Statin Adherence: Does Gender Matter?

Improved adherence to statin treatment and differences in results between men and women after pictorial risk communication-a sub-study of the VIPVIZA RCT

BACKGROUND

People with intermediate CVD risk constitute most of the population. Within this group, the proportion of events is lower compared to the high-risk group, but they contribute with the largest absolute number of events. Atherosclerosis is a dynamic process and progression can be slowed or even reversed with medication and lifestyle changes, but adherence to prescribed treatment is crucial.

AIM

To investigate the long-term effects of interventions with pictorial risk communication of cardiovascular (CVD) risk on average adherence in a group of statin users. Compare response in adherence over time between men and women after intervention.

METHODS

Participants on active statin treatment were followed up to 5 years after being randomly assigned to an intervention program aimed at raising CVD risk awareness among participants and their physicians. Merging prescribed medication databases with VIPVIZA study to study adherence over time. A moving average adherence was used to compare groups.

RESULTS

Generally, the average adherence to statins among the 512 participants was high. Men had a higher average adherence over time, while women had a sharper increase in adherence in conjuncture with the intervention program.

CONCLUSIONS

Both men and women were receptive to pictorial information regarding CVD risk, but the intervention effect was more pronounced in women. Sex differences are important when considering risk communication strategies. Periodically repeating the intervention was beneficial for maintaining the intervention effect over time.

TRIAL REGISTRATION

The VIPVIZA study is registered with ClinicalTrials.gov , May 8, 2013, number NCT01849575.

Sex-based utilization of guideline recommended statin therapy and cardiovascular disease outcomes: Data from a multisite healthcare network primary prevention cohort

Background

In the US, women have similar cardiovascular death rates as men. However, less is known about sex differences in statin use for primary prevention and associated atherosclerotic cardiovascular disease (ASCVD) outcomes.

Methods

Statin prescriptions using electronic health records were examined in patients without ASCVD (myocardial infarction (MI), revascularization or ischemic stroke) between 2013 and 2019. Guideline-directed statin intensity (GDSI) at index (at least moderate intensity, defined per pooled-cohort equation) and follow-up visits were compared between sexes across ASCVD risk groups, defined by the pooled-cohort equation. Cox regression hazard ratios were calculated for statin use and outcomes (myocardial infarction, stroke/transient ischemic attack (TIA), and all-cause mortality) stratified by sex. Interaction terms (statin and sex) were applied.

Results

Among 282,298 patients, (mean age ∼ 50 years) 17.1 % women and 19.5 % men were prescribed any statin at index visit. Time to GDSI was similar between sexes, but the proportion of high-risk women on GDSI at follow-up were lower compared to high-risk men (2-years: 27.7 vs 32.0 %, and 5-years: 47.2 vs 55.2 %, p < 0.05). When compared to GDSI, no statin use was associated with higher risk of MI and ischemic stroke/TIA among both sexes. High-risk women on GDSI had a lower risk of mortality (HR=1.39 [1.22-1.59]) vs. men (HR=1.67 [1.50-1.86]) of similar risk (p value interaction=0.004).

Conclusion

In a large contemporary healthcare system, there was underutilization of statins across both sexes in primary prevention. High-risk women were less likely to remain on GDSI compared to high-risk men. GDSI significantly improved the survival in both sexes regardless of ASCVD risk group. Future strategies to ensure continued use of GDSI, specifically among women, should be explored.

Sex-Based Utilization of Guideline Recommended Statin Therapy and Cardiovascular Disease Outcomes: A Primary Prevention Healthcare Network Registry

Background

In the US, women have similar cardiovascular death rates than men. Less is known about sex differences in statin use for primary prevention and associated atherosclerotic cardiovascular disease (ASCVD) outcomes.

Methods

Statin prescriptions using electronic health records were examined in patients without ASCVD (myocardial infarction (MI), revascularization or ischemic stroke) between 2013-2019. Guideline-directed statin intensity (GDSI) at index and follow-up visits were compared among sexes across ASCVD risk groups, defined by pooled-cohort equation. Cox regression hazard ratios (HR) [95% CI] were calculated for statin use and outcomes (myocardial infarction, stroke/transient ischemic attack (TIA), and all-cause mortality) stratified by sex. Interaction terms (statin and sex) were applied.

Results

Among 282,298 patients, (mean age ∼ 50 years) 17.1% women and 19.5% men were prescribed any statin at index visit. Time to GDSI was similar between sexes, but the proportion of high-risk women on GDSI at follow-ups was lower compared to high-risk men (2-years: 27.7 vs 32.0%, and 5-years: 47.2 vs 55.2%, p<0.05). When compared to GDSI, no statin use was associated with higher risk of MI and ischemic stroke/TIA amongst both sexes. High-risk women on GDSI had a lower risk of mortality (HR=1.39 [1.22-1.59]) versus men (HR=1.67 [1.50-1.86]) of similar risk (p value interaction=0.004).

Conclusion

In a large contemporary healthcare system, there was underutilization of statins across both sexes in primary prevention. High-risk women were less likely to be initiated on GDSI compared with high-risk men. GDSI significantly improved the survival in both sexes regardless of ASCVD risk group. Future strategies to ensure continued use of GDSI, specifically among women, should be explored.

Differenze di genere e ipercolesterolemia: evidenze real-world dallo studio WECARE (Women Effective CArdiovascular Risk Evaluation)

Introduction:

The therapeutic control of LDL-cholesterol is essential in cardiovascular prevention, as recommended by the recent guidelines.

Objective:

To evaluate gender differences in terms of demographic and clinical characteristics, treatment pattern, treatment adherence and healthcare costs in patients on lipid-lowering therapy, stratified by cardiovascular risk in the Italian real clinical practice.

Methods:

An observational analysis was conducted on the administrative databases of healthcare institutions, covering about 6.1 million health-assisted subjects. After inclusion of all patients on lipid-lowering therapy between January 2017 and June 2020, the population was investigated in the period before the first prescription of a lipid-lowering drug and followed-up for at least 12 months. Clinical and demographic variables were compared after stratification by gender and by cardiovascular risk (very high/high/other risk). The main outcome measures were treatment adherence and direct healthcare costs during follow-up.

Results:

Of the 684,829 patients with high/very high cardiovascular risk, 337,394 were men and 347,435 women, aged on average 69.3 years and 72.1 years, respectively (p < 0.001). Men were characterised by a worse comorbidity profile. Regardless of cardiovascular risk, female subjects were associated with larger utilisation of low-potency statins and lower adherence (p < 0.001). The annual healthcare costs per patient during follow-up were higher in men than in women (p < 0.001).

Conclusions:

The results highlighted larger utilisation of low-potency statins, a lower adherence and a milder comorbidity profile in women, the latter feasibly explaining the reduced healthcare costs compared to men.

Gaps in the Care of Subjects with Familial Hypercholesterolemia: Insights from the Thai Familial Hypercholesterolemia Registry

AIMS

Familial hypercholesterolemia (FH) is currently underdiagnosed and undertreated. The establishment of a FH registry could facilitate a deeper understanding of this disease. We described the clinical characteristics of subjects with FH from the Thai FH Registry, compared our data with the regional and global data, and identified gaps in the care of these subjects.

METHODS

A multicenter, nationwide prospective FH registry was established in Thailand. Our data were compared with those of the European Atherosclerosis Society-FH Studies Collaboration. Multiple logistic regression analyses were performed for variables associated with lipid-lowering medication (LLM) use and the attainment of low-density lipoprotein-cholesterol (LDL-C) goal.

RESULTS

The study includes 472 subjects with FH (mean age at FH diagnosis: 46±12 years, 61.4% women). A history of premature coronary artery disease was found in 12%. The percentage of LLM use in subjects with a Dutch Lipid Clinic Network score of ≥ 6 (probable or definite FH) in our registry (64%) was slightly lower than the regional data but higher than the global data. Among those who received statins, 25.2% and 6.4% achieved LDL-C levels of ＜100 mg/dL and ＜70 mg/dL, respectively. Women with FH were less likely to achieve LDL-C ＜70 mg/dL (adjusted odds ratio: 0.22, 95% confidence interval: 0.06-0.71, p=0.012).

CONCLUSIONS

FH in Thailand was diagnosed late, and treatment was inadequate for the majority of subjects. Women with FH were less likely to achieve LDL-C goals. Our insights could potentially help raise awareness and narrow the gap in patient care.

Systematic review on sex differences for drug use after stroke

INTRODUCTION

Systematic reviews and meta-analyses have synthetized the existing knowledge on sex-differences for the risk of stroke, the most recent ones highlighting an increased risk of stroke for women. However, whether there are sex differences in post stroke treatment in real world setting is not known. We therefore conducted a systematic review on this subject.

MATERIAL AND METHODS

All observational studies on sex-differences in poststroke drug use published until 20/04/2021 were identified from PubMed and Scopus. Articles were selected and assessed by two independent readers; a third resolved disagreements. Data extraction was performed using a standardized form; articles quality was assessed using the STROBE guidelines. The study is registered on PROSPERO: CRD42021250256.

RESULTS

Of the 604 identified articles, 33 were included. Most were published before 2015 and presented methodological limitations. These limitations differentially affected studies with statistically significant and non-significant results, questioning the reliability of conflicting results. The exploration of sex-differences in drug use varied between therapeutic classes (articles focusing on thrombolytics: 25; antithrombotics: 23; on antihypertensive: 13; lipid-lowering drugs: 9). After stroke, women were found less likely to be prescribed antithrombotics in 48% of the articles investigating this class, and lipid-lowering drugs in 56%. Thirty-one percent of the studies concerning antihypertensive drugs reported the opposite.

DISCUSSION/CONCLUSION

In women, a lack of use of antithrombotics and lipid-lowering drugs after stroke seem to emerge from this review. Conflicting results regarding sex-differences might relate to methodological limitations in studies with no statistical differences, and advocate for the conduct of newer and more comprehensive research.

Nonadherence to lipid-lowering therapy and strategies to improve adherence in patients with atherosclerotic cardiovascular disease

Despite the availability of effective therapies that lower low-density lipoprotein cholesterol (LDL-C) levels in patients with atherosclerotic cardiovascular disease, many eligible patients are inadequately treated and their LDL-C levels remain suboptimal. Patient nonadherence to lipid-lowering therapy (LLT) is a major contributor to the failure of LDL-C goal attainment. Several factors have been identified as contributing to LLT nonadherence, including healthcare disparities due to socioeconomic status, age, race, sex, and cost; limited access to healthcare; perceived side effects associated with LLT; health literacy; and the presence of comorbidities. Suboptimal LLT use has also been associated with clinician factors, including failure to identify patients who require LDL-C reassessment, insufficient LDL-C monitoring, and clinical inertia such as a lack of therapy intensification. Several strategies to enhance LLT adherence have been shown to be effective, including the implementation of educational initiatives and tools for both patients and physicians, the use of clinical protocols and algorithms to identify patients at risk and optimize treatment, and improvements in electronic healthcare records. Pharmacy-based programs designed to help patients with prescription refills, including reminders or the use of prescription delivery by mail, have also proven effective. Drugs requiring frequent administration can represent a barrier to treatment adherence; therefore, newer, more effective LLTs with lower frequency of administration and lower potential for polypharmacy may improve patient adherence to LLT. Implementation of strategies to identify patients at risk for LLT nonadherence and the use of flexible tools such as telemedicine to overcome geographical barriers may improve LLT adherence.

Associations Between Personality Functioning, Childhood Trauma and Non-adherence in Cardiovascular Disease: A Psychodynamically-Informed Cross-Sectional Study

Objective

Although treatment adherence and lifestyle changes significantly improve the prognosis of cardiovascular disease, many patients do not comply with clinician recommendations. Personality functioning appears to be of importance and is hypothesized to be superior to symptom-based measures in explaining individual differences in non-adherence.

Methods

194 cardiology inpatients (mean age = 70.6 years, 60% male) were assessed using self-report measures in a cross-sectional design. Patients were assessed using the short version of the Operationalized Psychodynamic Diagnosis Structure Questionnaire (OPD-SQS) to measure personality functioning, as well as the Childhood Trauma Screener (CTS), the Patient Health Questionnaire (PHQ-9) for symptoms of depression, and the Generalized Anxiety Disorder Scale-7 (GAD-7). To assess non-adherence we introduced a brief, novel scale.

Results

Non-adherence correlated significant with personality functioning (r = 0.325), childhood trauma (r = 0.204) and depressiveness (r = 0.225). In a stepwise multiple regression analysis with socio-demographic variables inputted into the model, higher deficits in personality functioning, higher levels of childhood trauma, and male gender were associated with non-adherence (adjusted R2 = 0.149, F(3,190) = 12.225, p &lt; 0.01). Level of depressive symptoms, anxiety, age, education, and income showed no significant additional predictive value and were excluded from the model.

Conclusion

In cardiovascular disease, personality functioning, childhood trauma and male gender are associated with non-adherence and appear to be more important than symptom reports of depression and anxiety. This highlights the relevance of basic impairments in intra- and interpersonal functioning in chronic disease, where the patient’s adherence is central.

Sex-Specific Differences in Cardiovascular Risk, Risk Factors and Risk Management in the Peripheral Arterial Disease Population

Cardiovascular disease (CVD) is the leading cause of mortality in women worldwide but has been primarily recognised as a man’s disease. The major components of CVD are ischaemic heart disease (IHD), stroke and peripheral arterial disease (PAD). Compared with IHD or stroke, individuals with PAD are at significantly greater risk of major cardiovascular events. Despite this, they are less likely to receive preventative treatment than those with IHD. Women are at least as affected by PAD as men, but major sex-specific knowledge gaps exist in the understanding of relevant CVD risk factors and efficacy of treatment. This prompted the American Heart Association to issue a “call to action” for PAD in women, in 2012. Despite this, PAD and CVD risk in women continues to be under-recognised, leading to a loss of opportunity to moderate and prevent CVD morbidity. This review outlines current evidence regarding cardiovascular risk in women and men with PAD, the relative significance of traditional and non-traditional risk factors and sex differences in cardiovascular risk management.

Statin usage and cardiovascular risk among people living with HIV in the U.S. Military HIV Natural History Study

OBJECTIVES

Using the American College of Cardiology/American Heart Association 2013 atherosclerotic cardiovascular disease (ASCVD) management guidelines, we conducted a retrospective cross-sectional analysis of people living with HIV in the US Military HIV Natural History Study to determine whether individuals were receiving statins when indicated.

METHODS

Prescription data was taken from Military Health System data. Statin eligibility was defined by ASCVD guidelines. We used the 10-year ASCVD pooled cohorts' equation to evaluate risk for each participant.

RESULTS

Across all categories, 31.9% (n = 390) of individuals met criteria for statin use, and when adding these subjects to the number of those already receiving statins (n = 96), 62.1% of all eligible subjects (n = 302/486) were actually receiving statin therapy. In multivariable analysis, individuals of African American race [odds ratio (OR) = 0.48, 95% confidence interval (CI): 0.31-0.73] or Hispanic ethnicity (OR = 0.42, 95% CI: 0.19-0.94) were less likely to receive statin prescriptions than white individuals. Individuals with a higher CD4 count (OR = 1.12, 95% CI: 1.05-1.20 per 100 cells/μL]) were significantly more likely to receive a statin prescription.

CONCLUSIONS

These data highlight discrepancies between ASCVD guidelines and primary care management of people living with HIV (PLWH) in the military health system, along with important racial differences. Targeted interventions are critical to identify and treat appropriate candidates for statin therapy among PLWH in the military and other settings.

Challenges in Optimizing Lipid Management in Women

While there are physiologic differences in lipid metabolism in men and women, pharmacologic therapy is very effective in both with similar management strategies recommended in the current guidelines for the management of dyslipidemia. Despite similar guidelines for treatment, studies have shown that women have worse control of dyslipidemia than their male counterparts. This may stem from multiple contributing factors including underestimation of cardiovascular disease risk in women, decreased prescription and utilization of lipid-lowering therapies, decreased medication adherence, and higher risk of statin intolerance, all of which may contribute to lower attainment of lipid targets. Furthermore, heart disease is the leading cause of mortality in women, with heart disease noted an average of 7-10 years later than in men. This has historically led to the misperception that women are protected from heart disease and can be treated less aggressively. In fact, traditional risk factors for atherosclerotic cardiovascular disease often impact risk in women to a greater extent than they do in men. Unique risk factors such as pregnancy-related disorders also contribute to the level of risk and therefore warrant consideration in risk stratification. This review summarizes the efficacy of contemporary lipid-lowering therapies in women versus men and discusses the challenges that arise with lipid management in women along with potential ways to tackle these obstacles.

Temporal Trends in Hospitalization for Lower Extremity Peripheral Artery Disease in Ontario: The Importance of Diabetes

We sought to assess temporal trends in peripheral artery disease (PAD)-related hospitalization rates in Ontario. Trends in quarterly rates of PAD hospitalization per 100,000 Ontarians between 2006 and 2019 were assessed using autocorrelated linear regression. Stratified analyses according to age, sex, and most responsible diagnosis code type (with vs without diabetes-specific PAD codes) were performed. From 2006 to 2019, overall PAD hospitalizations did not decrease significantly when diabetes-specific codes were included. A significant decrease was observed among women and those older than 65 years old. Future studies of PAD epidemiology and outcomes using administrative data should include diabetic angiopathy.

Sex Disparities in Cardiovascular Risk Factor Assessment and Screening for Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review

Background

Insight in sex disparities in the detection of cardiovascular risk factors and diabetes-related complications may improve diabetes care. The aim of this systematic review is to study whether sex disparities exist in the assessment of cardiovascular risk factors and screening for diabetes-related complications.

Methods

PubMed was systematically searched up to April 2020, followed by manual reference screening and citations checks (snowballing) using Google Scholar. Observational studies were included if they reported on the assessment of cardiovascular risk factors (HbA1c, lipids, blood pressure, smoking status, or BMI) and/or screening for nephropathy, retinopathy, or performance of feet examinations, in men and women with diabetes separately. Studies adjusting their analyses for at least age, or when age was considered as a covariable but left out from the final analyses for various reasons (i.e. backward selection), were included for qualitative analyses. No meta-analyses were planned because substantial heterogeneity between studies was expected. A modified Newcastle-Ottawa Quality Assessment Scale for cohort studies was used to assess risk of bias.

Results

Overall, 81 studies were included. The majority of the included studies were from Europe or North America (84%).The number of individuals per study ranged from 200 to 3,135,019 and data were extracted from various data sources in a variety of settings. Screening rates varied considerably across studies. For example, screening rates for retinopathy ranged from 13% to 90%, with half the studies reporting screening rates less than 50%. Mixed findings were found regarding the presence, magnitude, and direction of sex disparities with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, with some evidence suggesting that women, compared with men, may be more likely to receive retinopathy screening and less likely to receive foot exams.

Conclusion

Overall, no consistent pattern favoring men or women was found with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, and screening rates can be improved for both sexes.

Differences between men and women in the use of preventive medications following a major cardiovascular event: Australian prospective cohort study

Most cardiovascular disease (CVD) events can be prevented with appropriate risk management. Existing evidence suggests women are less likely than men to receive guideline-recommended medications, however data on sex-differences in preventive medication use following a CVD event are lacking. Relative risks (RRs) comparing use of blood pressure- and lipid-lowering medications in men and women at 3-, 6-, 9- and 12-months following hospitalisation for myocardial infarction (MI) or stroke from 2012 to 2017 were quantified using linked data from 8,278 participants enrolled in the Australian 45 and Up Study. Overall, 51% of women and 58% of men were using both blood-pressure- and lipid-lowering medications three months after a MI or stroke event, decreasing to 48% and 53%, respectively, at 12 months after an event. Adjusting for potential confounders, women were 9% less likely than men (RR = 0.91 [95% CI: 0.87, 0.95]) to be using both medications and 19% more likely (RR = 1.19 [95% CI: 1.07, 1.32]) to use neither medication three months after a MI or stroke event. At the 12-month mark, women were 8% less likely (RR = 0.92 [95% CI: 0.88, 0.97]) to be using both medications and 14% more likely (RR = 1.14 [95% CI: 1.03, 1.26]) to use neither medication. Women were consistently less likely to use both preventive medications and more likely to use neither medication at each follow-up time point. Overall, there were major shortfalls in basic preventive medication use post-CVD event and sex disparities are likely to further jeopardise efforts to reduce CVD events in the community.

Medication Adherence After Acute Coronary Syndrome in Women Compared With Men: A Systematic Review and Meta-Analysis

Introduction: Pharmacological treatment is an important component of secondary prevention in acute coronary syndrome (ACS) survivors. However, adherence to medication regimens is often suboptimal, reducing the effectiveness of treatment. It has been suggested that sex influences adherence to cardiovascular medication, but results differ across studies, and a systematic overview is lacking. Methods: We performed a systematic search of PubMed and EMBASE on 16 October 2019. Studies that reported sex-specific adherence for one or more specific medication classes for ACS patients were included. Odds ratios, or equivalent, were extracted per medication class and combined using a random effects model. Results: In total, we included 28 studies of which some had adherence data for more than one medication group. There were 7 studies for angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) (n = 100,909, 37% women), 8 studies for antiplatelet medication (n = 37,804, 27% women), 11 studies for beta-blockers (n = 191,339, 38% women), and 17 studies for lipid-lowering medication (n = 318,837, 35% women). Women were less adherent to lipid-lowering medication than men (OR = 0.87, 95% CI 0.82-0.92), but this sex difference was not observed for antiplatelet medication (OR = 0.95, 95% CI 0.83-1.09), ACEIs/ARBs (OR = 0.95, 95% CI 0.78-1.17), or beta-blockers (OR = 0.97, 95% CI 0.86-1.11). Conclusion: Women with ACS have poorer adherence to lipid-lowering medication than men with the same condition. There are no differences in adherence to antiplatelet medication, ACEIs/ARBs, and beta-blockers between women and men with ACS.

Gender gap in risk factor control of coronary patients far from closing: results from the European Society of Cardiology EUROASPIRE V registry

AIMS

This study aims to provide an overview on contemporary gender differences in the risk factor control of coronary heart disease (CHD) patients.

METHODS AND RESULTS

Analyses were based on the cross-sectional ESC (European Society of Cardiology) EORP (EurObservational Research Programme) EUROASPIRE V (European Survey of Cardiovascular Disease Prevention and Diabetes) survey including data on CHD patients across 27 European countries. Men and women between 18 and 80 years old, hospitalized for a first or recurrent coronary event were included in the study. Data were available for 8261 patients of which 25.8% women. Overall, women had a worse risk factor control compared with men. Whereas women were more likely to be non-smokers (79.3% vs. 87.2%; P < 0.001), they were less likely to reach recommended levels of physical activity (36.8% vs. 27.5%; P < 0.001), and they were less likely to be non-obese (65.1% vs. 54.3%; P < 0.001). There is indication that risk factors such as smoking behaviour and obesity differed depending on country income level. No gender differences could be observed in blood pressure on target (P > 0.05). Moreover, a lower proportion of women reached low-density lipoprotein cholesterol (LDL-C) target levels (31.4% vs. 22.1%; P < 0.001), and they were less likely to reach glycated haemoglobin (HbA1c) targets if having self-reported diabetes (56.7% vs. 48.6%; P < 0.001).

CONCLUSION

The risk factor control of CHD women is substantial worse compared with men despite little gender differences in cardiovascular medication intake. Further actions are needed to increase the awareness of the worse risk factor control in female CHD patients.

Examining the Nocebo Effect of Statins Through Statin Adverse Events Reported in the Food and Drug Administration Adverse Event Reporting System

BACKGROUND

This study aimed to evaluate whether the high frequency of reported statin adverse effects (AEs) may be associated with the nocebo effect. We compared nocebo-related subjective AEs with objective AEs and investigated factors potentially associated with the nocebo effect.

METHODS

A retrospective cohort study was conducted using the Food and Drug Administration Adverse Event Reporting System between January 2010 and December 2019 for statins, including, atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin. Subjective AEs included fatigue, subjective muscular, and nervous system AEs. Objective AEs were defined as hepatic and objective muscular AEs. We compared the number of subjective and objective AEs using the Mann-Whitney U test and examined trends in the frequency of subjective versus objective reports over time using linear regression with interaction terms. We evaluated the association between AEs and gender and country using linear regression. Quantitative detection of signals was estimated using proportional reporting ratio and reporting odds ratio for simvastatin.

RESULTS

Of 2 994 487 overall AE reports, more subjective than objective AEs were reported per quarter (mean±SD: 4777±1375.45 versus 999±276.95; P<0.0001), and over time during the study period (P<0.001). Women reported more subjective AEs than men per quarter (fatigue: 86.98 more per quarter, P=0.035; subjective muscular AE: 417.95, P<0.0001; nervous system AE: 273.60, P<0.0001), but fewer objective muscular AEs (-125.23 per quarter, P<0.0001). More subjective AEs and fewer objective AEs were reported per quarter in the United States relative to other countries. Simvastatin-associated reports showed signals for higher objective muscular AEs relative to all other statins (reporting odds ratio, 1.53 [95% CI, 1.49-1.58]).

CONCLUSIONS

This study found that significantly more subjective than objective AEs are reported for statins. Subjective statin AEs, potentially related to the nocebo effect are reported more often by women than by men, and in the United States than in other countries.

Denosumab-associated hypocalcemia: Does gender play a role?

OBJECTIVE

It is well recognized that the presentation, treatment, and outcomes of various diseases may differ between men and women. We recently reported a 7.4% rate of denosumab-associated hypocalcemia in community-dwelling osteoporotic patients. This study sought to investigate the role of gender in this complication.

STUDY DESIGN

Retrospective community-dwelling cohort.

METHOD

The databases of a large health maintenance organization were searched for adult patients treated with denosumab for osteoporosis in 2010-2018. Rates and predictors of denosumab-associated hypocalcemia (serum calcium ≤8.5 mg/mL) were analyzed by gender.

RESULTS

The cohort included 1871 women and 134 men. Compared with the women, the men were characterized by older median age (81 vs. 77 years, p = 0.005), higher likelihood to receive denosumab as a first-line treatment (22% vs. 6%, p < 0.001), less treatment with calcium supplements (42% vs. 53%, p = 0.012), and lower median eGFR level (66.1 vs. 79.8 mL/min/1.73m², p < 0.001). Denosumab-associated hypocalcemia developed in 133 women (7.1%) and 16 men (11.9%) (p = 0.04); the drug was discontinued in 75% and 61%, respectively. The strongest predictors of hypocalcemia in women were levels of pretreatment albumin-adjusted serum calcium (OR 0.08, 95% CI (0.04, 0.14)) and creatinine (OR 2.43, 95% CI (1.45, 4.05)). There were no predictors in men. On propensity matching of 126 men and 126 women, gender was not a predictor of hypocalcemia.

CONCLUSION

Denosumab-treated men were significantly older than treated women and had a lower eGFR and more advanced osteoporosis. These findings suggest that selection bias rather than male genderper se underlies the higher rate of denosumab-associated hypocalcemia in men.

Patterns of Use and Discontinuation of Secondary Prevention Medications After Stroke

OBJECTIVE

To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA.

METHODS

This is a retrospective cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with ≥1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for ≥90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation.

RESULTS

Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged ≥75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub-hazard ratio [SHR] 0.70; 95% confidence interval [CI] 0.62-0.79), quarterly contact with a primary care physician (SHR 0.62; 95% CI 0.57-0.67), and prescription by a specialist physician (SHR 0.87; 95% CI 0.77-0.98) were all inversely associated with antihypertensive discontinuation.

CONCLUSIONS

Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwarranted discontinuation.

Medical Treatment in Coronary Patients: Is there Still a Gender Gap? Results from European Society of Cardiology EUROASPIRE V Registry

PURPOSE

This study is aimed at investigating gender differences in the medical management of patients with coronary heart disease (CHD).

METHODS

Analyses were based on the ESC EORP EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) survey. Consecutive patients between 18 and 80 years, hospitalized for a coronary event, were included in the study. Information on cardiovascular medication intake at hospital discharge and at follow-up (≥ 6 months to < 2 years after hospitalization) was collected.

RESULTS

Data was available for 8261 patients (25.8% women). Overall, no gender differences were observed in the prescription and use of cardioprotective medication like aspirin, beta-blockers, and ACE-I/ARBs (P > 0.01) at discharge and follow-up respectively. However, a statistically significant difference was found in the use of statins at follow-up, in disfavor of women (82.8% vs. 77.7%; P < 0.001). In contrast, at follow-up, women were more likely to use diuretics (31.5% vs. 39.5%; P < 0.001) and calcium channel blockers (21.2% vs. 28.8%; P < 0.001), whereas men were more likely to use anticoagulants (8.8% vs. 7.0%; P < 0.001). Overall, no gender differences were found in total daily dose intake (P > 0.01). Furthermore, women were less likely than men to have received a CABG (20.4% vs. 13.2%; P < 0.001) or PCI (82.1% vs. 74.9%; P < 0.001) at follow-up. No gender differences were observed in prescribed (P = 0.10) and attended (P = 0.63) cardiac rehabilitation programs.

CONCLUSION

The EUROASPIRE V results show only limited gender differences in the medical management of CHD patients. Current findings suggest growing awareness about risk in female CHD patients.

Sex differences in cardiometabolic risk factors, pharmacological treatment and risk factor control in type 2 diabetes: findings from the Dutch Diabetes Pearl cohort

INTRODUCTION

Sex differences in cardiometabolic risk factors and their management in type 2 diabetes (T2D) have not been fully identified. Therefore, we aimed to examine differences in cardiometabolic risk factor levels, pharmacological treatment and achievement of risk factor control between women and men with T2D.

RESEARCH DESIGN AND METHODS

Cross-sectional data from the Dutch Diabetes Pearl cohort were used (n=6637, 40% women). Linear and Poisson regression analyses were used to examine sex differences in cardiometabolic risk factor levels, treatment, and control.

RESULTS

Compared with men, women had a significantly higher body mass index (BMI) (mean difference 1.79 kg/m² (95% CI 1.49 to 2.08)), while no differences were found in hemoglobin A_1c (HbA_1c) and systolic blood pressure (SBP). Women had lower diastolic blood pressure (-1.94 mm Hg (95% CI -2.44 to -1.43)), higher total cholesterol (TC) (0.44 mmol/L (95% CI 0.38 to 0.51)), low-density lipoprotein cholesterol (LDL-c) (0.26 mmol/L (95% CI 0.22 to 0.31)), and high-density lipoprotein cholesterol (HDL-c) sex-standardized (0.02 mmol/L (95% CI 0.00 to 0.04)), and lower TC:HDL ratio (-0.29 (95% CI -0.36 to -0.23)) and triglycerides (geometric mean ratio 0.91 (95% CI 0.85 to 0.98)). Women had a 16% higher probability of being treated with antihypertensive medication in the presence of high cardiovascular disease (CVD) risk and elevated SBP than men (relative risk 0.84 (95% CI 0.73 to 0.98)), whereas no sex differences were found for glucose-lowering medication and lipid-modifying medication. Among those treated, women were less likely to achieve treatment targets of HbA_1c (0.92 (95% CI 0.87 to 0.98)) and LDL-c (0.89 (95% CI 0.85 to 0.92)) than men, while no differences for SBP were found.

CONCLUSIONS

In this Dutch T2D population, women had a slightly different cardiometabolic risk profile compared with men and a substantially higher BMI. Women had a higher probability of being treated with antihypertensive medication in the presence of high CVD risk and elevated SBP than men, and were less likely than men to achieve treatment targets for HbA_1c and LDL levels.

Low-Density Lipoprotein Cholesterol Targets in Patients With Coronary Heart Disease in Extremadura (Spain): LYNX Registry

Background

Low-density lipoprotein cholesterol (LDL-C) contributes decisively to the development of cardiovascular disease (CVD). In the LYNX registry we determined the rate of achievement of the target value of LDL-C, the use of lipid-lowering therapy (LLT) and the predictive factors of not reaching the target in patients with stable coronary heart disease (CHD).

Methods

LYNX included consecutive patients with stable CHD treated at the University Hospital of Caceres, Extremadura (Spain) from September 2016 to September 2018, and those who must have an LDL-C target below 70 mg/dL according to the European Society of Cardiology (ESC) 2016 guidelines. The variables independently associated with the breach of the LDL-C objective were evaluated by multivariable logistic regression.

Results

A total of 674 patients with stable CHD were included. The average LDL-C levels were 68.3 ± 24.5 mg/dL, with 56.7% showing a level below 70 mg/dL. LLT was used by 96.7% of patients, 71.7% were treated with high-powered statins and 30.1% with ezetimibe. The risk of not reaching the target value of LDL-C was higher in women, in active smokers, and in those who had multivessel CHD or had atrial fibrillation. Patients with diabetes mellitus, those who took potent statins or co-administration treatment with ezetimibe were more likely to reach the target level of LDL-C.

Conclusions

The treatment of dyslipidemia in patients with chronic CHD remains suboptimal; however, an increasing number of very high-risk patients achieve the LDL-C objective, although there is still enormous potential to improve cardiovascular outcome through the use of more intensive LLT.

Impact of Sex and Age on the Mevalonate Pathway in the Brain: A Focus on Effects Induced by Maternal Exposure to Exogenous Compounds

The mevalonate pathway produces cholesterol and other compounds crucial for numerous cellular processes. It is well known that age and sex modulate this pathway in the liver. Recently, similar effects were also noted in different brain areas, suggesting that alterations of the mevalonate pathway are at the root of marked sex-specific disparities in some neurodevelopmental disorders related to disturbed cholesterol homeostasis. Here, we show how the mevalonate pathway is modulated in a sex-, age- and region-specific manner, and how maternal exposure to exogenous compounds can disturb the regulation of this pathway in the brain, possibly inducing functional alterations.

Perceptions and experiences of using mobile technology for medication adherence among older adults with coronary heart disease: A qualitative study

OBJECTIVE

Medication non-adherence is linked to adverse clinical outcomes (i.e. rehospitalization, mortality) among patients with coronary heart disease. Given its global adoption and growing popularity among older adults, mobile technology may be an effective strategy to improve medication adherence. The aim of this article is to present the perceptions, attitudes, and beliefs of individuals with coronary heart disease about using text messaging and mobile phone applications for medication adherence.

METHODS

We recruited 28 participants (veterans and non-veterans) with a history of coronary heart disease and antiplatelet medication use in Northern California. We formed six focus groups of individuals who participated in three sessions (total 18 sessions). We analyzed our data using grounded theory.

RESULTS

The median age was 69.5 ± 10.8 years for non-veterans (50% male) and 70 ± 8.6 years for veterans (100% male). In the first session, we found that participants perceived text message reminders as a convenient, easy, and flexible tool to establish a routine for taking medications. In the second session, participants were eager to use applications for their greater interactivity, individualized health monitoring, and personalized medication information. The third session, participants shared preferred features (i.e. drug interactions, tracking symptoms) after using two applications at home for 2 weeks.

CONCLUSIONS

Older adults are engaged and can be proficient mobile technology users. Text messaging and mobile phone applications are perceived as helpful tools for medication adherence. Future research should include rigorous clinical trials to test the efficacy of mobile health technology to promote medication adherence in populations that require strict medication adherence.

Interventions to Improve Adherence to Cardiovascular Medication: What About Gender Differences? A Systematic Literature Review

BACKGROUND

Compared to men, women have lower treatment rates for cardiovascular disease (CVD), are at higher risk for medication non-adherence and have different reasons for being non-adherent. The aim of this study was to synthesize and evaluate gender-specific adherence-promoting interventions for cardiovascular medication and gender-specific effects of gender-neutral interventions.

METHODS

A systematic literature search was performed in PubMed, Embase, PsycINFO, CINAHL and Cochrane Library from January 2007 to October 2019. Intervention studies (with control group) aimed at improving cardiovascular medication adherence with minimally 14 weeks follow-up were included. Two reviewers independently screened titles and abstracts. Full text was obtained for selected abstracts and screened for final inclusion. Data extraction included gender-specific targeting or analysis.

RESULTS

The search identified 6502 citations. After screening title and abstract, full text was obtained from 127 potentially eligible articles. Ultimately, 11 articles were included that analyzed gender differences in gender-neutral interventions. Two reported a gender-specific intervention effect. Using an electronic reminder device, one study increased statin adherence in women. The other found a larger increase in adherence to CVD medication following telephone counseling for men than women. Nine studies did not identify a gender-specific effect.

CONCLUSION

Despite differences in levels of and reasons for non-adherence, most studies addressing adherence did not analyze potential differences in effect by gender. Moreover, none of the identified studies used gender-specific adherence promoting interventions. Increasing awareness about gender differences in adherence might lead to better tailoring of interventions to gender-specific needs and better results in improving adherence.

Patient-Associated Characteristics Influencing the Risk for Non-Persistence with Statins in Older Patients with Peripheral Arterial Disease

BACKGROUND AND OBJECTIVES

Secondary prevention of peripheral arterial disease includes administration of statins regardless of the patient's serum cholesterol level. Our study aimed to identify patient-associated risk factors for statin non-persistence and comparison of the explanatory power of models based on clusters of patient-associated characteristics.

METHODS

Our study cohort (n = 8330) was assembled from the database of the largest health insurance provider in the Slovak Republic. Statin users aged ≥ 65 years in whom peripheral arterial disease was diagnosed during 2012 were included. Patients were followed for 5 years; those with a treatment gap period of at least 6 months without statin prescription were classified as "non-persistent". The risk factors for non-persistence were identified within six models (sociodemographic, cardiovascular events, comorbid conditions, statin-related characteristics, cardiovascular co-medication and full model) using Cox regression. The explanatory power of models was assessed using Harrell's C-index.

RESULTS

At the end of the follow-up, 35.7% of patients were found to be non-persistent. The full model had the highest explanatory power (C = 0.632). Female sex, atorvastatin and rosuvastatin as initially administered statins, being a new statin user and an increasing co-payment were associated with an increased risk for non-persistence. Increasing age, history of ischaemic stroke, diabetes mellitus, general practitioner as index prescriber, increasing overall number of medications and co-administration of certain cardiovascular co-medications were associated with a lower likelihood for non-persistence.

CONCLUSIONS

Patients identified as high risk for non-persistence require special attention aimed at the improvement of their persistence with statin treatment.

The Mediating Role of Diabetes Distress and Depressive Symptoms in Type 2 Diabetes Medication Adherence Gender Differences

Background. Medication adherence is negatively related to both diabetes distress (DD) and depressive symptoms (DS). Past research suggests gender differences in adherence, DD, and DS. A gap exists in determining if gender differences in adherence are mediated by DD and DS, or if gender moderates differences in adherence by DD/DS. Aims. This study investigated the relationship between gender, DD, DS, and medication adherence and tested for mediating and moderating effects on medication adherence among American Indian adults with type 2 diabetes. Method. The Maawaji idi-oog mino-ayaawin (Gathering for Health) study was a community-based participatory research collaboration with five American Indian tribes. Participants, randomly recruited from clinic records, shared information during computer-assisted personal interviews. This study includes the 166 participants who reported using medications to treat their diabetes. The relationship between gender, DD, DS, and medication adherence are explored. Possible mediating and moderating effects on medication were tested using regression and path analysis. Results. Females had higher levels of DD and DS and lower levels of medication adherence. Higher levels of DD and DS were both associated with lower medication adherence. No evidence was found that gender moderates the relationship between DD or DS and medication adherence. Instead, DD and DS mediated the relationship between gender and medication adherence. Conclusions. Medication adherence differences in male and female patients may be attributable to DD and DS. The present research highlights both DD and DS as targets for clinicians and researchers alike.

Sex-differences in factors and outcomes associated with adherence to statin therapy in primary care: Need for customisation strategies

Despite the invaluable efficacy of statins, adherence to therapy is extremely poor in clinical practice. Improvement interventions should be as personalized as possible, but it is necessary to know factors that most influence adherence, and sex seems to be a key determinant. Thus, we aimed at exploring potential areas of sex-differences in statin adherence in a real-world population. For this purpose, we assessed adherence (as proportion of days covered) on a wide cohort of new statin users aged >40 years, and we evaluated its association with several covariates through sex-stratified log-binomial regression models. In addition, to compare also the benefits of optimal statin adherence in primary prevention of cardiovascular disease between men and women, we implemented sex-stratified Cox proportional hazard models. Our study showed that women are more likely to stop or be less adherent to statin treatment than men. Moreover, we observed significant sex-differences on effect size of several factors associated with adherence that should be taken into consideration for the management of patients. Finally, we observed no significant difference between men and women regarding statin efficacy in terms of reduction of incident hospitalization for ischemic heart disease and/or non-haemorrhagic cerebrovascular disease. These results invoke the responsibility of physicians to a prompt and personalized intervention. Physicians should consider routine screening for non-adherence in their clinical practice, target patients at higher risk of non-adherence, and improved motivation and communication.

Sex differences in cardiovascular risk management for people with diabetes in primary care: a cross-sectional study

Background

Diabetes is a stronger risk factor for cardiovascular complications in women than men.

Aim

To evaluate whether there are sex differences in cardiovascular risk management in patients with diabetes in primary care.

Design & setting

A cross-sectional study was undertaken using data from 12 512 individuals with diabetes within the Dutch Julius General Practitioners Network (JGPN) from 2013.

Method

Linear and Poisson regression analyses were used to assess sex differences in risk factor levels, assessment, treatment, and control.

Results

No sex differences were found in HbA1c levels and control, while small differences were found for cardiovascular risk management. Blood pressure levels were higher (mean difference [MD] 1.09 mmHg; 95% confidence intervals [CI] = 0.41 to 1.77), while cholesterol levels (MD -0.38 mmol/l; 95% CI = -0.42 to -0.34) and body mass index ([BMI] MD -1.79 kg/m²; 95% CI = -2.03 to 1.56) were lower in men than women. Risk factor assessment was similar between sexes, apart from high-density lipoprotein cholesterol (HDL-c), which was more commonly assessed in women (risk ratio [RR] 1.16; 95% CI = 1.13 to 1.20). Among those with a treatment indication for prevention, women with cardiovascular disease (CVD) were less likely to receive lipid-lowering drugs (RR 0.84; 95% CI = 0.76 to 0.93) than men, while women without CVD were more likely to receive lipid-lowering drugs (RR 1.16; 95% CI = 1.04 to 1.2). Among those treated, women were more likely to achieve systolic blood pressure (SBP) control (RR 1.06; 95% CI = 1.02 to 1.10) and less likely to achieve low-density lipoprotein cholesterol (LDL-c) control (RR 0.88; 95% CI = 0.85 to 0.91) than men.

Conclusion

In this Dutch primary care setting, sex differences in risk factor assessment and treatment of people with diabetes were small. However, women with diabetes were less likely to achieve control for LDL-c and more likely to achieve blood pressure control than men with diabetes.

Atherosclerotic cardiovascular disease risk assessment and predictors of statin use in Filipino-American Women

WHAT IS KNOWN AND OBJECTIVE

Race and gender disparities in the context of appropriate treatment with lipid-lowering therapies do exist. The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines outlined four groups, three for primary prevention and one for secondary prevention, whom would benefit from statin therapy to target atherosclerotic cardiovascular disease (ASCVD). The application of these recommendations in Filipino women living in the United States is unknown; however, this population is known to have elevated cardiovascular risk. Socio-economic and clinical characteristics that predict statin utilization of this Asian American subgroup need to be explored.

METHODS

This was an exploratory analysis of data collected during a cross-sectional study of Filipino-American Women (FAW). The Pooled Cohort equation was used to estimate 10-year ASCVD risk. Bivariate analysis was employed to determine the association between statin treatment and clinical and socio-economic factors. Data were analysed using SAS^® 9.4; statistical significance was set at P < 0.05.

RESULTS AND DISCUSSION

A total of 384 women (mean age 56.3 years) were included in the original study, and the average 10-year ASCVD risk was 3.5 ± 3.7%. Upon applying the 2013 ACC/AHA guidelines, 97 FAW were categorized into one of the primary prevention groups. Women considered to benefit from a statin based on the guideline criteria but were not prescribed a statin were considered the not statin treated group (n = 55). From the original cohort, 93 FAW reported current statin therapy use and were categorized as statin treated. The clinical characteristics associated with not being statin treated were as follows: untreated blood pressure (P = 0.012), higher diastolic blood pressure (P = 0.015), higher total cholesterol (P < 0.001), higher triglycerides (P = 0.041), higher low-density lipoprotein (P < 0.001) and higher glucose (P = 0.011). The socio-economic factor associated with not being statin treated was having two or more insurance payers (P = 0.005). Overall, this population had a waist circumference and body mass index (BMI) that exceeds guidelines for Asian women (31.5 or 80 cm).

WHAT IS NEW AND CONCLUSION

Predictors of statin utilization in FAW are not well documented in the literature. These findings emphasize room for improvement for the prescribing of statins in primary prevention for this study population. Applying culturally appropriate screening strategies to identify cardiovascular risk factors early such as BMI or waist circumference may assist with quantifying patients into one of the statin benefit groups if eligible.

Non-achievement of LDL-cholesterol targets in patients with diabetes at very-high cardiovascular risk receiving statin treatment: Incidence and risk factors

BACKGROUND

Cardiovascular diseases are the first cause of mortality in patients with diabetes, and LDL-cholesterol is a well-established cardiovascular risk factor. This study aimed to assess rate of LDL-cholesterol target attainment among patients with diabetes at very-high cardiovascular risk treated with statins, and to identify predictive factors of non-attainment of target in this population.

METHODS

Patients were recruited in the Nutrition-Diabetes unit of Montpellier University Hospital, France, from 2014 to 2017. We included all consecutive patients with type 1 or type 2 diabetes receiving statin treatment and at very-high cardiovascular risk according to 2016 ESC guidelines, therefore having a LDL-cholesterol target of <1.8 mmol/L. LDL-cholesterol levels were measured upon admission. Variables independently associated with non-attainment of LDL-Cholesterol target were assessed using multivariable logistic regression.

RESULTS

654 patients were included. Mean age was 63.8 years (SD 11.0), 41.9% were women and 42.3% had a history of cardiovascular disease. 59% of patients did not achieve LDL-cholesterol target, with a median value (interquartile range) of 2.4 mmol/L (2.1-2.9) versus 1.4 mmol/L (1.1-1.6) in patients at target. Risk of non-attainment of LDL-cholesterol target value was increased in women (odds ratio [95% confidence interval]: 2.27 [1.62-3.17]) and decreased in patients with history of coronary artery disease (0.64 [0.45-0.89]) or history of stroke or transient ischemic attack (0.59 [0.33-1.07]).

CONCLUSIONS

Management of dyslipidemia is suboptimal, even in very-high risk patients with diabetes under statins. Lipid-lowering treatment should be intensified, in particular in very high risk patients with diabetes who are women or in primary cardiovascular prevention. Clinical Trial number: NCT03449784.