 and 2007 in Northern Norway: Measurements, mechanistic modeling and a comparison of study designs

BACKGROUND

Human biomonitoring studies have demonstrated decreasing concentrations of many persistent organic pollutants (POPs) in years after emission peaks.

OBJECTIVES

To describe time trends of POPs in blood using four cross-sectional samples of 30 year olds from Tromsø, Norway across 1986-2007, and to compare the measured concentrations of polychlorinated biphenyl 153 (PCB-153) to model-estimated values. A second objective was to compare the repeated cross-sectional time trends with those observed in our previous longitudinal study using repeated individual measurements in older men from the same surveys.

METHODS

Serum from 45 persons aged 30 years in each of the following years: 1986, 1994, 2001, and 2007 was analyzed for 14 POPs. Further, predicted concentrations of PCB-153 in each sampling year were derived using the emission-based CoZMoMAN model.

RESULTS

The median decreases in summed serum POP concentrations (lipid-adjusted) in 1994, 2001, and 2007 relative to 1986 were - 71%, - 81%, and - 86% for women and - 65%, - 77%, and - 87% for men, respectively. The overall time trend in predicted PCB-153 concentrations demonstrated agreement with the observed trend although model predictions were higher than the measured concentrations at all time points. Compared to our previous longitudinal study of repeated individual measurements in older men, similar although more prominent declines were observed in the younger cross-sectional samples.

DISCUSSION

Observed declines in serum concentrations from 1986 to 2007 were substantial for legacy POPs in men and women at reproductive ages in Northern Norway and are generally consistent with previous longitudinal biomonitoring efforts in the study population. The measured concentrations and observed declines likely reflect a combination of recent and historic exposures. Small differences in time trends observed between the studies could be attributed to different study designs (i.e. the chosen age group or sex and cross-sectional versus repeated individual measurement sampling).

Primary care of patients with high cardiovascular risk : Blood pressure, lipid and diabetic target levels and their achievement in Hungary

Cardiovascular diseases are responsible for the majority of premature deaths in Hungary as well. Most of them could be prevented with healthy lifestyle of patients and adequate drug prescription of primary care physicians. Earlier European surveys found wide differences between the practices and achievements of different countries in this field. The study was based on and designed according to the framework of previous European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) studies and aimed presenting Hungarian results and comparing with the achievements of other countries and previous Hungarian surveys. Among rural and urban settings, 679 patients under continuous care (236 diabetics, 218 with dyslipidaemia, and 225 with hypertension) were consecutively selected by 20 experienced general practitioners. The mean age of patients was 60.3 years (men) and 64.0 years (women). Among diabetics, less than 7 % of glycated hemoglobin (HbA1c) values were found in 42.5 % patients, while only 11.4 % patients had fasting plasma sugar less than 6.0 mmol/L. Of the patients treated for dyslipidaemia, the target level of triglyceride was reached by 40.6 %, recommended total cholesterol by 14.2 % and the HDL-cholesterol by 71.8 %. The therapeutic control of total and HDL-cholesterol was better in men, although women had better triglyceride values. The achievement among patients with hypertension was 42.0 %. Significantly higher blood pressure was measured by patients who were treated with not recommended combinations of antihypertensive medication. A remarkable improvement could be observed in Hungary in the field of secondary prevention. It was greater among patients with hypertension and dyslipidaemia and smaller in diabetes care. Compared to the results of published European surveys, Hungary occupies a good position, but further improvement is still required.

Evaluating an implementation strategy in cardiovascular prevention to improve prescribing of statins in Germany: an intention to treat analysis

BACKGROUND

The prescription of statins is an evidence-based treatment to reduce the risk of cardiovascular events in patients with elevated cardiovascular risk or with a cardiovascular disorder (CVD). In spite of this, many of these patients do not receive statins.

METHODS

We evaluated the impact of a brief educational intervention in cardiovascular prevention in primary care physicians' prescribing behaviour regarding statins beyond their participation in a randomised controlled trial (RCT). For this, prescribing data of all patients > 35 years who were counselled before and after the study period were analysed (each n > 75,000). Outcome measure was prescription of Hydroxymethylglutaryl-CoA Reductase Inhibitors (statins) corresponding to patients' overall risk for CVD. Appropriateness of prescribing was examined according to different risk groups based on the Anatomical Therapeutic Chemical Classification System (ATC codes).

RESULTS

There was no consistent association between group allocation and statin prescription controlling for risk status in each risk group before and after study participation. However, we found a change to more significant drug configurations predicting the prescription of statins in the intervention group, which can be regarded as a small intervention effect.

CONCLUSION

Our results suggest that an active implementation of a brief evidence-based educational intervention does not lead to prescription modifications in everyday practice. Physician's prescribing behaviour is affected by an established health care system, which is not easy to change.

TRIAL REGISTRATION

ISRCTN71348772.

The sixth survey of the Tromso Study (Tromso 6) in 2007-08: collaborative research in the interface between clinical medicine and epidemiology: study objectives, design, data collection procedures, and attendance in a multipurpose population-based health survey

AIMS

To provide a synopsis of the sixth survey of the Tromsø Study, Tromsø 6, objectives and new target areas, study design, follow-up studies, data collection, attendance, and participant characteristics.

METHODS

The Tromsø Study, initiated in 1974, is an epidemiological, prospective study of health conditions and chronic diseases, and a resource for the surveillance of disease risk factors. The purpose of Tromsø 6 (2007-08) was to collect novel and repeated measurements of exposure data and to assess levels of disease risk factors. Tromsø 6 included a main study that comprised two screening visits and several follow-up studies. Main study data collection: First visit (n=12,984): questionnaires, interviews, measurements of height, weight, hip and waist circumference, heart rate, blood pressure, forearm bone density, grip strength, pain sensitivity measurements, and blood and hair samples and nose and throat swab cultures. Second visit (n=7307): sampling of biological specimens (blood, urine, nose and throat swab cultures) and clinical examinations (12-lead electrocardiography, cognitive tests, visual acuity test, retinal photography, carotid ultrasound, spirometry, dual-energy X-ray absorptiometry, and echocardiography.

RESULTS

A total of 12,984 participants aged 30-87 years were examined. The attendance rate was 66%, lower than in previous Tromsø Study surveys. The attendance was lowest in the youngest and oldest, those invited for the first time, and lower in men than women.

CONCLUSIONS

The completion of the survey with this comprehensive data collection went satisfactorily. The decreasing attendance rate calls for new recruitment strategies and optimisation of the study organisation to facilitate attendance.

Lipid lowering treatment patterns and goal attainment in Nordic patients with hyperlipidemia

OBJECTIVES

Observational studies and surveys have shown that lipid-lowering treatment is not optimal neither with regard to number of patients treated nor with number of patients achieving recommended goals. To address this issue in the Nordic countries, we evaluated the published literature on lipid-lowering therapies in preventive cardiology in this region.

DESIGN

Nordic papers published from 2000 throughout 2006 dealing with lipid-lowering management in coronary heart disease prevention were identified. In total, 19 studies were analyzed.

RESULTS

Approximately half of the patients are inadequately treated and have not achieved recommended treatment goals of total cholesterol <5.0 and LDL-cholesterol <3.0 mmol/L. Statins were prescribed most often in low or medium doses. The predictive factors for treatment were cholesterol level, risk of cardiovascular disease, previous cardiovascular disease, age, and gender.

CONCLUSIONS

There is a considerable need to improve standards of preventive cardiology. Statins have to be given evidence based to achieve treatment goals according to lipid levels, and higher doses of statins or combination therapy with a statin and a cholesterol absorption inhibitor or niacin is often needed.

Statin treatment in a cohort of 20 212 men and women in Norway according to cardiovascular risk factors and level of education

AIMS

To study the influence of patients' education and cardiovascular risk factors on the probability of statin treatment.

METHODS

A prospective cohort study of participants in regional health surveys in Norway 2000-2002 with statin use recorded in the Norwegian Prescription Database 2004-2006 as outcome measure. Information on history of cardiovascular disease (CVD) and diabetes, lipid levels, blood pressure, use of cardiovascular drugs, body mass index, family history, smoking, physical activity, marital status and place of residence was obtained at baseline. A total of 20,212 men and women aged 40-41, 45-46 and 59-61 years who reported never use of statins were included. Educational level was retrieved from Statistics Norway. Adjusted relative risks (RR) were estimated by Poisson regression.

RESULTS

Whereas 655 participants reported a history of CVD or diabetes, 19,557 reported no such history. In the non-CVD/diabetes group 1,620 persons (8%) became statin users and 222 persons (34%) in the CVD/diabetes group. RR of becoming a statin user for high vs. low education increased from 0.64 [95% confidence interval (CI) 0.55, 0.73] to 0.91 (95% CI 0.79, 1.05) after adjustment in the non-CVD/diabetes group and from 0.94 (95% CI 0.70, 1.26) to 1.35 (95% CI 1.00, 1.81) in the CVD/diabetes group.

CONCLUSIONS

Patients with no history of CVD/diabetes were prescribed statins according to cardiovascular risk independent of education. There was a tendency to a higher probability of statin treatment among highly educated compared with people of lower educational level in the group with a history of CVD or diabetes, after adjustment for other CVD risk factors, particularly in women.

Implementing the European guidelines for cardiovascular disease prevention in the primary care setting in Cyprus: lessons learned from a health care services study

BACKGROUND

Recent guidelines recommend assessment and treatment of the overall risk for cardiovascular disease (CVD) through management of multiple risk factors in patients at high absolute risk. The aim of our study was to assess the level of cardiovascular risk in patients with known risk factors for CVD by applying the SCORE risk function and to study the implications of European guidelines on the use of treatment and goal attainment for blood pressure (BP) and lipids in the primary care of Cyprus.

METHODS

Retrospective chart review of 1101 randomly selected patients with type 2 diabetes mellitus (DM2), or hypertension or hyperlipidemia in four primary care health centres. The SCORE risk function for high-risk regions was used to calculate 10-year risk of cardiovascular fatal event. Most recent values of BP and lipids were used to assess goal attainment to international standards. Most updated medications lists were used to compare proportions of current with recommended antihypertensive and lipid-lowering drug (LLD) users according to European guidelines.

RESULTS

Implementation of the SCORE risk model labelled overall 39.7% (53.6% of men, 31.3% of women) of the study population as high risk individuals (CVD, DM2 or SCORE > or =5%). The SCORE risk chart was not applicable in 563 patients (51.1%) due to missing data in the patient records, mostly on smoking habits. The LDL-C goal was achieved in 28.6%, 19.5% and 20.9% of patients with established CVD, DM2 (no CVD) and SCORE > or =5%, respectively. BP targets were achieved in 55.4%, 5.6% and 41.9% respectively for the above groups. There was under prescription of antihypertensive drugs, LLD and aspirin for all three high risk groups.

CONCLUSION

This study demonstrated suboptimal control and under-treatment of patients with cardiovascular risk factors in the primary care in Cyprus. Improvement of documentation of clinical information in the medical records as well as GPs training for implementation and adherence to clinical practice guidelines are potential areas for further discussion and research.

Aspects of statin prescribing in Norwegian counties with high, average and low statin consumption - an individual-level prescription database study

Background

A previous study has shown that variations in threshold and intensity (lipid goal attainment) of statins for primary prevention contribute to regional differences in overall consumption of statins in Norway. Our objective was to explore how differences in prevalences of use, dosing characteristics, choice of statin and continuity of therapy in individual patients adds new information to previous results.

Methods

Data were retrieved from The Norwegian Prescription Database. We included individuals from counties with high, average, and low statin consumption, who had at least one statin prescription dispensed during 2004 (N = 40 143).

1-year prevalence, prescribed daily dose (PDD), statin of choice, and continuity of therapy assessed by mean number of tablets per day.

Results

The high-consumption county had higher prevalence of statin use in all age groups.

Atorvastatin and simvastatin were dispensed in 79–87% of all statin users, and the proportion was significantly higher in the high-consumption county.

The estimated PDDs were higher than the DDDs, up to twice the DDD for atorvastatin. The high-consumption county had the highest PDD for simvastatin (25.9 mg) and atorvastatin (21.9 mg), and more users received tablets in the upper range of available strengths. Continuity of therapy was similar in the three counties.

Conclusion

Although differences in age-distribution seems to be an important source of variation in statin consumption, it cannot account for the total variation between counties in Norway. Variations in prevalences of use, and treatment intensity in terms of PDD and choice of statin also affect the total consumption. The results in this study seems to correspond to previous findings of more frequent statin use in primary prevention, and more statin users achieving lipid goal in the highest consuming county.

Which population groups should be targeted for cardiovascular prevention? A modelling study based on the Norwegian Hordaland Health Study (HUSK)

OBJECTIVE

To assess level of cardiovascular risk factors in a non-selected, middle-aged population. To estimate the proportion target for risk intervention according to present guidelines and according to different cut-off levels for two risk algorithms.

DESIGN

Population survey, modelling study.

SETTING

The Norwegian Hordaland Health Study (HUSK) 1997-99.

SUBJECTS

A total of 22 289 persons born in 1950-57.

MAIN OUTCOME MEASURES

Own and relatives' cardiovascular morbidity, antihypertensive and lipid-lowering treatment, smoking, blood pressure, cholesterol. Framingham and Systematic Coronary Risk Evaluation (SCORE) algorithms. The European guidelines on CVD prevention in clinical practice were applied to estimate size of risk groups.

RESULTS

Some 9.7% of men and 7.6% of women had CVD, diabetes mellitus, a high level of one specific risk factor, or received lipid-lowering or antihypertensive treatment. Applying a SCORE (60 years) cut-off level at 5% to the rest of the population selected 52.4% of men and 0.8% of women into a primary prevention group, while a cut-off level at 8% included 22.0% and 0.06% respectively. A cut-off level for the Framingham score (60 years) of 20% selected 43.6% of men and 4.7% of women, while a cut-off level of 25% selected 25.6% of men and 1.8% of women.

CONCLUSION

The findings illustrate how choices regarding risk estimation highly affect the size of the target population. Modelling studies are important when preparing guidelines, to address implications for resource allocation and risk of medicalization. The population share to be targeted for primary prevention ought to be estimated, including the impact of various cut-off points for risk algorithms on the size of the risk population.

Statins prescribing for the secondary prevention of ischaemic heart disease in Torino, Italy. A case of ageism and social inequalities

BACKGROUND

Socio-demographic and clinical characteristics can influence statins prescribing for the secondary prevention of ischaemic heart disease (IHD). We studied the determinants of the prescription of statins in people with IHD in a population in Italy, the country with the lowest prescribing rate in Europe.

METHODS

All 2001/2002 residents in Torino, aged 30-85 years, with a hospital discharge diagnosis of IHD were linked to the regional Database of Drug Prescriptions to identify those persons who, within 3 months after discharge, had been prescribed statins. Log-binomial models were used to test statins prescription associations with clinical and socio-demographic characteristics.

RESULTS

Statins were prescribed to 31.0% of 7446 patients. Among persons >74 years of age, the prescription rate was 40% lower than that found for younger persons. A positive association was also found for: female gender, being married, a main discharge diagnosis of acute myocardial infarction, revascularization, diabetes and discharge from a cardiology ward. Age was an important effect modifier of the relationship between the prescribing rate and social, but not clinical, determinants.

CONCLUSIONS

The prevention of IHD with statins is influenced by age, clinical and social factors. The prescribing rate is higher among population groups for whom statins are of proven efficacy. Among patients for whom the efficacy is uncertain, the decision to prescribe is influenced by non-clinical factors, suggesting that there exist both age-based and social-based mechanisms of rationing. Age and social determinants act in concert to further reduce the propensity of physicians to prescribe statins.

Components of the metabolic syndrome in long-term survivors of testicular cancer

BACKGROUND

A possible explanation of the excess cardiovascular risk in testicular cancer (TC) survivors is development of metabolic syndrome. The association between metabolic syndrome and TC treatment is examined in long-term survivors.

PATIENTS AND METHODS

In a national follow-up study (1998-2002), 1463 TC survivors (diagnosed 1980-1994) participated. Patients >60 years were excluded in the present study, leaving 1135 patients eligible. The patients were divided in four treatment groups: surgery (n = 225); radiotherapy (n = 446) and two chemotherapy groups: cumulative cisplatin dose (Cis) <or=850 mg (n = 376) and Cis >850 mg (n = 88). A control group consisted of 1150 men from the Tromsø Population Study. Metabolic syndrome was defined according to a modified National Cholesterol Education Program definition.

RESULTS

Both chemotherapy groups had increased odds for metabolic syndrome compared with the surgery group, highest for the Cis >850 group [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.6-4.7]. Also, the Cis >850 group had increased odds (OR 2.1, 95% CI 1.3-3.4) for metabolic syndrome compared with the control group. The association between metabolic syndrome and the Cis >850 group was strengthened after adjusting for testosterone, smoking, physical activity, education and family status.

CONCLUSION

TC survivors treated with cisplatin-based chemotherapy have an increased risk of developing metabolic syndrome compared with patients treated with other modalities or with controls.

Why do sales of lipid-lowering drugs vary between counties in Norway? Evidence from the OPPHED Health Study 2000-2001

OBJECTIVE

To study and compare plausible factors that might explain varying sales of lipid-lowering drugs (LLDs) in the two neighbouring counties of Hedmark and Oppland in Norway, with a similar age distribution, socioeconomic structure, and access to healthcare services.

DESIGN, SETTING, SUBJECTS

Cross-sectional population study comprising 10 598 attendants aged 40, 45, 60, and 75 years in the OPPHED Health Study, 2000-2001 (attendance rate 61%).

MAIN OUTCOME MEASURE

Treatment eligibility (cardiovascular morbidity and risk score), treatment frequency in treatment-eligible subgroups and treatment intensity in terms of achievement of total cholesterol (TC) goal.

RESULTS

Proportions eligible for LLD treatment in Hedmark and Oppland were similar. There was no difference in prevalence of LLD use among participants with cardiovascular disease or diabetes (secondary prevention subgroup). However, LLD use among men in the primary prevention subgroup was higher in Hedmark compared with Oppland, 6.3% and 4.1%, respectively (p < 0.05). The same tendency was seen among women. In both sexes, more LLD users in the primary prevention subgroup achieved the TC goal in Hedmark compared with Oppland (p < 0.05).

CONCLUSION AND IMPLICATIONS

The proportion of the population eligible for LLD treatment in the two counties should imply similar treatment rates in both. Higher LLD treatment frequency and intensity in the primary prevention subgroup in Hedmark are probably both contributing factors that explain the higher sales of LLDs in Hedmark compared with Oppland. Feasible intervention thresholds for primary prevention with concurrent reimbursement rules should be defined in guidelines to avoid unintentional variation in LLD use in the future.

Beyond guidelines: achieving the optimum in LDL cholesterol control

PURPOSE OF REVIEW

Despite clear treatment guidelines, a major part of the population is not achieving the recommended LDL cholesterol target levels. This fact is more prominent among high-risk populations in which the majority of patients are untreated or undertreated.

RECENT FINDINGS

The review will elaborate on the key issues of treating large populations: patient compliance, drug efficacy, cost-benefit, and physician quality of care.

SUMMARY

A programme aimed at improving control of hyperlipidemia should address all four issues. The primary care physician should be empowered and given tools for optimizing treatment.