Coronary heart disease in moderately hypercholesterolemic, hypertensive black and non-black patients randomized to pravastatin versus usual care: the antihypertensive and lipid lowering to prevent heart attack trial (ALLHAT-LLT)

Impact of metabolic control on all-cause mortality in a nationwide cohort of patients with diabetes from Colombia

Objective

The magnitude of the mortality benefit conferred by good integral metabolic control in diabetes in not sufficiently known, especially among Latin American patients. We prospectively studied the association between sustained control of blood glucose (HbA1c<7%), systolic blood pressure (SBP) (<130 mmHg) and LDL (LDLc, <100mg/dL) and non-HDL (non-HDLc, <130 mg/dL) cholesterol, and death from any cause among all adult patients with diagnosed diabetes in Colombia.

Methods

We retrospectively analyzed data from a nationwide, centralized, mandatory registry of all patients with diagnosed diabetes assisted by the Colombian health system between July 1, 2015, and June 30, 2019. We estimated the associations of sustained achievement of each goal, and of the joint triple goal (HbA1c + SBP + LDLc) with all-cause death. Associations were assessed after adjustment for sex, age, race, insurance type and BMI in multivariable logistic models.

Results

We studied 1 352 846 people with diabetes. Sustained SBP (OR 0.42 [0.41-0.43]), HbA1c (OR 0.25 [0.24-0.26]) and LDLc (OR 0.28 [0.27-0.29]) control had strong negative associations with death. Moreover, among the 5.4% of participants who achieved joint, sustained metabolic control, the OR for death was 0.19 (0.18-0.21). Importantly, the impact of sustained, joint metabolic control was significantly smaller for patients of black race compared to other races (OR 0.31 [0.23-0.43] versus 0.18 [0.17-0.20], p-value for interaction <0.001), mostly at the expense of a smaller impact of LDLc control. The results were similar across body-mass index categories.

Conclusions

Sustained and simultaneous metabolic control was associated with remarkably lower odds of death.

Effects of Posttrial Antihypertensive Drugs on Morbidity and Mortality: Findings from 15-Year Passive Follow-Up after ALLHAT Ended

BACKGROUND

Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) ended in 2002, but it is important to study its long-term outcomes during the posttrial period by incorporating posttrial antihypertensive medication uses in the analysis.

PURPOSES

The primary aim is to explore the patterns of antihypertensive medication use during the posttrial period from Medicare Part-D data over the 11-year period from 2007 to 2017. The secondary aim is to examine the potential effects of these posttrial antihypertensive medications on the observed mortality and morbidity benefits.

METHODS

This is a posttrial passive follow-up study of ALLHAT participants in 567 US centers in 1994-1998 with the last date of active in-trial follow-up on March 31, 2002, by linking with their Medicare and National Death Index data through 2017 among 8,007 subjects receiving antihypertensive drugs (3,637 for chlorthalidone, 2,189 for amlodipine, and 2,181 for lisinopril). Outcomes included posttrial antihypertensive drug use, all-cause mortality, and cardiovascular disease (CVD) mortality.

RESULTS

Of 8007 subjects, 3,637 participants were initially randomized to diuretic (chlorthalidone). The majority (67.9%) of them still received diuretics in 2007, and 52.7%, 47.2%, and 44.0% received β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers (CCBs), respectively. Compared to participants who received diuretic-based antihypertensives, those who received CCB had a nonsignificantly higher risk of all-cause mortality (1.17, 0.99-1.37), whereas those who received ACE/ARB (angiotensin receptor blockers) had a significantly higher risk of all-cause mortality (1.26, 1.09-1.45). For the combined fatal or nonfatal hospitalized events, the risk of CVD was significantly higher in patients receiving CCB (1.30, 1.04-1.61) and ACE/ARB (1.49, 1.22-1.81) as compared to patients receiving diuretics.

CONCLUSION

After the conclusion of the ALLHAT, almost all patients switched to combination antihypertensive therapies, independently by the original drug class, and the combination therapies (mostly based on diuretics) reduced the incidence of major cardiovascular outcomes and mortality.

Statin Therapy Before Transition to End-Stage Renal Disease With Posttransition Outcomes

Background Although studies have shown that statin therapy in patients with non-dialysis-dependent chronic kidney disease was associated with a lower risk of death, this was not observed in dialysis patients newly initiated on statins. It is unclear if statin therapy benefits administered during the predialysis period persist after transitioning to end-stage renal disease. Methods and Results In 47 720 veterans who transitioned to end-stage renal disease during 2007 to 2014, we examined the association of statin therapy use 1 year before transition with posttransition all-cause and cardiovascular mortality and hospitalization incidence rates over the first 12 months of follow-up. Associations were examined using multivariable adjusted Cox proportional hazard models and negative binomial regressions. Sensitivity analyses included propensity score and subgroup analyses. The cohort's mean± SD age was 71±11 years, and the cohort included 4% women, 23% blacks, and 66% diabetics. Over 12 months of follow-up, there were 13 411 deaths, with an incidence rate of 35.3 (95% CI , 34.7-35.8) deaths per 100 person-years. In adjusted models, statin therapy compared with no statin therapy was associated with lower risks of 12-month all-cause (hazard ratio [95% CI], 0.79 [0.76-0.82]) and cardiovascular (hazard ratio [95% CI ], 0.83 [0.78-0.88]) mortality, as well as with a lower rate of hospitalizations (incidence rate ratio [95% CI ], 0.89 [0.87-0.92]) after initiating dialysis. These lower outcome risks persisted across strata of clinical characteristics, and in propensity score analyses. Conclusions Among veterans with non-dialysis-dependent chronic kidney disease, treatment with statin therapy within the 1 year before transitioning to end-stage renal disease is associated with favorable early end-stage renal disease outcomes.

Risk factor control in secondary prevention of cardiovascular disease: results from the multi-ethnic HELIUS study

OBJECTIVE

To evaluate the quality of contemporary secondary prevention of cardiovascular disease (CVD), and the differences between six ethnic groups in a large, observational cohort.

DESIGN

We included participants with a self-reported history of CVD from the HEalthy LIfe in an Urban Setting (HELIUS) study, which investigates inequalities in health between six ethnic groups living in Amsterdam, the Netherlands. We quantified the proportions of patients who were at the preventive treatment goal according to the guidelines of the European Society of Cardiology for six risk factors: hypertension, dyslipidaemia, smoking, overweight, physical inactivity and diabetes mellitus, and the use preventive medication.

RESULTS

Of 22,165 participants, 1163 (5%) reported a history of CVD. Mean age was 54 years. Overall, 69% had a systolic blood pressure of <140 mm Hg, and 42% had a low-density lipoprotein (LDL) cholesterol of <2.5 mmol/l. Non-smoking was found in 67%. Body mass index (BMI) <25 kg/m² was found in 24%, and 54% reported adequate physical activity. The mean number of risk factors per patient was three (±1.1) out of six, and only 2% had all risk factors on target. Across the ethnic groups, non-smoking was more prevalent in the Ghanaian and Moroccan groups than in the Dutch (p < 0.001 and p = 0.001, respectively); BMI <25 kg/m² and adequate physical activity were less prevalent among all ethnic minority groups compared with the Dutch group.

CONCLUSION

We found large treatment gaps in secondary prevention of CVD. Ethnic differences in risk factors were found; however, strategies to improve overall risk factor management may be mandated before designing ethnic-specific strategies.

Meta-Analyses of Statin Therapy for Primary Prevention Do Not Answer Key Questions: An Empirical Appraisal of 5 Years of Statin Meta-Analyses

Although meta-analyses of statins in primary prevention are designed to provide doctors and patients with better evidence about the risks and potential benefits of treatment, they may ignore important patient-centered outcomes and concerns. We examined all meta-analyses of statins for primary prevention over the last 5 years. We assessed whether each meta-analysis addressed five key points: whether authors examined endpoints based on the use of statin therapy, and not stratified by low-density lipoprotein reduction; whether authors included only studies of statin versus placebo, and not varying doses or brands of statin; whether authors considered commonly cited harms; whether secondary prevention patients were excluded; and, whether overall mortality was examined. We examined 189 articles to identify 24 meta-analyses of statins that made claims regarding primary prevention. Six studies (25%) reported outcomes as a function of reduction in serum lipid levels rather than treatment received. Seven studies (29%) included trials of high-dose versus low-dose statin in their analysis. Five studies (21%) did not examine all-cause mortality. The majority of studies (n = 21, 88%) failed to exclude patients with known cardiovascular disease, and 22 (92%) studies failed to assess two of three common safety concerns. Nevertheless, most (n = 20, 83%) meta-analyses supported the use of statins in primary prevention. Based on our findings, we conclude that most recent meta-analyses of statins for primary prevention do not adequately address the question they seek to answer.

Changes in use of lipid-lowering medications among black and white dual enrollees with diabetes transitioning from Medicaid to Medicare Part D drug coverage

BACKGROUND

The use of lipid-lowering agents is suboptimal among dual enrollees, particularly blacks.

OBJECTIVES

To determine whether the removal of restrictive drug caps under Medicare Part D reduced racial differences among dual enrollees with diabetes.

RESEARCH DESIGN

An interrupted time series with comparison series design (ITS) cohort study.

SUBJECTS

A total of 8895 black and white diabetes patients aged 18 years and older drawn from a nationally representative sample of fee-for-service dual enrollees (January 2004-December 2007) in states with and without drug caps before Part D.

MEASURES

We examined the monthly (1) proportion of patients with any use of lipid-lowering therapies; and (2) intensity of use. Stratification measures included age (less than 65, 65 y and older), race (white vs. black), and sex.

RESULTS

At baseline, lipid-lowering drug use was higher in no drug cap states (drug cap: 54.0% vs. nondrug cap: 66.8%) and among whites versus blacks (drug cap: 58.5% vs. 44.9%, no drug cap: 68.4% vs. 61.9%). In strict drug cap states only, Part D was associated with an increase in the proportion with any use [nonelderly: +0.07 absolute percentage points (95% confidence interval, 0.06-0.09), P<0.001; elderly: +0.08 (0.06-0.10), P<0.001] regardless of race. However, we found no evidence of a change in the white-black gap in the proportion of users despite the removal of a significant financial barrier.

CONCLUSIONS

Medicare Part D was associated with increased use of lipid-lowering drugs, but racial gaps persisted. Understanding non-coverage-related barriers is critical in maximizing the potential benefits of coverage expansions for disparities reduction.

Interethnic Variation in Lipid Profiles: Implications for Underidentification of African-Americans at risk for Metabolic Disorders

Interethnic differences exist in the distribution of serum lipids, with African Americans (AA) generally having a healthier lipid profile than other US ethnic groups. Similar lipid distributions are observed among other African ancestry groups with distinct lifestyle characteristics, suggesting the importance of inherited factors. Despite healthier serum lipids, AA experience a disproportionate burden of Type 2 Diabetes and Cardiovascular Disease. As evidence of a different relationship between serum lipids and disease exists, the characterization of metabolic risk using lipid concentration (as in Metabolic Syndrome criteria) may lead to the under-identification of AA at risk. Given the disproportionately high rate of metabolic disorders in AA, understanding interethnic differences in the association between serum lipids and disease should be a research priority, as better appreciation of these differences will enhance knowledge of disease etiology, improve intervention targeting, and may lead to mechanisms to ameliorate debilitating health disparities in the US and globally.

Long-term follow-up of moderately hypercholesterolemic hypertensive patients following randomization to pravastatin vs usual care: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT)

The authors conducted a randomized, controlled, multicenter trial, in which they assigned well-controlled hypertensive participants aged 55 years and older with moderate hypercholesterolemia to receive pravastatin (n=5170) or usual care (n=5185) for 4 to 8 years, when trial therapy was discontinued. Passive surveillance using national databases to ascertain deaths and hospitalizations continued for a total follow-up of 8 to 13 years to assess whether mortality and morbidity differences persisted or new differences developed. During the post-trial period, fatal and nonfatal outcomes were available for 98% and 64% of participants, respectively. The primary outcome was all-cause mortality and the secondary outcomes included cardiovascular mortality, coronary heart disease (CHD), stroke, heart failure, cardiovascular disease, and end-stage renal disease. No significant differences appeared in mortality for pravastatin vs usual care (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.89-1.03) or other secondary outcomes. Similar to the previously reported in-trial result, there was a significant treatment effect for CHD in black patients (HR, 0.79; 95% CI, 0.64-0.98). However, the in-trial result showing a significant treatment by race effect did not remain significant during the entire follow-up (P=.08). These findings are consistent with evidence from other large trials that show statins prevent CHD and add evidence that they are effective for CHD prevention in black patients.

ALLHAT: still providing correct answers after 7 years

PURPOSE OF REVIEW

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is re-evaluated considering information from recent subgroup and exploratory analyses, other new clinical trials, and meta-analyses. The ALLHAT analyses specifically emphasize heart failure findings, results in Black participants and those with chronic kidney disease, selection and doses of thiazide and similar diuretics, and the association of antihypertensive drug use with new-onset diabetes and its cardiovascular consequences.

RECENT FINDINGS

The initial ALLHAT conclusion, that thiazide diuretics are superior to angiotensin-converting enzyme inhibitors (ACEIs), calcium antagonists (CCBs) and alpha-blockers in preventing one or more major clinical outcomes, including heart failure and stroke, and unsurpassed in significantly preventing any cardiovascular or renal outcome, has been further validated for patients with diabetes, renal disease, and/or metabolic syndrome. The evidence is even more compelling for Black patients. New-onset diabetes associated with thiazides did not increase cardiovascular outcomes. The diuretic was superior to all in preventing heart failure with preserved left-ventricular ejection fraction (LVEF) and similar to the ACEI in preventing heart failure with impaired LVEF. It was also unsurpassed in preventing atrial fibrillation.

SUMMARY

The totality of evidence re-affirms the initial ALLHAT conclusion that thiazide and similar diuretics (at evidence-based doses) are the preferred first-step therapy in most patients with hypertension.