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Piazza G, Desai NR, Baber U, Exter J, Kalich B, Monteleone P. Practical solutions for implementation of blood cholesterol guidelines in clinical practice. Trends Cardiovasc Med 2024; 34:371-378. [PMID: 37634754 DOI: 10.1016/j.tcm.2023.08.001] [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: 06/30/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
Underutilization of lipid-lowering therapy (LLT) and failure to attain guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals are important quality gaps in cardiovascular risk optimization, especially among patients with atherosclerotic cardiovascular disease (ASCVD). Large database analyses demonstrate an unmet need for improved LDL-C measurement, and that nearly 75% of patients with ASCVD have an LDL-C level above guideline-recommended levels, and greater than 50% are not treated with statins or ezetimibe. Proposed solutions for overcoming these obstacles to optimal lipid management include provider- and patient-facing educational interventions, health information technology strategies, implementation of incentive-based care, advocacy efforts, and systems-based process innovations. While individual interventions may not be enough to overcome the totality of barriers to optimal LLT, comprehensive multifaceted approaches that address barriers at the provider, patient, and healthcare delivery level are likely to offer the greatest likelihood of success and improved patient outcomes.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Nihar R Desai
- Section of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Jason Exter
- Amgen Inc., Thousand Oaks, CA, United States
| | | | - Peter Monteleone
- The University of Texas at Austin Dell School of Medicine, Austin, TX, United States
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Hoagland A, Kipping S. Challenges in Promoting Health Equity and Reducing Disparities in Access Across New and Established Technologies. Can J Cardiol 2024; 40:1154-1167. [PMID: 38417572 DOI: 10.1016/j.cjca.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/01/2024] Open
Abstract
Medical innovations and novel technologies stand to improve the return on high levels of health spending in developed countries, particularly in cardiovascular care. However, cardiac innovations also disrupt the landscape of accessing care, potentially creating disparities in who has access to novel and extant technologies. These disparities might disproportionately harm vulnerable groups, including those whose nonmedical conditions-including social determinants of health-inhibit timely access to diagnoses, referrals, and interventions. We first document the barriers to access novel and existing technologies in isolation, then proceed to document their interaction. Novel cardiac technologies might affect existing available services, and change the landscape of care for vulnerable patient groups who seek access to cardiology services. There is a clear need to identify and heed lessons learned from the dissemination of past innovations in the development, funding, and dissemination of future medical technologies to promote equitable access to cardiovascular care. We conclude by highlighting and synthesizing several policy implications from recent literature.
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Affiliation(s)
- Alex Hoagland
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada.
| | - Sarah Kipping
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada
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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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Norris CM, Mullen KA, Foulds HJ, Jaffer S, Nerenberg K, Gulati M, Parast N, Tegg N, Gonsalves CA, Grewal J, Hart D, Levinsson AL, Mulvagh SL. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 7: Sex, Gender, and the Social Determinants of Health. CJC Open 2024; 6:205-219. [PMID: 38487069 PMCID: PMC10935698 DOI: 10.1016/j.cjco.2023.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/31/2023] [Indexed: 03/17/2024] Open
Abstract
Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health.
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Affiliation(s)
- Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kerri-Anne Mullen
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather J.A. Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shahin Jaffer
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kara Nerenberg
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martha Gulati
- Barbra Streisand Women’s Heart Centre, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Nazli Parast
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Nicole Tegg
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | - Jasmine Grewal
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donna Hart
- Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | | | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Beh CY, Fok RWY, Goh LH. Exploring barriers and facilitators of primary care physicians towards optimising statin therapy in patients with hyperlipidaemia in the very high-risk group: a qualitative study in Singapore. BMJ Open 2023; 13:e073125. [PMID: 37673455 PMCID: PMC10496678 DOI: 10.1136/bmjopen-2023-073125] [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: 02/25/2023] [Accepted: 08/24/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVES To explore the perspectives of primary care physicians with regard to the barriers and facilitators towards optimising statin therapy in patients with hyperlipidaemia in the very high-risk group. DESIGN Qualitative descriptive study. SETTING Four polyclinics in a public primary care institution in Singapore. PARTICIPANTS Seven men and five women working as primary care physicians were recruited for in-depth interviews. RESULTS The major barriers to statin optimisation identified were patients' lack of knowledge and awareness, patients' fear of side effects, negative external influences on patients, poor doctor-patient relationship, time constraint during consultations, physicians' unfamiliarity with guidelines, low health literacy among the local population and lack of strong national policy. The major facilitators identified were patient education, providing continuity of care, improving electronic medical record systems' capabilities, physician education and public education. CONCLUSION We identified several important barriers and facilitators of statin therapy optimisation in this study. This information offers insights into the development of a multipronged approach to address barriers across different levels with the aim of optimising statin use, reducing cardiovascular events and improving patient outcomes.
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Affiliation(s)
- Chun Yen Beh
- National University Polyclinics, National University Health System, Singapore
| | - Rose Wai-Yee Fok
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Lay Hoon Goh
- Department of Family Medicine, National University Health System, Singapore
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Jean-Marie EM, Tashtish N, Albar Z, Miller D, Sullivan C, Al-Kindi S, Rajagopalan S, Neeland IJ. Disparities in statin prescription among patients with severe hypercholesterolemia in an integrated healthcare system. Am J Prev Cardiol 2023; 14:100492. [PMID: 37008590 PMCID: PMC10064414 DOI: 10.1016/j.ajpc.2023.100492] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/21/2023] [Accepted: 03/20/2023] [Indexed: 04/04/2023] Open
Abstract
Background Severe hypercholesterolemia (SH), defined as a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dl, is associated with an increased risk for premature atherosclerotic cardiovascular disease. Despite guideline recommendations, many patients with severe hypercholesterolemia remain untreated. We conducted an observational analysis of a large pool of SH patients, exploring demographic and social factors contributing to disparities in the prescription of statin and other lipid-lowering therapies. Methods We included all adults (age 18 or older) in the University Hospitals Health Care System, with an LDL-C ≥ 190 mg/dl on a lipid profile drawn between January 2, 2014, and March 15, 2022. Variables were compared across relevant categories of age, gender, race and ethnicity, medical history, prescription medication status, insurance type, and provider referral type. We used the Fischer exact test and Pearson Chi-square (χ 2) for variable comparisons. Results A total of 7,942 patients were included in the study. The median age was 57 [IQR 48-66] years with 64% female, and 17% Black patients. Only 58% of the total cohort was prescribed statin therapy. Higher age was independently associated with a higher likelihood of receiving a statin, with an odds ratio of 1.25 (95% CI [1.21 - 1.30] per 10 years, p<0.001). Additional factors that were associated with higher rates of statin prescription in patients with SH were Black race (OR 1.90, 95% CI [1.65 - 2.17], p<0.001), smoking (OR 2.42, 95% CI [2.17 -2.70], p<0.001), and presence of diabetes (OR 3.88, 95% CI [3.27 - 4.60], p<0.001). Similar trends were also seen with other lipid-lowering therapies such as ezetimibe and fibrates. Conclusions In our Northeast Ohio healthcare system, less than two-thirds of patients with severe hypercholesterolemia are prescribed a statin. Statin prescription rates were highly dependent on age and the presence of additional ASCVD risk factors.
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Affiliation(s)
- Elizabeth M. Jean-Marie
- Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
- Corresponding author.
| | - Nour Tashtish
- Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Zainab Albar
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Drew Miller
- Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Claire Sullivan
- Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Sadeer Al-Kindi
- Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Sanjay Rajagopalan
- Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Ian J. Neeland
- Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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Dunn K, Kopel J, Diab M, Babb F. Analyzing and Improving the Utilization of Statin Drugs in Family Medicine Patients with Type II Diabetes. J Community Hosp Intern Med Perspect 2023; 13:35-38. [PMID: 37877046 PMCID: PMC10593177 DOI: 10.55729/2000-9666.1162] [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: 11/28/2022] [Revised: 12/25/2022] [Accepted: 01/05/2023] [Indexed: 10/26/2023] Open
Abstract
Background Statins are the primary drug used to reduce morbidity and mortality for cardiovascular disease. However, many type II diabetes mellitus (T2DM) patients who are currently not on a statin would otherwise qualify. Therefore, we investigated the proportion of T2DM patients on a statin compared to the total number of T2DM patients eligible to be on a statin. We also examined potential barriers that prevent T2DM patients from being prescribed statins by physicians. Methods A retrospective chart study on family medicine patients was collected data on age, race, cholesterol readings, blood pressure, and whether the patient was on blood pressure medications, aspirin, and/or a statin. The information gathered was used to determine the patients' 10-year risk of cardiovascular disease. A survey was given to residents and faculty to assess the cost, side effects, and other behavioral factors had on a patients' choice to be on a statin. Results Among the 706 T2DM patients, we found that a large proportion (75.2%) were both eligible and prescribed a statin according to the American Heart Association Guidelines. In addition, over 58% of the patients had a 0%-25% 10-year risk of cardiovascular disease risk. Among the 14 family medicine physicians surveyed, the fear of or history of side effects with statin medications were the greatest barriers to starting statins. Conclusion The large proportion of family medicine patients that were eligible were prescribed a statin. According to the survey, physicians Believed that the greatest barrier for a patient starting on a statin is the fear of or history of side effects with statin medications.
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Affiliation(s)
- Keegan Dunn
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX,
USA
| | - Jonathan Kopel
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX,
USA
| | - Mousab Diab
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX,
USA
| | - Franklyn Babb
- Professor of Family Medicine, Texas Tech University Health Sciences Center, Lubbock, TX,
USA
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Pan M, Manza-A. Agovi A, Anikpo IO, Fasanmi EO, Thompson EL, Reeves JM, Thompson CT, Johnson ME, Golub V, Ojha RP. Effect of 2018 American College of Cardiology/American Heart Association Guideline Change on Statin Prescription for People Living with HIV. Prev Med Rep 2023; 33:102175. [PMID: 36968517 PMCID: PMC10034116 DOI: 10.1016/j.pmedr.2023.102175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/23/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines were updated in 2018 to explicitly recommend statin use for primary cardiovascular disease prevention among people living with HIV (PLWH), but little is known about the effect of this guideline change. We aimed to assess the effect of the 2018 ACC/AHA guideline change on statin prescription among PLWH. We used data from an institutional HIV registry to identify PLWH aged 40-75 years, engaged in HIV care between June 2016 and May 2021, had a LDL cholesterol between 70 and 189 mg/dl, 10-year atherosclerotic cardiovascular disease (ASCVD) risk score ≥7.5%, no prior statin prescription, and no history of diabetes or ASCVD. Our outcome of interest was a new statin prescription within 12 months of eligibility. We estimated standardized risk difference (RD) with 95% confidence limits (CL) by comparing prescription probabilities before and after guideline change. Our study population comprised 251 PLWH (171 before, 80 after the guideline change), of whom 57% were aged <55 years, 82% were male, and 45% were non-Hispanic black. The standardized 12-month statin prescription risk was 43% (95% CL: 31%, 60%) after the guideline change and 19% (95% CL: 13%, 26%) before the guideline change (RD = 25%, 95% CL: 9.1%, 40%). Our results suggest that the 2018 ACC/AHA guideline change increased statin prescription among PLWH, but a sizable proportion of eligible PLWH were not prescribed statin. Future studies are needed to identify strategies to enhance implementation of statin prescription guidelines among PLWH.
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Zheutlin AR, Zhang M, Conroy MB. Clinical encounter length and initiation of statin therapy for primary prevention among adults with elevated atherosclerotic cardiovascular disease risk. Am J Prev Cardiol 2023; 13:100450. [PMID: 36593972 PMCID: PMC9804006 DOI: 10.1016/j.ajpc.2022.100450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/31/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Alexander R. Zheutlin
- University of Utah School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Mingyuan Zhang
- Data Science Services, University of Utah School of Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Molly B. Conroy
- University of Utah School of Medicine, University of Utah, Salt Lake City, UT, United States
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Parhofer KG, Anastassopoulou A, Calver H, Becker C, Rathore AS, Dave R, Zamfir C. Estimating Prevalence and Characteristics of Statin Intolerance among High and Very High Cardiovascular Risk Patients in Germany (2017 to 2020). J Clin Med 2023; 12:jcm12020705. [PMID: 36675634 PMCID: PMC9864390 DOI: 10.3390/jcm12020705] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 01/18/2023] Open
Abstract
Statin intolerance (SI) (partial and absolute) could lead to suboptimal lipid management. The lack of a widely accepted definition of SI results into poor understanding of patient profiles and characteristics. This study aims to estimate SI and better understand patient characteristics, as reflected in clinical practice in Germany using supervised machine learning (ML) techniques. This retrospective cohort study utilized patient records from an outpatient setting in Germany in the IQVIA™ Disease Analyzer. Patients with a high cardiovascular risk, atherosclerotic cardiovascular disease, or hypercholesterolemia, and those on lipid-lowering therapies between 2017 and 2020 were included, and categorized as having “absolute” or “partial” SI. ML techniques were applied to calibrate prevalence estimates, derived from different rules and levels of confidence (high and low). The study included 292,603 patients, 6.4% and 2.8% had with high confidence absolute and partial SI, respectively. After deploying ML, SI prevalence increased approximately by 27% and 57% (p < 0.00001) in absolute and partial SI, respectively, eliciting a maximum estimate of 12.5% SI with high confidence. The use of advanced analytics to provide a complementary perspective to current prevalence estimates may inform the identification, optimal treatment, and pragmatic, patient-centered management of SI in Germany.
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Affiliation(s)
- Klaus G. Parhofer
- Ludwig Maximilians University, Medical Clinic IV, Großhadern, 81377 Munich, Germany
| | | | | | - Christian Becker
- Daiichi Sankyo Germany GmbH, Zielstattstraße 48, 81379 Munich, Germany
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Nandiwada S, Manca DP, Yeung RO, Lau D. Achievement of treatment targets among patients with type 2 diabetes in 2015 and 2020 in Canadian primary care. CMAJ 2023; 195:E1-E9. [PMID: 36623861 PMCID: PMC9829075 DOI: 10.1503/cmaj.220673] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND An update on the degree to which patients with type 2 diabetes in Canada achieve treatment targets is needed to document progress and identify subgroups that need attention. We sought to estimate the frequency with which patients managed in primary care met treatment targets (i.e., HbA1c ≤ 7.0%, blood pressure < 130/80 mm Hg and low-density lipoprotein cholesterol [LDL-C] < 2.00 mmol/L), guideline-based use of statins and of angiotensin-convertingenzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and the effects of patient age and sex. METHODS We conducted a cross-sectional study of 32 503 and 44 930 adults with diabetes in Canada on June 30, 2015, and 2020, respectively, using electronic medical record data from primary care practices across 5 provinces. We grouped achievement of diabetes targets by age and sex, and compared between groups using logistic regression with adjustment for cardiovascular comorbidities. RESULTS In 2020, target HbA1c levels were achieved for 63.8% of women and 58.9% of men. Blood pressure and LDL-C targets were achieved for 45.6% and 45.8% of women, and for 43.1% and 59.4% of men, respectively. All 3 treatment targets were achieved for 13.3% of women and 16.5% of men. Overall, 45.3% and 54.0% of women and men, respectively, used statins; 46.5% of women used ACE inhibitors or ARBs, compared with 51.9% of men. With the exception of blood pressure and HbA1c levels among women, target achievement was lower among younger patients. Achievement of the LDL-C target, statin use and ACE inhibitor or ARB use were lower among women at any age. From 2015 to 2020, target achievement increased for HbA1c, remained consistent for LDL-C and declined for blood pressure; use of statins and of ACE inhibitors or ARBs also declined. INTERPRETATION Target achievement for blood pressure and use of statins and of ACE inhibitors and ARBs declined between 2015 and 2020, and was suboptimal in all patient groups. Widespread quality improvement is needed to increase evidence-based therapy for people with diabetes.
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Affiliation(s)
- Shiva Nandiwada
- Departments of Medicine (Nandiwada, Yeung, Lau) and of Family Medicine (Manca), University of Alberta, Edmonton, Alta
| | - Donna P Manca
- Departments of Medicine (Nandiwada, Yeung, Lau) and of Family Medicine (Manca), University of Alberta, Edmonton, Alta
| | - Roseanne O Yeung
- Departments of Medicine (Nandiwada, Yeung, Lau) and of Family Medicine (Manca), University of Alberta, Edmonton, Alta
| | - Darren Lau
- Departments of Medicine (Nandiwada, Yeung, Lau) and of Family Medicine (Manca), University of Alberta, Edmonton, Alta.
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12
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Verma SK, Huang J, Hutchinson HG, Estevez I, Kuang K, Reynolds SL, Schneeweiss S. Statin Use and Severe Acute Liver Injury Among Patients with Elevated Alanine Aminotransferase. Clin Epidemiol 2022; 14:1535-1545. [PMID: 36540900 PMCID: PMC9759991 DOI: 10.2147/clep.s385712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/30/2022] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION While serious liver injury among statin users is extremely rare, baseline liver enzyme testing is still recommended prior to initiating therapy. The benefit of such screening should be reevaluated based on empirical evidence. This study compared the risk of severe acute liver injury (SALI) between statin initiators with an elevated ALT (>35U/L) matched to statin initiators with a normal ALT level (≤35U/L). Statin initiators with an elevated ALT were additionally compared against matched non-users. METHODS The study created cohorts from Optum and MarketScan claims data. Exposed and comparison cohorts were propensity score (PS) matched in each dataset and findings were pooled using meta-analysis. Proportional hazards regression was used to estimate hazard ratios (HRs), and a prespecified non-inferiority margin for SALI was set at a HR of 1.8. RESULTS 232,889 patients with elevated ALT were PS-matched to 232,889 with normal ALT level. The overall incidence rate of SALI was about 19/100,000 person-years among statin initiators. Statin initiators with elevated ALT had no meaningfully increased risk of SALI compared to those with normal ALT (HR=1.15; 95% CI 0.75 to 1.75). Comparing statin initiators with non-initiators with elevated ALT values equally yielded no increased risk (HR=0.76; 95% CI 0.52 to 1.11). CONCLUSION In this large population-based study, SALI in statin users was rare. Importantly, the results showed no evidence that baseline ALT status is a reliable indicator for an increased risk of severe liver injury among statin initiators.
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Affiliation(s)
- Santosh K Verma
- Science, Aetion, Inc, New York, NY, USA
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA
| | - Joanna Huang
- Payer Evidence, AstraZeneca, Wilmington, DE, USA
| | | | | | | | | | - Sebastian Schneeweiss
- Science, Aetion, Inc, New York, NY, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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De Geest S, Thys A, Zullig LL. Implementation science: accelerating the pharma pipeline to its full potential. J Comp Eff Res 2022; 11:1309-1311. [PMID: 36426902 DOI: 10.2217/cer-2022-0152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Sabina De Geest
- Department of Public Health, Institute of Nursing Science, University of Basel, Basel, CH 4051S, Switzerland.,Department of Public Health & Primary Care, Academic Center for Nursing & Midwifery, KU Leuven, Leuven, B-3000, Belgium
| | | | - Leah L Zullig
- Center for Innovation to Accelerate Discovery & Practice Transformation (ADAPT), Durham Veterans Affairs Health Care & System, NC 27701, USA.,Department of Population Health Sciences, School of Medicine, Duke University, NC 27701, USA
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14
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Butalia S, Chen G, Duan Q, Anderson TJ. Care gaps in achieving cholesterol targets in people with diabetes: A population-based study in a universal health care setting. Diabetes Res Clin Pract 2022; 184:109177. [PMID: 34923023 DOI: 10.1016/j.diabres.2021.109177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 11/01/2021] [Accepted: 12/11/2021] [Indexed: 11/30/2022]
Abstract
AIMS Statins are first line therapy in people with diabetes. Little is known about real-world statin intensity use and low-density lipoprotein cholesterol (LDL-C) levels achieved. We aimed to describe statin intensity used, achievement of LDL-C targets, and factors associated with achieving targets among adults with diabetes. METHODS This population based (∼4.3 million), retrospective observational study, used clinical and administrative databases. Statin use by intensity, adherence, and achievement of LDL-C targets in adults with diabetes were described. Multiple logistic regression assessed the factors associated with achieving targets. RESULTS Out of 331,312 individuals with diabetes, 88% had an index LDL-C test. At follow up, 31% overall did not achieve LDL-C targets and overall adherence was 66%. Failure to achieve targets was 49%, 30%, and 25% in low-, moderate-, and high-intensity statin groups, respectively. Those who were older, males, had a history of myocardial infarction, stroke, congestive heart failure, renal disease, better adherence, and higher intensity statin users were more likely to achieve targets. CONCLUSIONS One-third of people on statins did not achieve targets. Strategies to fill the gap between ideal and current levels of LDL-C achieved are needed if the benefits of statins demonstrated in trials are to be translated into practice.
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Affiliation(s)
- Sonia Butalia
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre - North Tower, 9th Floor, 1403 - 29th Street NW, Calgary, AB T2N 2T9, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, Calgary, University of Calgary, 3rd Floor TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, Heritage Medical Research Building (HMRB), Room 72, Foothills Campus, University of Calgary, 3310 Hospital Drive NW, Calgary, AB T2N 4N1, Canada.
| | - Guanmin Chen
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, Heritage Medical Research Building (HMRB), Room 72, Foothills Campus, University of Calgary, 3310 Hospital Drive NW, Calgary, AB T2N 4N1, Canada; Data & Analytics, Alberta Health Services, 4520 16 Avenue NW, Calgary, AB T3B 0M6, Canada.
| | - Qiuli Duan
- Data & Analytics, Alberta Health Services, 4520 16 Avenue NW, Calgary, AB T3B 0M6, Canada.
| | - Todd J Anderson
- Libin Cardiovascular Institute, Cumming School of Medicine, Heritage Medical Research Building (HMRB), Room 72, Foothills Campus, University of Calgary, 3310 Hospital Drive NW, Calgary, AB T2N 4N1, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada.
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15
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Ober AJ, Takada S, Zajdman D, Todd I, Horwich T, Anderson A, Wali S, Ladapo JA. Factors affecting statin uptake among people living with HIV: primary care provider perspectives. BMC FAMILY PRACTICE 2021; 22:215. [PMID: 34717560 PMCID: PMC8556944 DOI: 10.1186/s12875-021-01563-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/05/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is a major cause of morbidity and mortality among people living with HIV (PLWH), but statin therapy, safe and effective for PLWH, is under-prescribed. This study examined clinic leadership and provider perceptions of factors associated with statin prescribing for PLWH receiving care in eight community health clinics across Los Angeles, California. METHODS We conducted semi-structured telephone interviews with clinic leadership and providers across community health clinics participating in a larger study (INSPIRE) aimed at improving statin prescribing through education and feedback. Clinics included federally qualified health centers (N = 5), community clinics (N = 1) and county-run ambulatory care clinics (N = 2). Leadership and providers enrolled in INSPIRE (N = 39) were invited to participate in an interview. We used the Consolidated Framework for Implementation Research (CFIR) to structure our interview guide and analysis. We used standard qualitative content analysis methods to identify themes within CFIR categories; we also assessed current CVD risk assessment and statin-prescribing practices. RESULTS Participants were clinic leaders (n = 6), primary care physicians with and without an HIV specialization (N = 6, N = 6, respectively), infectious diseases specialists (N = 12), nurse practitioners, physician assistants and registered nurses (N = 7). Ninety-five percent of providers from INSPIRE participated in an interview. We found that CVD risk assessment for PLWH is standard practice but that there is variation in risk assessment practices and that providers are unsure whether or how to adjust the risk threshold to account for HIV. Time, clinic and patient priorities impede ability to conduct CVD risk assessment with PLWH. CONCLUSIONS Providers desire more data and standard practice guidance on prescribing statins for PLWH, including estimates of the effect of HIV on CVD, how to adjust the CVD risk threshold to account for HIV, which statins are best for people on antiretroviral therapy and on shared decision-making around prescribing statins to PLWH. While CVD risk assessment and statin prescribing fits within the mission and workflow of primary care, clinics may need to emphasize CVD risk assessment and statins as priorities in order to improve uptake.
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Affiliation(s)
| | - Sae Takada
- RAND Corporation, Santa Monica, CA, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | | | - Ivy Todd
- RAND Corporation, Santa Monica, CA, USA
| | - Tamara Horwich
- Division of Cardiology, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Abraelle Anderson
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Soma Wali
- Olive View - UCLA Medical Center, Sylmar, CA, USA
| | - Joseph A Ladapo
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA
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16
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Brunette CA, Vassy JL. The role of SLCO1B1 genotyping in lowering cardiovascular risk. Pharmacogenomics 2021; 22:649-656. [PMID: 34196599 DOI: 10.2217/pgs-2021-0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Charles A Brunette
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA.,Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA 52242, USA
| | - Jason L Vassy
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA.,Department of Medicine, Harvard Medical School, Boston, MA 02115, USA.,Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston, MA 02115, USA.,Population Precision Health, Ariadne Labs, Boston, MA 02215, USA
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17
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Hasan S, Naugler C, Decker J, Fung M, Morrin L, Campbell NRC, Anderson TJ. Laboratory reporting of framingham risk score increases statin prescriptions in at-risk patients. Clin Biochem 2021; 96:1-7. [PMID: 34197811 DOI: 10.1016/j.clinbiochem.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/11/2021] [Accepted: 06/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The under-utilization of cardiovascular preventative therapy with statins warrants novel interventions to optimize prescriptions in at-risk patients. We investigated the role of a laboratory generated Framingham Risk Score (FRS) provided to primary care clinicians in changing statin use in a primary care setting. METHODS Data was acquired from the electronic medical records of 1573 anonymized patients undergoing routine lipid testing. Follow-up statin use and low-density lipoprotein cholesterol levels were obtained for 2 years post intervention. FRS parameters were entered into a laboratory information system, and provided to ordering physicians along with the cholesterol profile and the appropriate current Canadian Dyslipidemia treatment recommendation in a single report. Statin prescription rates following the intervention were compared with historical use 6 months prior to the study. RESULTS A total of 1283 participants (mean age of 60 ± 11 years) had an FRS report and were considered for analysis. Two hundred individuals filled a statin prescription in the 6 months prior to their index lipid test, and an additional 84 filled a statin prescription following the intervention (42% increase). The relative and absolute increase in statin prescription was 47.3% and 13.6% in the high-risk group p < 0.001, 53.3% and 8.1% in the intermediate-risk group p < 0.001, and 17.0% and 1.42% in the low-risk group p = 0.008, respectively. CONCLUSION The use of the laboratory reported FRS was associated with a significant increase in the rate of statin prescription across all risk groups. The expansion of FRS reporting across other health regions would improve cardiovascular risk prevention.
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Affiliation(s)
- Sarah Hasan
- Department of Cardiac Sciences, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada
| | - Christopher Naugler
- O'Brien Institute of Public Health Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada; Department of Pathology and Laboratory Medicine, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada
| | - Jeffrey Decker
- Chinook Primary Care Network, Alberta Health Services, 817 4 Ave S #200, Lethbridge, AB T1J 0P3, Canada
| | - Marinda Fung
- Department of Cardiac Sciences, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada
| | - Louise Morrin
- Medicine and Digestive Health Strategic Clinical Networks, Alberta Health Services, Canada
| | - Norm R C Campbell
- Libin Cardiovascular Institute, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada; O'Brien Institute of Public Health Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada; Department of Medicine, Physiology and Pharmacology and Community Health Sciences, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada
| | - Todd J Anderson
- Department of Cardiac Sciences, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada.
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18
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Campbell DJT, Lee-Krueger RCW, McBrien K, Anderson T, Quan H, Leung AA, Chen G, Lu M, Naugler C, Butalia S. Strategies for enhancing the initiation of cholesterol lowering medication among patients at high cardiovascular disease risk: a qualitative descriptive exploration of patient and general practitioners' perspectives on a facilitated relay intervention in Alberta, Canada. BMJ Open 2020; 10:e038469. [PMID: 33234627 PMCID: PMC7689086 DOI: 10.1136/bmjopen-2020-038469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/17/2020] [Accepted: 10/28/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The objective of our study was to explore the perspectives of patients and general practitioners (GPs) regarding interventions to increase initiation of cholesterol lowering medication (or statins), including a proposed laboratory-based facilitated relay intervention. DESIGN Qualitative descriptive study using interviews and focus groups for data collection, and thematic analysis for data analysis. SETTING Primary care providers and patients in Calgary, Alberta, Canada. PARTICIPANTS 17 GPs with primarily community-based, non-academic practices with at least 1 year of practice experience participated in semistructured interviews. 14 patients at high risk of cardiovascular disease participated in focus groups. MAIN OUTCOME MEASURES Exploration of strategies that might be used to enhance the prescription of, and adherence to statin therapy for patients with statin-indicated conditions. RESULTS GPs proposed a variety of interventions to improve statin prescription, including electronic record audit solutions, GP directed education, and patient-oriented campaigns. Patients expressed that they may benefit from being provided access to their laboratory test results, as well as targeted education. Both parties provided positive feedback on the proposed laboratory-based facilitated relay intervention, while pointing out areas for improvement. Notably, GPs were concerned that the patient-directed component of the intervention might jeopardise therapeutic relationships, and patients were concerned about accidental disclosure of personal health information. Important considerations for the design of facilitated relay messaging should include brevity, simplicity and the provision of contact information for inquiries. CONCLUSIONS GPs and patients described several suggestions for increasing statin initiation and welcomed the proposal of a laboratory-based facilitated relay strategy. These findings support further testing of this intervention which may enhance GPs' ability to successfully engage patients in cardiovascular risk reduction through statin therapy.
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Affiliation(s)
- David J T Campbell
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Kerry McBrien
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Todd Anderson
- Department of Cardiac Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Guanmin Chen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mingshan Lu
- Department of Economics, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Naugler
- Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sonia Butalia
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Medicinal Chemistry Friendliness of Pigments from Monascus-Fermented Rice and the Molecular Docking Analysis of Their Anti-Hyperlipidemia Properties. FERMENTATION-BASEL 2020. [DOI: 10.3390/fermentation6040111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this study, the physicochemical properties, pharmacokinetics properties, and drug-likeness of pigments from Monascus-fermented rice (Monascus pigments, MPs) were predicted in silico using SwissADME tool. In silico prediction of physicochemical properties showed that MPs had desirable lipophilic drug-like physicochemical properties including molecular weight (236 to 543), TPSA (44.76 to 179.77), lipophilicity (−0.81 to 4.14), and water solubility (−4.94 to −0.77). The pharmacokinetic properties of MPs (i.e., GIA, P-glycoprotein substrate, and CYP3A4 inhibitor) illustrated that most MPs had high intestinal absorption and bioavailability, but some MPs might cause pharmacokinetics-related drug–drug interactions. Following this, six main well-known MPs (monascin, ankaflavin, rubropunctatin, monascorubrin, rubropunctamine, monascorubramine) were selected for molecular docking with some enzyme receptors. The docking results were shown with the best molecular docking poses, and the interacting residues, number and distance of hydrogen bonds of the MPs and monacolin K (for docking with 3-hydroxy-3-methyl glutaryl coenzyme A reductase (HMG-CoA reductase)), or MPs and oleic acid (for docking with lipase). Dissociation constants showed that MPs had lower inhibitory potential for HMGR (compared with Monacolin K), and higher inhibitory potential for lipase. Individual pigments from Monascus-fermented rice, therefore, have the potential to be developed as drug candidates for controlling hyperlipidemia.
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