Long-term achievement of the therapeutic objectives of lipid-lowering agents in primary prevention patients and cardiovascular outcomes: An observational study

New Male Users of Lipid-Lowering Drugs for Primary Prevention of Cardiovascular Disease: The Impact of Treatment Persistence on Morbimortality. A Longitudinal Study

The objective of this study was to analyse persistence to lipid-lowering drug use for primary prevention of cardiovascular disease (CVD) in a new users cohort, to explore all-cause and cardiovascular related morbidity, comorbidity and mortality in this group and, finally, to study the relationship between persistence and morbimortality. We selected subjects who started lipid-lowering treatment for primary prevention of CVD between 1 January 2010 and 31 December 2017 (N = 1424), and classified them as treatment-persistent or -nonpersistent. Bivariate analyses were performed to compare sociodemographic and clinical variables, morbimortality and time to event between groups. The association between morbidities was explored using comorbidity network analysis. The effect of persistence was analysed using logistic regression and Cox survival analyses. Only 38.7% of users were persistent with treatment. Persistent and nonpersistent users had similar sociodemographic and clinical profiles, although differed in age, smoking status, and glycemia. Comorbidity networks revealed that the number of co-occurring diagnoses was higher in nonpersistent than persistent users. Adjusted analyses indicated a protective effect of treatment persistence, especially against major adverse cardiovascular events (MACE), but this effect was not statistically significant. Observational studies are crucial to characterize real-world effectiveness.

Impact of cardiovascular risk factor control on long-term cardiovascular and all-cause mortality in the general population

PURPOSE

In clinical trials, lowering cardiovascular risk factors (CVRFs) reduces cardiovascular (CV) morbidity and mortality. We assessed the impact of controlling CVRFs at baseline on long-term all-cause and CV mortality in the general population.

METHODS

Analysis was based on the Third French MONICA population-based survey (1994-1997). Vital status was obtained 18 years after inclusion. Statistical analysis was based on Cox-modelling.

RESULTS

About 3402 participants aged 35-64 were included and 569 (17%) presented with 2 or more uncontrolled CVRFs, 1194 (35%) had one uncontrolled CVRF, 770 (23%) had all CVRFs controlled under treatment (or were former smokers) and 869 (25%) exhibited no CVRF. During the follow-up, 389 deaths occurred (76 were due to CV causes). Considering all-cause mortality, the adjusted hazard ratios (aHR) for subjects with one uncontrolled CVRF and for those with two or more were 1.38 [1.03-1.83] (p = 0.029) and 1.80 [1.33-2.43](p < 0.001), respectively, as compared with subjects presenting with all their CVRFs controlled. For subjects exhibiting no CVRF, the aHR was 0.66 [0.44-0.98] (p = 0.042). Considering CV mortality, aHRs for subjects presenting with one and two or more uncontrolled CVRF were 1.70 [0.84-3.42] (p = 0.138) and 3.67 [1.85-7.29] (p < 0.001), respectively, as compared with subjects who had either all their CVRFs controlled or exhibited no CVRF.

CONCLUSIONS

Failing to control CVRFs significantly increases long-term all-cause and CV mortality in the French general population. Key messages Only 30% of patients with cardiovascular risk factors were controlled. Failing to control cardiovascular risk factors significantly increased long-term cardiovascular and all-cause mortality. A residual risk for all-cause mortality remained even when patients were controlled.

Cardiovascular risk and lifestyle habits of consumers of a phytosterol-enriched yogurt in a real-life setting

BACKGROUND

Data on the characteristics of consumers of phytosterol-enriched products and modalities of consumption are rare. An observational study evaluating the lifestyle characteristics and cardiovascular risk (CVR) profile of phytosterol-enriched yogurt consumers was performed in France.

METHODS

Subjects were recruited from general practitioners via electronic medical records. Data were obtained from 358 consumers and 422 nonconsumers with 519 subject questionnaires (243 consumers, 276 nonconsumers; 67% response).

RESULTS

Consumers had more cardiovascular risk factors than nonconsumers (2.0 ± 1.5 versus 1.6 ± 1.4; P < 0.001) and a higher 10-year SCORE cardiovascular risk (1.8 ± 2.0% versus 1.6 ± 2.2%; P = 0.008); they were older (P = 0.030) and had a higher incidence of hypercholesterolaemia (P < 0.001) and family or personal history of heart disease (P = 0.023/P = 0.026, respectively). Among consumers not on cholesterol-lowering medication, 99% were eligible for lifestyle interventions and 56% were eligible for lipid-lowering drug according to European guidelines. Consumers had a healthier lifestyle, with a higher (fruit/vegetable - saturated fatty acid) score than nonconsumers (P = 0.035), focused more on low-intensity leisure activity (P = 0.023), spent more time travelling by foot or bicycle (P = 0.012) and were more likely to act to reduce CVR. Phytosterol-enriched yogurt intake conformed to recommendations in two-thirds of consumers and was mainly consumed because of concerns over cholesterol levels and CVR.

CONCLUSIONS

The higher cardiovascular disease risk profile of phytosterol-enriched yogurt consumers corresponds to a population for whom European guidelines recommend lifestyle changes to manage cholesterol. The coherence of the data in terms of risk factors, adherence to lifestyle recommendations and the consumption of phytosterol-enriched yogurt conforming to recommendations reflects a health-conscious consumer population.

Mixed dyslipidemias in primary care patients in France

OBJECTIVE

To determine the prevalence of single and mixed dyslipidemias among patients treated with statins in clinical practice in France.

METHODS

This is a prospective, observational, cross-sectional, pharmacoepidemiologic study with a total of 2544 consecutive patients treated with a statin for at least 6 months.

MAIN OUTCOME MEASURES

Prevalence of isolated and mixed dyslipidemias of low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), and triglycerides among all patients and among patients at high cardiovascular risk; clinical variables associated with attainment of lipid targets/normal levels in French national guidelines.

RESULTS

At least one dyslipidemia was present in 50.8% of all patients and in 71.1% of high-risk patients. Dyslipidemias of LDL-C, HDL-C, and triglycerides were present in 27.7%, 12.4%, and 28.7% of all patients, respectively, and in 51.0%, 18.2%, and 32.5% of high-risk patients, respectively. Among all subjects with any dyslipidemia, 30.9% had mixed dyslipidemias and 69.4% had low HDL-C and/or elevated triglycerides, while 30.6% had isolated elevated LDL-C; corresponding values for high-risk patients were 36.8%, 58.9%, and 41.1%. Age, gender, body mass index and Framingham Risk Score >20% were the factors significantly associated with attainment of normal levels for ≥2 lipid levels.

CONCLUSIONS

At least one dyslipidemia persisted in half of all patients and two-thirds of high cardiovascular risk patients treated with a statin. Dyslipidemias of HDL-C and/or triglycerides were as prevalent as elevated LDL-C among high cardiovascular risk patients.

Low-density lipoprotein cholesterol reduction and goal achievement with ezetimibe/simvastatin versus atorvastatin or rosuvastatin in patients with diabetes, metabolic syndrome, or neither disease, stratified by National Cholesterol Education Program risk category

BACKGROUND

Patients with diabetes mellitus (DM) and metabolic syndrome are at increased risk of coronary heart disease (CHD). Studies have shown differential statin efficacy on low-density lipid cholesterol (LDL-C) by CHD risk strata.

OBJECTIVE

The aim of this study was to evaluate the consistency of effect with ezetimibe/simvastatin (E/S) combination therapy, atorvastatin, or rosuvastatin in patients with DM, metabolic syndrome, or neither condition (No DM/metabolic syndrome), stratified by the National Cholesterol Education Panel Adult Treatment Panel III (NCEP ATP III) CHD risk group.

METHODS

Post hoc analyses of 2 multicenter, double-blind, randomized, 6-week studies comparing E/S 10/10, 10/20, 10/40, or 10/80 mg with either atorvastatin 10, 20, 40, or 80 mg, or rosuvastatin 10, 20, or 40 mg. Treatments were compared by pooling across all doses for LDL-C reduction and NCEP LDL-C goal attainment in patients with DM, metabolic syndrome without DM, or No DM/metabolic syndrome across NCEP CHD risk strata.

RESULTS

NCEP LDL-C goal attainment was lowest in the high-risk group with atherosclerotic vascular disease (12-64%) and greatest in the moderate and low-risk groups (84-100%). In contrast, LDL-C reduction was generally similar irrespective of disease or risk subgroup. All treatments were generally well tolerated, with overall similar safety regardless of disease and risk level.

CONCLUSIONS

In these studies, CHD risk strata were inversely related to the likelihood of attaining NCEP LDL-C goals, but did not appear to affect the percentage LDL-C change from baseline. This demonstrates the need for especially aggressive cholesterol lowering necessary to reach the lower LDL-C goal for high-risk patients.

Application in general practice of treatment guidelines for patients with dyslipidaemia: the RESPECT study

BACKGROUND

Screening for and management of dyslipidaemia are crucial in primary and secondary prevention of cardiovascular disease. The impact on general practitioners (GP) of the 2005 French guidelines for hypercholesterolaemia has not been evaluated.

AIMS

To compare GP's estimation of cardiovascular risk with that from a theoretical calculation; to analyse the consequences of cardiovascular-risk estimation on the threshold of therapeutic intervention and the target low-density lipoprotein cholesterol (LDL-C) concentration; and to analyse patients' awareness of their hypercholesterolaemia.

METHODS

The RESPECT study was a transverse, multicentre, observational survey conducted between March 2006 and February 2007 by 1797 GP in France. Inclusion criteria were adults with primary hypercholesterolaemia who had not taken lipid-lowering drugs within the previous 6 months.

RESULTS

Of the 5627 patients included (60.9% men; mean age+/-standard deviation 58.2+/-11.0 years; body mass index 27.2+/-4.1 kg/m(2); mean total cholesterol 2.68+/-0.37 g/L; LDL-C 1.79+/-0.35 g/L), 1963 (36.2%) had at least three cardiovascular risk factors. GP identified a high cardiovascular risk level in 40.8%, moderate risk in 45.8% and low risk in 13.4% of patients. These compared with calculated rates of 48, 23 and 29%, respectively (kappa concordance 59.4%). For most patients (98.2%), GP defined the therapeutic target based on LDL-C concentration. The target LDL-C was significantly different when cardiovascular risk was estimated by GP versus that calculated theoretically. The higher the estimated risk level, the greater the rate of introduction of lipid-lowering drugs and the shorter the time to the next GP visit. Most patients considered themselves to be well or rather well informed about their cholesterol concentration (91.3%), the causes (64.3%) and consequences of cholesterol-induced diseases (83.7%), and the difference between 'good' and 'bad' cholesterol (57%). Most (81.5%) patients were aware of the benefits of lipid-lowering drugs on cardiovascular disease prevention; 95.8% considered adequate diet and compliance with pharmacological treatment to be very important.

CONCLUSION

Recent French guidelines for hypercholesterolaemia are used widely by GP in practice. They enable correct assessment of overall cardiovascular risk level, have an impact on the therapeutic threshold of intervention by physicians and improve patients' awareness of the relevance of cholesterol concentration.

Cholesterol goal attainment in patients with coronary heart disease and elevated coronary risk: results of the Hong Kong hospital audit study

OBJECTIVE

We sought to determine 1) long-term lipid-lowering treatment patterns; 2) cholesterol goal attainment rates and possible determinants of goal achievement; and 3) effects of cholesterol goal attainment on coronary events in hospitalized Hong Kong patients.

METHODS

In this retrospective cohort analysis, records of two public Hong Kong hospitals were reviewed for 196 adults (69% with coronary heart disease (CHD) or CHD-risk equivalent) who received at least one lipid-lowering therapy during hospitalization. Low-density lipoprotein cholesterol (LDL-C) targets were <2.6 mmol/l (<100 mg/dL) for patients with CHD or CHD risk equivalents and <3.37 mmol/l (<130 mg/dL) for those without.

RESULTS

Most participants were initiated on regimens of low to midequipotency doses and never had their regimens adjusted to higher potency. Approximately 44% of patients not at LDL-C at baseline failed to achieve goal during a median follow-up of 1.9 years. Patients with higher coronary risk and/or LDL-C levels at baseline were less likely than their lower-risk counterparts to achieve goal; for each 1-mmol/l (38.7-mg/dL) increase in LDL-C at baseline, the likelihood of attaining goal declined by 64%. Patients achieving cholesterol goal had significantly longer cardiovascular event-free times.

CONCLUSIONS

A total of 44% of Hong Kong patients not at LDL-C goals at baseline did not achieve them over 1.9 years. More effective and well-tolerated therapies, including adjunctive regimens (e.g., ezetimibe-statin, niacin-statin), may be necessary to enhance LDL-C goal achievement and increase event-free time.

Correlates of LDL-cholesterol goal attainment in patients under lipid lowering therapy

BACKGROUND

LDL-cholesterol therapeutic objectives attainment under lipid lowering therapy remains inadequate. The correlates of LDL-cholesterol therapeutic objective attainment have not been thoroughly explored in an observational setting.

METHODS

Patients under lipid lowering therapy and managed by general practitioners were included. LDL-cholesterol therapeutic objective was defined according to the number of cardiovascular risk factors associated with dyslipidemia (AFSSAPS-2005 guidelines).

RESULTS

Most of the 2727 patients (mean age: 64.7+/-11.0) received a statin (70.0%) or a fibrate (24.3%) in monotherapy. 58.5% of patients at high cardiovascular risk did not reach therapeutic objective. Compared to simvastatin, patients receiving fibrates were less likely to be at therapeutic objective (OR=0.38, 95% CI=[0.26-0.54]). So were patients receiving fluvastatin (OR=0.41, IC95%=[0.26-0.64]) or pravastatin (OR=0.49, IC95%=[0.35-0.70]) at the dosages used by GPs. No significant difference appeared with atorvastatin (OR=0.99, 95% CI=[0.71-1.39]) or rosuvastatin (OR=1.25, CI95%=[0.77-2.02]). Patients with LDL-cholesterol levels<0.7 g/L tended to be prescribed high doses of lipid lowering therapy.

CONCLUSIONS

In real conditions of lipid lowering therapy use, LDL-cholesterol therapeutic objective attainment was inadequate in high-risk patients, and TO differences were observed between drugs at prescribed doses.

[Knowledge and implementation of cardiovascular risk clinical practice guidelines by general practitioners and specialists]

INTRODUCTION AND OBJECTIVES

Patients at a high risk of cardiovascular disease rarely achieve the preventive targets stipulated by the clinical practice guidelines published by professional bodies. The aims of the ACORISC registry were to determine the level of compliance with guidelines on prevention by general practitioners and specialists and to assess the findings in terms of risk factors.

METHODS

The study included 5849 consecutive patients (mean age 65 years) with type 2 diabetes or chronic ischemic heart disease who were seen as outpatients. In addition, 384 participating physicians were questioned on their knowledge and use of practice guidelines.

RESULTS

Overall, 91% of patients also had hypertension. Physicians tended to have better knowledge of and to implement guidelines published by the closest related professional bodies. Some 14% of treatment provided was inappropriate, half of which involved oral antidiabetics. Conversely, 48% of patients for whom guidelines recommended an angiotensin inhibitor did not receive one. The target figures for blood pressure, body mass index, and cholesterol were achieved in only 13%, 21% and 39% of patients, respectively.

CONCLUSIONS

Overall, 75% of risk factors in patients with diabetes or chronic ischemic heart disease were not appropriately treated by general practitioners or specialists in accordance with current clinical practice guidelines. The inappropriate use of oral antidiabetics was particularly common.