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Shah NN, Ghazi L, Yamamoto Y, Kumar S, Martin M, Simonov M, Riello Iii RJ, Faridi KF, Ahmad T, Wilson FP, Desai NR. Pragmatic Trial of Messaging to Providers About Treatment of Hyperlipidemia (PROMPT-LIPID): A Randomized Clinical Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010335. [PMID: 38634282 DOI: 10.1161/circoutcomes.123.010335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Lipid-lowering therapy (LLT) is underutilized for very high-risk atherosclerotic cardiovascular disease. PROMPT-LIPID (PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia) sought to determine whether electronic health record (EHR) alerts improve 90-day LLT intensification in patients with very high-risk atherosclerotic cardiovascular disease. METHODS PROMPT-LIPID was a pragmatic trial in which cardiovascular and internal medicine clinicians within Yale New Haven Health (New Haven, CT) were cluster-randomized to receive an EHR alert with individualized LLT recommendations or no alert for outpatients with very high-risk atherosclerotic cardiovascular disease and LDL-C (low-density lipoprotein cholesterol), ≥70 mg/dL. The primary outcome was 90-day LLT intensification (change to high-intensity statin and addition of ezetimibe or PCSK9i [proprotein subtilisin/kexin type 9 inhibitors]). Secondary outcomes included LDL-C level, proportion of patients with LDL-C of <70 or < 55 mg/dL, rate of major adverse cardiovascular events, ED visit incidence, and 6-month mortality. Results were analyzed using logistic and linear regression clustered at the provider level. RESULTS The no-alert group included 47 clinicians and 1370 patients (median age, 71 years; 50.1% female, median LDL-C, 93 mg/dL); the alert group included 49 clinicians and 1130 patients (median age, 72 years; 47% female, median LDL-C 91, mg/dL). The primary outcome was observed in 14.1% of patients in the alert group as compared with 10.4% in the no-alert group. There were no differences in any secondary outcomes at 6 months. Among 542 patients whose clinicians (n=46) did not dismiss the EHR alert recommendations, LLT intensification was significantly greater (21.2% versus 10.4%, odds ratio, 2.33 [95% CI, 1.48-3.66]). CONCLUSIONS With a real-time, targeted, individualized EHR alert as compared with usual care, the proportion of patients with atherosclerotic cardiovascular disease with LLT intensification was numerically higher but not statistically significant. Among clinicians who did not dismiss the alert, there was a > 2-fold increase in LLT intensification. EHR alerts, coupled with strategies to reduce clinician dismissal, may help address persistent gaps in LDL-C management. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04394715, https://www.clinicaltrials.gov/ct2/show/study/NCT04394715.
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Affiliation(s)
- Nimish N Shah
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
| | - Lama Ghazi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, AL (L.G.)
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Sanchit Kumar
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Melissa Martin
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Michael Simonov
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Ralph J Riello Iii
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Kamil F Faridi
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - F Perry Wilson
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (N.N.S., K.F.F., T.A., F.P.W., N.R.D.)
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT (Y.Y., S.K., M.M., M.S., R.J.R., T.A., F.P.W., N.R.D.)
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Bagheri Kholenjani F, Shahidi S, Vaseghi G, Ashoorion V, Sarrafzadegan N. First Iranian guidelines for the diagnosis, management, and treatment of hyperlipidemia in adults. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2024; 29:18. [PMID: 38808220 PMCID: PMC11132424 DOI: 10.4103/jrms.jrms_318_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/10/2023] [Accepted: 11/08/2023] [Indexed: 05/30/2024]
Abstract
This guideline is the first Iranian guideline developed for the diagnosis, management, and treatment of hyperlipidemia in adults. The members of the guideline developing group (GDG) selected 9 relevant clinical questions and provided recommendations or suggestions to answer them based on the latest scientific evidence. Recommendations include the low-density lipoprotein cholesterol (LDL-C) threshold for starting drug treatment in adults lacking comorbidities was determined to be over 190 mg/dL and the triglyceride (TG) threshold had to be >500 mg/dl. In addition to perform fasting lipid profile tests at the beginning and continuation of treatment, while it was suggested to perform cardiovascular diseases (CVDs) risk assessment using valid Iranian models. Some recommendations were also provided on lifestyle modification as the first therapeutic intervention. Statins were recommended as the first line of drug treatment to reduce LDL-C, and if its level was high despite the maximum allowed or maximum tolerated drug treatment, combined treatment with ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, or bile acid sequestrants was suggested. In adults with hypertriglyceridemia, pharmacotherapy with statin or fibrate was recommended. The target of drug therapy in adults with increased LDL-C without comorbidities and risk factors was considered an LDL-C level of <130 mg/dl, and in adults with increased TG without comorbidities and risk factors, TG levels of <200 mg/dl. In this guideline, specific recommendations and suggestions were provided for the subgroups of the general population, such as those with CVD, stroke, diabetes, chronic kidney disease, elderly, and women.
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Affiliation(s)
- Fahimeh Bagheri Kholenjani
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shahla Shahidi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Golnaz Vaseghi
- Applied Physiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Ashoorion
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nizal Sarrafzadegan
- Address for correspondence: Dr. Nizal Sarrafzadegan, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail:
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Colantonio LD, Wang Z, Jones J, Dhalwani NN, Shannon ED, Liu C, Kalich BA, Muntner P, Rosenson RS, Bittner V. Low-Density Lipoprotein Cholesterol Testing Following Myocardial Infarction Hospitalization Among Medicare Beneficiaries. JACC. ADVANCES 2024; 3:100753. [PMID: 38939806 PMCID: PMC11198160 DOI: 10.1016/j.jacadv.2023.100753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/26/2023] [Accepted: 10/13/2023] [Indexed: 06/29/2024]
Abstract
Background Low-density lipoprotein cholesterol (LDL-C) is used to guide lipid-lowering therapy after a myocardial infarction (MI). Lack of LDL-C testing represents a missed opportunity for optimizing therapy and reducing cardiovascular risk. Objectives The purpose of this study was to estimate the proportion of Medicare beneficiaries who had their LDL-C measured within 90 days following MI hospital discharge. Methods We conducted a retrospective cohort study of Medicare beneficiaries ≥66 years of age with an MI hospitalization between 2016 and 2020. The primary analysis used data from all beneficiaries with fee-for-service coverage and pharmacy benefits (532,767 MI hospitalizations). In secondary analyses, we used data from a 5% random sample of beneficiaries with fee-for-service coverage without pharmacy benefits (10,394 MI hospitalizations), and from beneficiaries with Medicare Advantage (176,268 MI hospitalizations). The proportion of beneficiaries who had their LDL-C measured following MI hospital discharge was estimated accounting for the competing risk of death. Results In the primary analysis (mean age 76.9 years, 84.4% non-Hispanic White), 29.9% of beneficiaries had their LDL-C measured within 90 days following MI hospital discharge. Among Hispanic, Asian, non-Hispanic White, and non-Hispanic Black beneficiaries, the 90-day postdischarge LDL-C testing was 33.8%, 32.5%, 30.0%, and 26.0%, respectively. Postdischarge LDL-C testing within 90 days was highest in the Middle Atlantic (36.4%) and lowest in the West North Central (23.4%) U.S. regions. In secondary analyses, the 90-day postdischarge LDL-C testing was 26.9% among beneficiaries with fee-for-service coverage without pharmacy benefits, and 28.6% among beneficiaries with Medicare Advantage coverage. Conclusions LDL-C testing following MI hospital discharge among Medicare beneficiaries was low.
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Affiliation(s)
- Lisandro D. Colantonio
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Zhixin Wang
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jenna Jones
- Center for Observational Research, Amgen Inc, Thousand Oaks, California, USA
| | - Nafeesa N. Dhalwani
- Center for Observational Research, Amgen Inc, Thousand Oaks, California, USA
| | - Erin D. Shannon
- Center for Observational Research, Amgen Inc, Thousand Oaks, California, USA
| | - Cici Liu
- ICON Clinical Research Inc, Blue Bell, Pennsylvania, USA
| | | | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Robert S. Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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5
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 182] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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Tong A, Wu W, Chen Z, Wen J, Jia R, Liu B, Cao H, Zhao C. Modulation of gut microbiota and lipid metabolism in rats fed high-fat diets by Ganoderma lucidum triterpenoids. Curr Res Food Sci 2022; 6:100427. [PMID: 36632433 PMCID: PMC9826932 DOI: 10.1016/j.crfs.2022.100427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 09/05/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022] Open
Abstract
Ganoderma lucidum triterpenoids (GP) have been reported to help prevent and improve hyperlipidemia. Modulation of the gut microbiota was proposed as underlying factor as well as a novel measure to prevent and treat hyperlipidemia. The effects of GP on high-fat diet (HFD)-induced hyperlipidemia and gut microbiota modulation were determined in rats. Ultra-performance liquid chromatography tandem quadrupole time-of-flight mass spectrometry (UPLC-QTOF MS-MS) indicated that GP were enriched with ganoderic acids G, B, H, A, and F. After feeding with GP supplementation, serum lipid levels including total triglyceride, total cholesterol, and low-density-lipoprotein cholesterol were significantly decreased in hyperlipidemic rats. Furthermore, administration of GP also has reversed the HFD-induced gut microbiota dysbiosis, including a significant increase in Alloprevotella and reduced proportion of Blautia. The result above suggests that GP would be developed as a functional food to ameliorate lipid metabolic disorders and hyperlipidemia.
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Affiliation(s)
- Aijun Tong
- College of Food Science, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Weihao Wu
- College of Food Science, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Zhengxin Chen
- College of Food Science, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Jiahui Wen
- College of Food Science, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Ruibo Jia
- College of Food Science, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Bin Liu
- College of Food Science, Fujian Agriculture and Forestry University, Fuzhou, 350002, China,National Engineering Research Center of Juncao, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Hui Cao
- College of Food Science and Technology, Guangdong Ocean University, Guangdong Provincial Key Laboratory of Aquatic Product Processing and Safety, Zhanjiang, 524088, China,Universidade de Vigo, Nutrition and Bromatology Group, Department of Analytical and Food Chemistry, Faculty of Sciences, 32004, Ourense, Spain,Corresponding author. College of Food Science and Technology, Guangdong Ocean University, Guangdong Provincial Key Laboratory of Aquatic Product Processing and Safety, Zhanjiang, 524088, China.
| | - Chao Zhao
- College of Marine Sciences, Fujian Agriculture and Forestry University, Fuzhou, 350002, China,College of Food Science, Fujian Agriculture and Forestry University, Fuzhou, 350002, China,Corresponding author. College of Marine Sciences, Fujian Agriculture and Forestry University, Fuzhou, 350002, China.
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Zheutlin AR, Derington CG, Herrick JS, Rosenson RS, Poudel B, Safford MM, Brown TM, Jackson EA, Woodward M, Reading S, Orroth K, Exter J, Virani SS, Muntner P, Bress AP. Lipid-Lowering Therapy Use and Intensification Among United States Veterans Following Myocardial Infarction or Coronary Revascularization Between 2015 and 2019. Circ Cardiovasc Qual Outcomes 2022; 15:e008861. [PMID: 36252093 PMCID: PMC10680021 DOI: 10.1161/circoutcomes.121.008861] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 06/14/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Understanding how statins, ezetimibe, and PCSK9i (proprotein convertase subtilisin/kexin type 9 serine protease inhibitors) are prescribed after a myocardial infarction (MI) or elective coronary revascularization may improve lipid-lowering therapy (LLT) intensification and reduce recurrent atherosclerotic cardiovascular disease events. We described the use and intensification of LLT among US veterans who had a MI or elective coronary revascularization between July 24, 2015, and December 9, 2019, within 12 months of hospital discharge. METHODS LLT intensification was defined as increasing statin dose, or initiating a statin, ezetimibe, or a PCSK9i, overall and among those with an LDL-C (low-density lipoprotein cholesterol) ≥70 or 100 mg/dL. Poisson regression was used to determine patient characteristics associated with a greater likelihood of LLT intensification following hospitalization for MI or elective coronary revascularization. RESULTS Among 81 372 index events (mean age, 69.0 years, 2.3% female, mean LDL-C 89.6 mg/dL, 33.8% with LDL-C <70 mg/dL), 39.7% were not taking any LLT, and 22.0%, 37.2%, and 0.6% were taking a low-moderate intensity statin, a high-intensity statin, and ezetimibe, respectively, before MI/coronary revascularization during the study period. Within 14 days, 3 months, and 12 months posthospitalization, 33.3%, 41.9%, and 47.3%, respectively, of veterans received LLT intensification. LLT intensification was most common among veterans taking no LLT (82.5%, n=26 637) before MI/coronary revascularization. Higher baseline LDL-C, having a lipid test, and attending a cardiology visit were each associated with a greater likelihood of LLT intensification, while age ≥75 versus <65 years was associated with a lower likelihood of LLT intensification within 12 months posthospitalization. CONCLUSIONS Less than half of veterans received LLT intensification in the year after MI or coronary revascularization suggesting a missed opportunity to reduce atherosclerotic cardiovascular disease risk.
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Affiliation(s)
| | - Catherine G Derington
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jennifer S Herrick
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision Enhancement and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Robert S Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bharat Poudel
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Todd M Brown
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth A Jackson
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark Woodward
- The George Institute for Global Health, School of Public Health, Imperial College London, UK
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Stephanie Reading
- Center for Observational Research, Amgen Inc., Amgen Inc., Thousand Oaks, CA, USA
| | - Kate Orroth
- Center for Observational Research, Amgen Inc., Amgen Inc., Thousand Oaks, CA, USA
| | - Jason Exter
- Center for Observational Research, Amgen Inc., Amgen Inc., Thousand Oaks, CA, USA
| | - Salim S Virani
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Health Policy and Quality Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center of Excellence, Houston, TX, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
| | - Adam P Bress
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision Enhancement and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
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Shah NN, Ghazi L, Yamamoto Y, Martin M, Simonov M, Riello RJ, Faridi KF, Ahmad T, Wilson FP, Desai NR. Rationale and design of a pragmatic trial aimed at improving treatment of hyperlipidemia in outpatients with very high risk atherosclerotic cardiovascular disease: A pragmatic trial of messaging to providers about treatment of hyperlipidemia (PROMPT-LIPID). Am Heart J 2022; 253:76-85. [PMID: 35841944 PMCID: PMC9936562 DOI: 10.1016/j.ahj.2022.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 05/20/2023]
Abstract
BACKGROUND Despite guideline recommendations to optimize low-density lipoprotein cholesterol (LDL-C) reduction with intensification of lipid-lowering therapy (LLT) in patients with atherosclerotic cardiovascular disease (ASCVD), few of these patients achieve LDL-C < 70 mg/dL in practice. PURPOSE We developed a real-time, targeted electronic health record (EHR) alert with embedded ordering capability to promote intensification of evidence based LLT in outpatients with very high risk ASCVD. METHODS We designed a pragmatic, multicenter, single-blind, cluster randomized trial to test the effectiveness of an EHR-based LLT intensification alert. The study will enroll about 100 providers who will be randomized to either receive the alert or undergo usual care for outpatients with high risk ASCVD with LDL-C > 70 mg/dL. Total enrollment will include 2,500 patients. The primary outcome will be the proportion of patients with LLT intensification at 90 days. Secondary outcomes include achieved LDL-C at 6 months and the proportion of patients with LDL-C < 70 mg/dL or < 55 mg/dL at 6 months. RESULTS Enrollment of 1,250 patients (50% of goal) was reached within 47 days (50% women, mean age 72, median LDL-C 91). At baseline, 71%, 9%, and 3% were on statins, ezetimibe, or proprotein convertase subtilisin/kexin type 9 inhibitors, respectively. CONCLUSIONS PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia has rapidly reached 50% enrollment of patients with very high risk ASCVD, demonstrating low baseline LLT utilization. This pragmatic, EHR-based trial will determine the effectiveness of a real-time, targeted EHR alert with embedded ordering capability to promote LLT intensification. Findings from this low-cost, widely scalable intervention to improve LDL-C may have important public health implications. TRIAL REGISTRATION clinicaltrials.gov NCT04394715.
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Affiliation(s)
| | - Lama Ghazi
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Melissa Martin
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Michael Simonov
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | | | - Tariq Ahmad
- Section of Cardiovascular Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - F Perry Wilson
- Section of Cardiovascular Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT
| | - Nihar R Desai
- Section of Cardiovascular Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT.
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Adherence to Lipid Monitoring and Its Impact on Treat Intensification of LDL-C Lowering Therapies at an Urban Academic Medical Center. J Clin Lipidol 2022; 16:491-497. [DOI: 10.1016/j.jacl.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/21/2022] [Accepted: 05/06/2022] [Indexed: 11/23/2022]
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Rana JS, Virani SS, Moffet HH, Liu JY, Coghlan LA, Vasadia J, Ballantyne CM, Karter AJ. Association of Low-Density Lipoprotein Testing After an Atherosclerotic Cardiovascular Event with Subsequent Statin Adherence and Intensification. Am J Med 2022; 135:603-606. [PMID: 34861203 PMCID: PMC9081243 DOI: 10.1016/j.amjmed.2021.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE This study aimed to evaluate associations between outpatient low-density lipoprotein cholesterol (LDL-C) testing and subsequent statin adherence and intensification in patients after an atherosclerotic cardiovascular (ASCVD) event. METHODS This was a longitudinal study of adult members of Kaiser Permanente Northern California hospitalized with an ASCVD event (myocardial infarction or stroke) during January 01, 2016, to December 31, 2017, with follow-up through December 31, 2019. Outcomes were statin adherence (estimated using continuous medication gap [CMG]) and intensification (defined by an increased dose or switch to a higher-intensity statin) based on pharmacy dispensing. The exposure of interest was first outpatient LDL-C test after an ASCVD event. Baseline for follow-up was LDL-C test date or a date assigned using incidence density sampling. Multivariate logistic regression models were specified to estimate the odds ratios for statin adherence or intensification among those with vs without an LDL-C test, with adjustment for age, sex, race/ethnicity, smoking, hypertension, diabetes, body mass index, and estimated glomerular filtration rate. RESULTS There were 19,604 adults hospitalized with ASCVD, including 7054 adults not on high-intensity statins. The mean age was 69.5 years and 33.0% were female. Prevalence of good adherence (continuous medication gap ≤20%) was significantly higher (80.2% vs 75.9%; odds ratio 1.38; 95% confidence interval, 1.28-1.49; P <.001) among participants who had an LDL-C test compared with participants who did not. LDL-C testing was associated with significantly higher rates of treatment intensification (16.1% vs 10.7%; odds ratio 1.51; 95% confidence interval,1.29-1.76; P <0.001). CONCLUSIONS Low-density lipoprotein cholesterol testing is recommended for patients with a history of ASCVD and may be a high-value and low-cost intervention to improve adherence and statin management.
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Affiliation(s)
- Jamal S Rana
- Department of Cardiology, Kaiser Permanente Northern California, Oakland; Division of Research, Kaiser Permanente Northern California, Oakland; Department of Medicine, University of California San Francisco.
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jennifer Y Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Landis A Coghlan
- Department of Adult and Family Medicine, Kaiser Permanente Northern California, Santa Clara
| | - Jitesh Vasadia
- Department of Cardiology, Kaiser Permanente Northern California, Santa Rosa
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland; Department of Health Systems and Population Health, University of Washington, Seattle, Calif; Department of General Internal Medicine, University of California, San Francisco
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11
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Brownstein AJ, Derenbecker R, Gao Y, Ding J, Varghese B, Isakadze N, Spaulding EM, Marvel FA, Martin SS. Application of the very high risk criterion and evaluation of cholesterol guideline adherence in acute myocardial infarction patients at an urban academic medical center. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100082. [PMID: 38560081 PMCID: PMC10978217 DOI: 10.1016/j.ahjo.2021.100082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/23/2021] [Indexed: 04/04/2024]
Abstract
Objective The 2018 AHA/ACC cholesterol guidelines recommend considering non-statin agents among very high-risk (VHR) patients with LDL-C ≥ 70 mg/dL after maximizing statin therapy. We aimed to evaluate the prevalence of VHR status in acute myocardial infarction (AMI) patients at hospital discharge and the adherence to guideline-directed cholesterol therapy (GDCT) within one-year follow-up post-AMI. Methods We performed a retrospective analysis of patients who suffered a type 1 AMI between October 2015 and March 2019, and then were followed at our institution for 1 year after hospital discharge. We calculated the percentage of patients at VHR and among those with follow up lipid panels, we determined the proportion able to achieve GDCT. Results The mean age of the 331 AMI patients was 61.0 (SD 11.9) years and 33.6% were women. Overall, 268 (81.0%) patients were categorized as having VHR at discharge. Among patients at VHR, a lipid panel was rechecked in 153 individuals (57.1%) within 1 year of discharge, with the median time to lipid recheck being 22.4 weeks (interquartile range: 10.9-40.7 weeks). Among those with a lipid panel re-check, 100 (65.4%) of patients achieved GDCT. Conclusions Approximately 4 out of 5 AMI patients were considered VHR per the 2018 AHA/ACC guidelines, only about half had follow up lipid panels in the year following AMI, and about two-thirds of those with follow up lipid panels achieved GDCT.
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Affiliation(s)
- Adam J. Brownstein
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert Derenbecker
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yumin Gao
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jie Ding
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bibin Varghese
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nino Isakadze
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Erin M. Spaulding
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Francoise A. Marvel
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seth S. Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
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12
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Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) guidelines for management of dyslipidemia and cardiovascular disease risk reduction: Putting evidence in context. Prog Cardiovasc Dis 2021; 68:2-6. [PMID: 34371083 DOI: 10.1016/j.pcad.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 01/21/2023]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the United States (U.S.) and incurs significant cost to the healthcare system. Management of cholesterol remains central for ASCVD prevention and has been the focus of multiple national guidelines. In this review, we compare the American Heart Association (AHA)/American College of Cardiology (ACC) and the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Cholesterol guidelines. We review the evidence base that was used to generate recommendations focusing on 4 distinct themes: 1) the threshold of absolute 10-year ASCVD risk to start a clinician-patient discussion for the initiation of statin therapy in primary prevention patients; 2) the utility of coronary artery calcium score to guide clinician-patient risk discussion pertaining to the initiation of statin therapy for primary ASCVD prevention; 3) the use of moderate versus high-intensity statin therapy in patients with established ASCVD; and 4) the utility of ordering lipid panels after initiation or intensification of lipid lowering therapy to document efficacy and monitor adherence to lipid lowering therapy. We discuss why the VA/DoD and AHA/ACC may have reached different conclusions on these key issues.
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13
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Lipid Monitoring After Initiation of Lipid-Lowering Therapies: Return of Performance Measures? Curr Cardiol Rep 2021; 23:116. [PMID: 34269897 DOI: 10.1007/s11886-021-01545-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The 2015 American College of Cardiology (ACC)/American Heart Association (AHA) Focused Update of Secondary Prevention Lipid Performance Measures removed low-density lipoprotein cholesterol (LDL-C) assessment as a performance measure. This review discusses the evidence supporting the importance of lipid monitoring in the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). RECENT FINDINGS The 2018 AHA/ACC Multisociety cholesterol guideline (as did the 2013 guideline) recommends a lipid panel after initiating lipid-lowering therapy to monitor adherence and medication efficacy. The 2018 guideline also recommends adding nonstatin therapy in very-high-risk ASCVD patients with LDL-C ≥70 mg/dL despite maximally tolerated statin therapy. The removal of LDL-C monitoring as a performance measure is not consistent with the 2018 cholesterol guidelines. Given the importance of monitoring lipid-lowering medication efficacy and adherence and optimally reducing LDL-C in very-high-risk patients with additional evidence-based nonstatin therapy, LDL-C assessment after initiating lipid-lowering therapy should be reinstated as a performance measure for patients with ASCVD.
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14
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Agha AM, Virani SS, Ballantyne CM. Transatlantic guidelines on dyslipidemia and cardiovascular risk: key differences across the pond. Curr Opin Endocrinol Diabetes Obes 2021; 28:114-121. [PMID: 33395089 PMCID: PMC7963270 DOI: 10.1097/med.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to compare and contrast the key messages from the 2018 American Heart Association (AHA)/American College of Cardiology (ACC) Multisociety Guideline on the Management of Blood Cholesterol and the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) Guidelines for the Management of Dyslipidemias. We also review some of the evidence that served as the basis for these guidelines and share our opinion regarding these guidelines. RECENT FINDINGS Patients with atherosclerotic cardiovascular disease (ASCVD), severe hypercholesterolemia, familial hypercholesterolemia, or diabetes should be treated aggressively with lipid-lowering therapy. In addition to traditional risk factors included in risk scores, assessment of risk enhancers/modifiers may improve risk stratification. The addition of ezetimibe ± proprotein convertase subtilisin/kexin type 9 inhibitors plays an integral role in the management of very-high-risk ASCVD patients; the ESC/EAS guidelines support more aggressive use of these medications. SUMMARY Both the AHA/ACC Multisociety and ESC/EAS guidelines provide an evidence-based approach to management of blood cholesterol. The greatest difference between these two guidelines is the classification and recommended management of very-high-risk patients. Implementation of either guideline will likely lead to improved ASCVD outcomes compared with current treatment practice. VIDEO ABSTRACT http://links.lww.com/COE/A22.
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Affiliation(s)
- Ali M. Agha
- Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, TX, USA
| | - Salim S. Virani
- Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Christie M. Ballantyne
- Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, TX, USA
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15
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Barrios V, Escobar C, Gamarra J, Obaya JC, Pallarés V. [Management of patients with dyslipidaemia in Spain. The Cardio Right Care Control of cardiovascular risk project]. Semergen 2020; 47:28-37. [PMID: 33268266 DOI: 10.1016/j.semerg.2020.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/12/2020] [Accepted: 08/25/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To ascertain the opinion of physicians about diagnostic criteria, control targets, control rates, and therapeutic approach of patients with dyslipidaemia in Spain. METHODS A specific questionnaire was created about diagnostic criteria, control targets, control rates, lipid lowering therapies, and therapeutic inertia in patients with dyslipidaemia. Physicians completed the questionnaire online during a 4-month period. RESULTS A total of 959 questionnaires were collected from all over Spain. The most frequent scale to stratify cardiovascular risk is SCORE (54.9%), and guidelines from the European Society of Cardiology are the most common guidelines used (50.5%). The majority of patients are on primary prevention (57.7%), and 31.4% have a high-very high cardiovascular risk. More than 70% of investigators considered that the target among patients at very high risk and those in secondary prevention is an LDL cholesterol < 70 mg/dL. It is considered by 60.0% and 66.4% of investigators that their patients on primary and secondary prevention, respectively, achieve control targets. Statins are the most common lipid lowering drugs used, followed by ezetimibe. In the majority of cases, when a patient is not adequately controlled with statins, there is an increase in the dose or a change to another statin. Poor adherence to treatment and therapeutic inertia are the main reasons for poor LDL cholesterol control. CONCLUSIONS The Cardio Right Care CVR Control project allows those aspects to be identified, as well as areas of improvement in patients with dyslipidaemia in Spain.
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Affiliation(s)
- Vivencio Barrios
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - Carlos Escobar
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, España
| | - Javier Gamarra
- Centro de Salud Medina-Rural, Medina del Campo, Valladolid, España
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