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Deo SV, Al-Kindi S, Virani SS, Fremes S. Novel therapies to achieve the recommended low-density lipoprotein cholesterol concentration (LDL-C) targets for patients after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2024; 167:723-730.e4. [PMID: 37286075 DOI: 10.1016/j.jtcvs.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/21/2023] [Accepted: 05/29/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Salil V Deo
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; School of Medicine, Case Western Reserve University, Cleveland, Ohio; School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
| | - Sadeer Al-Kindi
- School of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | - Salim S Virani
- The Aga Khan University, Karachi, Pakistan; Texas Heart Institute and Baylor College of Medicine, Houston, Tex
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Gregg LP, Richardson PA, Herrera MA, Akeroyd JM, Jafry SA, Gobbel GT, Wydermyer S, Arney J, Hung A, Matheny ME, Virani SS, Navaneethan SD. Documented Adverse Drug Reactions and Discontinuation of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Chronic Kidney Disease. Am J Nephrol 2023; 54:126-135. [PMID: 37231800 PMCID: PMC10424561 DOI: 10.1159/000530988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) are frequently discontinued in patients with chronic kidney disease (CKD). Documented adverse drug reactions (ADRs) in medical records may provide insight into the reasons for treatment discontinuation. METHODS In this retrospective cohort of US veterans from 2005 to 2019, we identified individuals with CKD and a current prescription for an ACEi or ARB (current user group) or a discontinued prescription within the preceding 5 years (discontinued group). Documented ADRs in structured datasets associated with an ACEi or ARB were categorized into 17 pre-specified groups. Logistic regression assessed associations of documented ADRs with treatment discontinuation. RESULTS There were 882,441 (73.0%) individuals in the current user group and 326,794 (27.0%) in the discontinued group. There were 26,434 documented ADRs, with at least one documented ADR in 7,520 (0.9%) current users and 9,569 (2.9%) of the discontinued group. ADR presence was associated with treatment discontinuation, aOR 4.16 (95% CI: 4.03, 4.29). The most common documented ADRs were cough (37.3%), angioedema (14.2%), and allergic reaction (10.4%). ADRs related to angioedema (aOR 3.81, 95% CI: 3.47, 4.17), hyperkalemia (aOR 2.03, 95% CI: 1.84, 2.24), peripheral edema (aOR 1.53, 95% CI: 1.33, 1.77), or acute kidney injury (aOR 1.32, 95% CI: 1.15, 1.51) were associated with treatment discontinuation. CONCLUSION ADRs leading to drug discontinuation were infrequently documented. ADR types were differentially associated with treatment discontinuation. An understanding of which ADRs lead to treatment discontinuation provides an opportunity to address them at a healthcare system level.
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Affiliation(s)
- L. Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX
- Research Service Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Peter A. Richardson
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Michael A. Herrera
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Julia M. Akeroyd
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Shehrezade A. Jafry
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Glenn T Gobbel
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Sheena Wydermyer
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Jennifer Arney
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Department of Sociology, University of Houston-Clear Lake, Houston, TX
| | - Adriana Hung
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Center for Kidney Disease, Nashville, TN
- Division of Nephrology, Veterans Affairs Tennessee Valley Health Care System, Nashville, TN
| | - Michael E. Matheny
- Geriatrics Research Education and clinical Care Service, Tennessee Valley Healthcare System VA, Nashville, TN
- Departments of Biomedical Informatics, Biostatistics, and Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Salim S. Virani
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sankar D. Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Renal Section, Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
- Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, TX
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Virani SS, Ramsey DJ, Westerman D, Kuebeler MK, Chen L, Akeroyd JM, Gobbel GT, Ballantyne CM, Petersen LA, Turchin A, Matheny ME. Cluster Randomized Trial of a Personalized Clinical Decision Support Intervention to Improve Statin Prescribing in Patients With Atherosclerotic Cardiovascular Disease. Circulation 2023; 147:1411-1413. [PMID: 36871214 DOI: 10.1161/circulationaha.123.064226] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Affiliation(s)
- Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX (S.S.V., D.J.R., M.K.K., J.M.A., L.A.P.)
- Section of Cardiovascular Research (S.S.V., C.M.B.), Department of Medicine, Baylor College of Medicine, Houston, TX
- The Aga Khan University, Karachi, Pakistan (S.S.V.)
| | - David J Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX (S.S.V., D.J.R., M.K.K., J.M.A., L.A.P.)
| | - Dax Westerman
- Geriatrics Research Education and Clinical Care, Tennessee Valley Healthcare System VA, Nashville (D.W., G.T.G., M.E.M.)
- Departments of Biomedical Informatics, Biostatistics, and Medicine, Vanderbilt University Medical Center, Nashville, TN (D.W., G.T.G., M.E.M.)
| | - Mark K Kuebeler
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX (S.S.V., D.J.R., M.K.K., J.M.A., L.A.P.)
| | | | - Julia M Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX (S.S.V., D.J.R., M.K.K., J.M.A., L.A.P.)
| | - Glenn T Gobbel
- Geriatrics Research Education and Clinical Care, Tennessee Valley Healthcare System VA, Nashville (D.W., G.T.G., M.E.M.)
- Departments of Biomedical Informatics, Biostatistics, and Medicine, Vanderbilt University Medical Center, Nashville, TN (D.W., G.T.G., M.E.M.)
| | - Christie M Ballantyne
- Section of Cardiovascular Research (S.S.V., C.M.B.), Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX (S.S.V., D.J.R., M.K.K., J.M.A., L.A.P.)
- Section of Health Services Research (L.A.P.), Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Alexander Turchin
- Harvard Medical School, Boston, MA (A.T.)
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA (A.T.)
| | - Michael E Matheny
- Geriatrics Research Education and Clinical Care, Tennessee Valley Healthcare System VA, Nashville (D.W., G.T.G., M.E.M.)
- Departments of Biomedical Informatics, Biostatistics, and Medicine, Vanderbilt University Medical Center, Nashville, TN (D.W., G.T.G., M.E.M.)
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Monoclonal Antibodies, Gene Silencing and Gene Editing (CRISPR) Therapies for the Treatment of Hyperlipidemia-The Future Is Here. Pharmaceutics 2023; 15:pharmaceutics15020459. [PMID: 36839781 PMCID: PMC9963609 DOI: 10.3390/pharmaceutics15020459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/29/2022] [Accepted: 01/06/2023] [Indexed: 01/31/2023] Open
Abstract
Hyperlipidemia is a significant risk factor for atherosclerotic cardiovascular disease. Undertreatment of elevated lipids persists despite existing therapies. Here, we provide an update on monoclonal antibodies, gene silencing therapies, and gene editing techniques for the management of hyperlipidemia. The current era of cutting-edge pharmaceuticals targeting low density lipoprotein cholesterol, PCSK9, lipoprotein (a), angiopoietin-like 3, and apolipoprotein C3 are reviewed. We outline what is known, studies in progress, and futuristic goals. This review of available and upcoming biotechnological lipid therapies is presented for clinicians managing patients with familial hyperlipidemia, statin intolerance, hypertriglyceridemia, or elevated lipoprotein (a) levels.
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Culié D, Schiappa R, Contu S, Scheller B, Villarme A, Dassonville O, Poissonnet G, Bozec A, Chamorey E. Validation and Improvement of a Convolutional Neural Network to Predict the Involved Pathology in a Head and Neck Surgery Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12200. [PMID: 36231500 PMCID: PMC9564535 DOI: 10.3390/ijerph191912200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 06/16/2023]
Abstract
The selection of patients for the constitution of a cohort is a major issue for clinical research (prospective studies and retrospective studies in real life). Our objective was to validate in real life conditions the use of a Deep Learning process based on a neural network, for the classification of patients according to the pathology involved in a head and neck surgery department. 24,434 Electronic Health Records (EHR) from the first visit between 2000 and 2020 were extracted. More than 6000 EHR were manually classified in ten groups of interest according to the reason for consultation with a clinical relevance. A convolutional neural network (TensorFlow, previously reported by Hsu et al.) was then used to predict the group of patients based on their pathology, using two levels of classification based on clinically relevant criteria. On the first and second level of classification, macro-average performances were: 0.95, 0.83, 0.85, 0.97, 0.84 and 0.93, 0.76, 0.83, 0.96, 0.79 for accuracy, recall, precision, specificity and F1-score versus accuracy, recall and precision of 0.580, 580 and 0.582 for Hsu et al., respectively. We validated this model to predict the pathology involved and to constitute clinically relevant cohorts in a tertiary hospital. This model did not require a preprocessing stage, was used in French and showed equivalent or better performances than other already published techniques.
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Affiliation(s)
- Dorian Culié
- Head and Neck Surgery Department, Antoine Laccassagne Center, 06100 Nice, France
- Epidemiology, Biostatistics and Health Data Department, Antoine Laccassagne Center, 06100 Nice, France
| | - Renaud Schiappa
- Epidemiology, Biostatistics and Health Data Department, Antoine Laccassagne Center, 06100 Nice, France
| | - Sara Contu
- Epidemiology, Biostatistics and Health Data Department, Antoine Laccassagne Center, 06100 Nice, France
| | - Boris Scheller
- Head and Neck Surgery Department, Antoine Laccassagne Center, 06100 Nice, France
- Epidemiology, Biostatistics and Health Data Department, Antoine Laccassagne Center, 06100 Nice, France
| | - Agathe Villarme
- Head and Neck Surgery Department, Antoine Laccassagne Center, 06100 Nice, France
| | - Olivier Dassonville
- Head and Neck Surgery Department, Antoine Laccassagne Center, 06100 Nice, France
| | - Gilles Poissonnet
- Head and Neck Surgery Department, Antoine Laccassagne Center, 06100 Nice, France
| | - Alexandre Bozec
- Head and Neck Surgery Department, Antoine Laccassagne Center, 06100 Nice, France
- Epidemiology, Biostatistics and Health Data Department, Antoine Laccassagne Center, 06100 Nice, France
| | - Emmanuel Chamorey
- Epidemiology, Biostatistics and Health Data Department, Antoine Laccassagne Center, 06100 Nice, France
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Virani SS, Ballantyne CM, Petersen LA. Guideline-Concordant Statin Therapy Use in Secondary Prevention: Should the Medical Community Wait for Divine Intervention? J Am Coll Cardiol 2022; 79:1814-1817. [PMID: 35512861 DOI: 10.1016/j.jacc.2022.02.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 02/28/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Eid WE, Sapp EH, Wendt A, Lumpp A, Miller C. Improving Familial Hypercholesterolemia Diagnosis Using an EMR-based Hybrid Diagnostic Model. J Clin Endocrinol Metab 2022; 107:1078-1090. [PMID: 34871430 PMCID: PMC8947798 DOI: 10.1210/clinem/dgab873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Familial hypercholesterolemia (FH) confers a greatly increased risk for premature cardiovascular disease, but remains very underdiagnosed and undertreated in primary care populations. OBJECTIVE We assessed whether using a hybrid model consisting of 2 existing FH diagnostic criteria coupled with electronic medical record (EMR) data would accurately identify patients with FH in a Midwest US metropolitan healthcare system. METHODS We conducted a retrospective, records-based, cross-sectional study using datasets from unique EMRs of living patients. Using Structured Query Language to identify components of 2 currently approved FH diagnostic criteria, we created a hybrid model to identify individuals with FH. RESULTS Of 264 264 records analyzed, between 794 and 1571 patients were identified as having FH based on the hybrid diagnostic model, with a prevalence of 1:300 to 1:160. These patients had a higher prevalence of premature coronary artery disease (CAD) (38-58%) than the general population (1.8%) and higher than those having a high CAD risk but no FH (10%). Although most patients were receiving lipid-lowering therapies (LLTs), only 50% were receiving guideline-recommended high-intensity LLT. CONCLUSION Using the hybrid model, we identified FH with a higher clinical and genetic detection rate than using standard diagnostic criteria individually. Statin and other LLT use were suboptimal and below guideline recommendations. Because FH underdiagnosis and undertreatment are due partially to the challenges of implementing existing diagnostic criteria in a primary care setting, this hybrid model potentially can improve FH diagnosis and subsequent early access to appropriate treatment.
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Affiliation(s)
- Wael E Eid
- St. Elizabeth Physicians Regional Diabetes Center, Covington, KY 41011, USA
- College of Medicine, University of Kentucky, Lexington, KY 41011, USA
- Sanford School of Medicine, University of South Dakota, Sioux Falls, SD 41011, USA
- Faculty of Medicine, Department of Internal Medicine, Endocrine Unit, Alexandria University, Alexandria, Egypt
| | | | - Abby Wendt
- Department of Mathematics and Statistics, Northern Kentucky University, Highland Heights, KY 41099, USA
| | - Amity Lumpp
- St. Elizabeth Healthcare, Edgewood, KY 41017, USA
| | - Carl Miller
- Department of Mathematics and Statistics, Northern Kentucky University, Highland Heights, KY 41099, USA
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Gobbel GT, Matheny ME, Reeves RR, Akeroyd JM, Turchin A, Ballantyne CM, Petersen LA, Virani SS. Leveraging structured and unstructured electronic health record data to detect reasons for suboptimal statin therapy use in patients with atherosclerotic cardiovascular disease. Am J Prev Cardiol 2022; 9:100300. [PMID: 34950914 PMCID: PMC8671496 DOI: 10.1016/j.ajpc.2021.100300] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/19/2021] [Accepted: 11/27/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To determine whether natural language processing (NLP) of unstructured medical text can improve identification of ASCVD patients not using high-intensity statin therapy (HIST) due to statin-associated side effects (SASEs) and other reasons. METHODS Reviewers annotated reasons for not prescribing HIST in notes of 1152 randomly selected patients from across the VA healthcare system treated for ASCVD but not receiving HIST. Developers used reviewer annotations to train the Canary NLP tool to detect and extract notes containing one or more of these reasons. Negative predictive value (NPV), sensitivity, specificity and Area Under the Curve (AUC) were used to assess accuracy at detecting documents containing reasons when using structured data, NLP-extracted unstructured data, or both data sources combined. RESULTS At least one documented reason for not prescribing HIST occurred in 47% of notes. The most frequent reasons were SASEs (41%) and general intolerance (20%). When identifying notes containing any documented reason for not using HIST, adding NLP-extracted, unstructured data significantly (p<0.05) increased sensitivity (0.69 (95% confidence interval [CI] 0.60-0.76) to 0.89 (95% CI 0.81-0.93)), NPV (0.90 (95% CI 0.87 to 0.93) to 0.96 (95% CI 0.93-0.98)), and AUC (0.84 (95% confidence interval [CI] 0.81-0.88) to 0.91 (95% CI 0.90-0.93)) compared to structured data alone. CONCLUSIONS NLP extraction of data from unstructured text can improve identification of reasons for patients not being on HIST over structured data alone. The additional information provided through NLP of unstructured free text should help in tailoring and implementing system-level interventions to improve HIST use in patients with ASCVD.
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Affiliation(s)
- Glenn T. Gobbel
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, USA
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Michael E. Matheny
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, USA
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Ruth R. Reeves
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, USA
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Julia M. Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Alexander Turchin
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA, USA
| | - Christie M. Ballantyne
- Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Laura A. Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Salim S. Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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The Magnitude and Potential Causes of Sex Disparities in Statin Therapy in Veterans with Type 2 Diabetes: A 10-year Nationwide Longitudinal Cohort Study. Womens Health Issues 2021; 32:274-283. [PMID: 34949527 DOI: 10.1016/j.whi.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Past research has shown that women eligible for statin therapy are less likely than their male counterparts to receive any statin therapy or be prescribed a statin at the guideline-recommended intensity. We compared statin treatment in men and women veterans from a national cohort of older veterans with type 2 diabetes. METHODS The Veterans Health Administration Corporate Data Warehouse and Centers for Medicare and Medicaid Services data were used to create a unique dataset and perform a longitudinal study of veterans with type 2 diabetes from 2007 to 2016. Mixed-effects logistic regression was used to model the association between the primary exposure (sex) and statin use. RESULTS The study included 714,212 veterans with diabetes, including 9,608 women, with an overall mean age of 75.9 years. In the unadjusted model for any statin use, women veterans had a 14% significantly lower odds of having any statin use compared with men. After adjusting for all covariates, including markers of Veterans Administration care use (service-connected disability rating, Veterans Administration use, and primary care visits) that serve as proxies for access and mental health comorbidities (depression and psychiatric disorder), this disparity narrowed from 14% to 3% and was no longer statistically significant. In the model for high-intensity statin therapy (high-intensity vs. low or none), women were 10% less likely than men to use high-intensity statins in the base model that included only time and sex. After adjusting for all measured covariates, the direction of the association changed and women had 16% higher odds of high-intensity statin use compared with men (odds ratio, 1.16; 95% confidence interval, 1.03-1.31). CONCLUSIONS Consistent with prior research, in the unadjusted analysis a significant sex disparity was observed in statin use, with lower rates observed in women. For the outcome of any statin use, after adjustment for covariates that included variables that are proxies for access as well as psychiatric and depression comorbidities, this disparity lost statistical significance and narrowed. In the high-intensity statin versus low or none model, the direction of the association changed after controlling for measured covariates and women had a 16% higher odds of high-intensity statin use compared with men. This study highlights a persistent health disparity in lipid-lowering therapy for women veterans. Additional research is needed to further elucidate the reasons for and develop interventions to mitigate this persistent sex disparity in cholesterol management for veterans with diabetes.
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Jia X, Lee MT, Ramsey DJ, Mahtta D, Akeroyd JM, Turchin A, Navar AM, Matheny ME, Gobbel G, Stone NJ, Nambi V, Ballantyne CM, Petersen LA, Virani SS. Association of patient, provider and facility related characteristics with statin associated side effects and statin use: Insight from the veteran's affairs healthcare system. J Clin Lipidol 2021; 15:832-839. [PMID: 34666951 DOI: 10.1016/j.jacl.2021.09.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Statin associated side effects (SASE) are a leading cause of statin discontinuation. OBJECTIVE We evaluated patient, provider, and facility characteristics associated with SASEs and whether these characteristics impact statin utilization. METHODS Patients with atherosclerotic cardiovascular disease (ASCVD) receiving care across the Veterans Affairs healthcare system from October 1, 2014 to September 30, 2015 were included. Multivariable logistic regression analyses were performed to determine (a) factors associated with SASE and (b) factors associated with statin use in those with SASE. RESULTS Our cohort included 1,225,576 patients with ASCVD. Of these, 171,189 (13.7%) had at least 1 reported SASE since year 2000. The most significant odds for SASEs were observed with female sex (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.36, 1.45), White race (OR 1.43, 95% CI 1.41, 1.45), hypertension (OR 1.37, 95% CI 1.33, 1.41) and ischemic heart disease (IHD: OR 1.45, 95% CI 1.43, 1.47). Lower odds were noted with care at a teaching facility (OR 0.89, 95% CI 0.88, 0.90). Factors most associated with being on a statin among patients with SASE included having diabetes (OR 1.18, 95% CI 1.15, 1.20), IHD (OR 1.39, 95% CI 1.35, 1.43) and a higher number of cardiology visits (OR 1.08, 95% CI 1.07, 1.09), while female sex was associated with lower odds (OR 0.65, 95% CI 0.61, 0.69). CONCLUSION There are significant disparities in statin use by sex, ASCVD type, and comorbidities among secondary prevention patients with SASE, which represent areas for improvement in optimizing statin utilization.
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Affiliation(s)
- Xiaoming Jia
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Michelle T Lee
- Health Services Research and Development Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - David J Ramsey
- Health Services Research and Development Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Dhruv Mahtta
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Julia M Akeroyd
- Health Services Research and Development Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Alexander Turchin
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, United States
| | - Ann Marie Navar
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Michael E Matheny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States; Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, United States
| | - Glenn Gobbel
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States; Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, United States
| | - Neil J Stone
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Vijay Nambi
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Laura A Petersen
- Health Services Research and Development Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston TX, United States
| | - Salim S Virani
- Health Services Research and Development Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston TX, United States; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States.
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11
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Grundy SM, Stone NJ, Blumenthal RS, Braun LT, Heidenreich PA, Lloyd-Jones D, Orringer CE, Saseen JJ, Smith SC, Sperling LS, Virani SS. High-Intensity Statins Benefit High-Risk Patients: Why and How to Do Better. Mayo Clin Proc 2021; 96:2660-2670. [PMID: 34531060 DOI: 10.1016/j.mayocp.2021.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/03/2021] [Accepted: 02/16/2021] [Indexed: 01/07/2023]
Abstract
Review of the US and European literature indicates that most patients at high risk for atherosclerotic cardiovascular disease (ASCVD are not treated with high-intensity statins, despite strong clinical-trial evidence of maximal statin benefit. High-intensity statins are recommended for 2 categories of patients: those with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD. Most patients with ASCVD are candidates for high-intensity statins, with a goal for low-density lipoprotein cholesterol reduction of 50% or greater. A subgroup of patients with ASCVD are at very high risk and can benefit by the addition of nonstatin drugs (ezetimibe with or without bile acid sequestrant or bempedoic acid and/or a proprotein convertase subtilisin/kexin type 9 inhibitor). High-risk primary prevention patients are those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater. In patients with a 10-year risk of 7.5% to less than 20%, coronary artery calcium scoring is an option; if the coronary artery calcium score is 300 or more Agatston units, the patient can be up-classified to high risk. If high-intensity statin treatment is not tolerated in high-risk patients, a reasonable approach is to combine a moderate-intensity statin with ezetimibe. In very high-risk patients, proprotein convertase subtilisin/kexin type 9 inhibitors lower low-density lipoprotein cholesterol levels substantially and hence reduce risk as well.
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Affiliation(s)
- Scott M Grundy
- University of Texas Southwestern Medical Center and VA Medical Center, Dallas, TX.
| | - Neil J Stone
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Roger S Blumenthal
- Johns Hopkins University, Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
| | | | | | | | - Carl E Orringer
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | | | | | - Laurence S Sperling
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA
| | - Salim S Virani
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, TX
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12
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Lee MT, Mahtta D, Ramsey DJ, Liu J, Misra A, Nasir K, Samad Z, Itchhaporia D, Khan SU, Schofield RS, Ballantyne CM, Petersen LA, Virani SS. Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease. JAMA Cardiol 2021; 6:782-790. [PMID: 33881448 DOI: 10.1001/jamacardio.2021.0683] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance There is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively. Objective To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD. Design, Setting, and Participants This was a cross-sectional, multicenter, nationwide VA health care system-based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). Exposures Women vs men with premature and extremely premature ASCVD. Main Outcomes and Measures Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] ≥0.8). Results We identified 10 413 women and 137 187 men with premature ASCVD (age ≤55 years) and 1340 women and 8145 men with extremely premature (age ≤40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: -0.02; 95% CI, -0.03 to -0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR,0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD. Conclusions and Relevance This cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those with IHD, were also less statin adherent. Multidisciplinary and patient-centered interventions are needed to improve these disparities in women.
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Affiliation(s)
- Michelle T Lee
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Dhruv Mahtta
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David J Ramsey
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
| | - Jing Liu
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Arunima Misra
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Khurram Nasir
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Zainab Samad
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Dipti Itchhaporia
- Department of Medicine, Cardiology Division, Hoag Memorial Hospital, University of California at Irvine
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown
| | - Richard S Schofield
- Division of Cardiovascular Medicine, University of Florida, Gainesville.,Department of Veterans Affairs Medical Center, Gainesville, Florida
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Laura A Petersen
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Salim S Virani
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.,Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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13
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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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Tam CS, Gullick J, Saavedra A, Vernon ST, Figtree GA, Chow CK, Cretikos M, Morris RW, William M, Morris J, Brieger D. Combining structured and unstructured data in EMRs to create clinically-defined EMR-derived cohorts. BMC Med Inform Decis Mak 2021; 21:91. [PMID: 33685456 PMCID: PMC7938556 DOI: 10.1186/s12911-021-01441-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/15/2021] [Indexed: 11/29/2022] Open
Abstract
Background There have been few studies describing how production EMR systems can be systematically queried to identify clinically-defined populations and limited studies utilising free-text in this process. The aim of this study is to provide a generalisable methodology for constructing clinically-defined EMR-derived patient cohorts using structured and unstructured data in EMRs. Methods Patients with possible acute coronary syndrome (ACS) were used as an exemplar. Cardiologists defined clinical criteria for patients presenting with possible ACS. These were mapped to data tables within the production EMR system creating seven inclusion criteria comprised of structured data fields (orders and investigations, procedures, scanned electrocardiogram (ECG) images, and diagnostic codes) and unstructured clinical documentation. Data were extracted from two local health districts (LHD) in Sydney, Australia. Outcome measures included examination of the relative contribution of individual inclusion criteria to the identification of eligible encounters, comparisons between inclusion criterion and evaluation of consistency of data extracts across years and LHDs. Results Among 802,742 encounters in a 5 year dataset (1/1/13–30/12/17), the presence of an ECG image (54.8% of encounters) and symptoms and keywords in clinical documentation (41.4–64.0%) were used most often to identify presentations of possible ACS. Orders and investigations (27.3%) and procedures (1.4%), were less often present for identified presentations. Relevant ICD-10/SNOMED CT codes were present for 3.7% of identified encounters. Similar trends were seen when the two LHDs were examined separately, and across years. Conclusions Clinically-defined EMR-derived cohorts combining structured and unstructured data during cohort identification is a necessary prerequisite for critical validation work required for development of real-time clinical decision support and learning health systems.
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Affiliation(s)
- Charmaine S Tam
- Centre for Translational Data Science, The University of Sydney, Sydney, Australia. .,Northern Clinical School, The University of Sydney, Sydney, Australia.
| | - Janice Gullick
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, Australia
| | - Aldo Saavedra
- Centre for Translational Data Science, The University of Sydney, Sydney, Australia.,Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Stephen T Vernon
- Cardiothoracic and Vascular Health, Kolling Institute of Medical Research and Department of Cardiology, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, Australia
| | - Gemma A Figtree
- Northern Clinical School, The University of Sydney, Sydney, Australia.,Cardiothoracic and Vascular Health, Kolling Institute of Medical Research and Department of Cardiology, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, The University of Sydney, Sydney, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Michelle Cretikos
- Centre for Population Health, NSW Ministry of Health, Sydney, Australia
| | - Richard W Morris
- Centre for Translational Data Science, The University of Sydney, Sydney, Australia.,Northern Clinical School, The University of Sydney, Sydney, Australia
| | - Maged William
- Department of Cardiology, Central Coast Local Health District and University of Newcastle, Sydney, Australia
| | - Jonathan Morris
- Northern Clinical School, The University of Sydney, Sydney, Australia.,Clinical and Population Perinatal Health, Northern Sydney Local Health District, Sydney, Australia
| | - David Brieger
- Department of Cardiology, Concord Hospital, Sydney, Australia
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15
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Mahtta D, Ramsey D, Krittanawong C, Al Rifai M, Khurram N, Samad Z, Jneid H, Ballantyne C, Petersen LA, Virani SS. Recreational substance use among patients with premature atherosclerotic cardiovascular disease. Heart 2021; 107:650-656. [PMID: 33589427 DOI: 10.1136/heartjnl-2020-318119] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Despite an upsurge in the incidence of atherosclerotic cardiovascular diseases (ASCVD) among young adults, the attributable risk of recreational substance use among young patients has been incompletely evaluated. We evaluated the association of all recreational substances with premature and extremely premature ASCVD. METHODS In a cross-sectional analysis using the 2014-2015 nationwide Veterans Affairs Healthcare database and the Veterans wIth premaTure AtheroscLerosis (VITAL) registry, patients were categorised as having premature, extremely premature or non-premature ASCVD. Premature ASCVD was defined as having first ASCVD event at age <55 years for men and <65 years for women. Extremely premature was defined as having first ASCVD event at age <40 years while non-premature ASCVD was defined as having first ASCVD event at age ≥55 years for men and ≥65 years for women. Patients with premature ASCVD (n=135 703) and those with extremely premature ASCVD (n=7716) were compared against patients with non-premature ASCVD (n=1 112 455). Multivariable logistic regression models were used to study the independent association of all recreational substances with premature and extremely premature ASCVD. RESULTS Compared with patients with non-premature ASCVD, patients with premature ASCVD had a higher use of tobacco (62.9% vs 40.6%), alcohol (31.8% vs 14.8%), cocaine (12.9% vs 2.5%), amphetamine (2.9% vs 0.5%) and cannabis (12.5% vs 2.7%) (p<0.01 for all comparisons). In adjusted models, the use of tobacco (OR 1.97, 95% CI 1.94 to 2.00), alcohol (OR 1.50, 95% CI 1.47 to 1.52), cocaine (OR 2.44, 95% CI 2.38 to 2.50), amphetamine (OR 2.74, 95% CI 2.62 to 2.87), cannabis (OR 2.65, 95% CI 2.59 to 2.71) and other drugs (OR 2.53, 95% CI 2.47 to 2.59) was independently associated with premature ASCVD. Patients with polysubstance use had a graded response with the highest risk (~9-fold) of premature ASCVD among patients with use of ≥4 recreational substances. Similar trends were observed among patients with extremely premature ASCVD. Gender interactions with substance use were significant (p-interaction <0.05), with recreational substance use and premature ASCVD showing stronger associations among women than in men with premature ASCVD. CONCLUSIONS All subgroups of recreational substances were independently associated with a higher likelihood of premature and extremely premature ASCVD. Recreational substance use confers a greater magnitude of risk for premature ASCVD among women. A graded response relationship exists between increasing number of recreational substances used and higher likelihood of early-onset ASCVD.
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Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA
| | - Chayakrit Krittanawong
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA
| | - Nasir Khurram
- Division of Cardiovascular Medicine, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Zainab Samad
- Department of Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Christie Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA .,Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Facility-Level Variation in Reported Statin-Associated Side Effects Among Patients with Atherosclerotic Cardiovascular Disease-Perspective from the Veterans Affair Healthcare System. Cardiovasc Drugs Ther 2021; 36:295-300. [PMID: 33523335 DOI: 10.1007/s10557-021-07148-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE Statin-associated side effects (SASEs) can limit statin adherence and present a potential barrier to optimal statin utilization. How standardized reporting of SASEs varies across medical facilities has not been well characterized. METHODS We assessed facility-level variation in SASE reporting among patients with atherosclerotic cardiovascular disease receiving care across the Veterans Affairs (VA) healthcare system from October 1, 2014, to September 30, 2015. The facility rates for SASE reporting were expressed as cases per 1000 patients with ASCVD. Facility-level variation was determined using hierarchical regression analysis to calculate median rate ratios (MRR [95% confidence interval]) by first using an unadjusted model and then adjusting for patient, provider, and facility characteristics. RESULTS Of the 1,248,158 patients with ASCVD included in our study across 130 facilities, 13.7% had at least one SASE reported. Individuals with a history of SASE were less likely to be on a statin at follow-up compared with those without SASE (72.0% vs 80.8%, p < 0.01). The median (interquartile range) facility rate of SASE reported was 140.5 (109.4-167.7) cases per 1000 patients with ASCVD. Significant facility-level variation in the rate of SASE reported was observed: MRR 1.38 (1.33-1.44) in the unadjusted model and MRR 1.56 (1.47-1.65) in the adjusted model. CONCLUSION Significant facility-level variation in SASE reporting was found within the VA healthcare system suggesting room for improvement in standardized documentation of SASEs among medical facilities. This has the potential to lead to improvement in statin utilization.
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17
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Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7. Cardiovasc Drugs Ther 2021; 36:93-102. [PMID: 33400053 DOI: 10.1007/s10557-020-07125-3] [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: 12/08/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE We investigated facility-level variation in the use and adherence with antiplatelets and statins among patients with premature and extremely premature ASCVD. METHODS Using the 2014-2015 nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed patients with premature (age at first ASCVD event: males < 55 years, females < 65 years) and extremely premature ASCVD (< 40 years). We examined frequency and facility-level variation in any statin, high-intensity statin (HIS), antiplatelet use (aspirin, clopidogrel, ticagrelor, prasugrel, and ticlopidine), and statin adherence (proportion of days covered ≥ 0.8) across 130 nationwide VA healthcare facilities. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of statins or antiplatelets and statin adherence. RESULTS Our analysis included 135,703 and 7716 patients with premature and extremely premature ASCVD, respectively. Across all facilities, the median (IQR) prescription rate of any statin therapy, HIS therapy, and antiplatelets among patients with premature ASCVD was 0.73 (0.70-0.75), 0.36 (0.32-0.41), and 0.77 (0.73-0.81), respectively. MRR (95% CI) for any statin use, HIS use, and antiplatelet use were 1.53 (1.44-1.60), 1.58 (1.49-1.66), and 1.49 (1.42-1.56), respectively, showing 53, 58, and 49% facility-level variation. The median (IQR) facility-level rate of statin adherence was 0.58 (0.55-0.62) and MRR for statin adherence was 1.13 (1.10-1.15), showing 13% facility-level variation. Similar median facility-level rates and variation were observed among patients with extremely premature ASCVD. CONCLUSIONS There is suboptimal use and significant facility-level variation in the use of statin and antiplatelet therapy among patients with premature and extremely premature ASCVD. Interventions are needed to optimize care and minimize variation among young ASCVD patients.
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Hussain A, Al Rifai M, Mahtta D, Liu J, Jain V, Virani SS. Highlights from Studies Presented at the American Heart Association Scientific Session 2020: Navigating New Roads in Prevention. Curr Atheroscler Rep 2021; 23:4. [PMID: 33392871 PMCID: PMC7779087 DOI: 10.1007/s11883-020-00900-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE OF THE REVIEW This review highlights late-breaking science presented at the American Heart Association Scientific Session 2020 that demonstrated advancements in preventative cardiology and introduced novel treatment approaches for the management of chronic kidney disease, type 2 diabetes, and/or heart failure. RECENT FINDINGS The studies reviewed include clinical trials that assessed the use of omecamtiv in the treatment of heart failure with reduced heart failure (GALACTIC-HF); effects of sotagliflozin in patients with diabetes and recent heart failure exacerbation; cardiovascular outcomes with the use of omega-3 carboxylic acids in patients with high vascular risk and atherogenic dyslipidemia (STRENGTH) and omega-3 fatty acids in elderly patients with recent myocardial infarction (OMEMI); efficacy and safety of evinacumab in patients with refractory hypercholesterolemia; and the use of coronary computed tomography angiography for the assessment of suspected acute coronary syndrome. In addition, we review the results of the International Polycaps Study (TIPS-3) on the use of a polypill for the primary prevention of cardiovascular disease in intermediate-risk people. Finally, we discuss the SAMSON trial-a three-arm-N-of-1 trial-to identify the root cause of the symptoms contributing to patient nonadherence to statin therapy. The studies presented at the American Heart Association Scientific Session 2020 represent remarkable contributions in the field of cardiovascular disease and prevention.
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Affiliation(s)
- Aliza Hussain
- Section of Cardiology Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Mahmoud Al Rifai
- Section of Cardiology Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Dhruv Mahtta
- Section of Cardiology Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Jing Liu
- Section of Cardiology Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Salim S. Virani
- Section of Cardiology Department of Medicine, Baylor College of Medicine, Houston, TX USA
- Section of Cardiology Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030 USA
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Mahtta D, Gupta A, Ramsey DJ, Rifai MA, Mehta A, Krittanawong C, Lee MT, Nasir K, Samad Z, Blumenthal RS, Jneid H, Ballantyne CM, Petersen LA, Virani SS. Autoimmune Rheumatic Diseases and Premature Atherosclerotic Cardiovascular Disease: An Analysis From the VITAL Registry. Am J Med 2020; 133:1424-1432.e1. [PMID: 32598903 DOI: 10.1016/j.amjmed.2020.05.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although the association between autoimmune rheumatic diseases and atherosclerotic cardiovascular disease is well-known, there is a lack of data regarding the role of such disorders in patients with premature and extremely premature atherosclerotic cardiovascular disease. METHODS The Veterans With Premature Atherosclerosis (VITAL) registry, including patients with premature (males <55 years, females <65 years) and extremely premature atherosclerotic cardiovascular disease (<40 years), was created from the 2014-2015 nationwide Veterans Affairs (VA) health care system database. We assessed age at the time of first cardiovascular event to compare patients with premature (n = 135,703) and those with extremely premature atherosclerotic cardiovascular disease (n = 7716) with age-matched patients without atherosclerotic cardiovascular disease (nyoung = 1,153,535, nextremely young = 441,836). We assessed whether systemic lupus erythematosus, rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis were independently associated with premature and extremely premature atherosclerotic cardiovascular disease. RESULTS Patients with premature and extremely premature atherosclerotic cardiovascular disease had a higher prevalence of all rheumatic diseases as compared with age-matched patients without atherosclerotic cardiovascular disease. In fully adjusted models, systemic lupus erythematosus (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.56-1.83) and rheumatoid arthritis (OR: 1.72, 95% CI: 1.63-1.81) were associated with increased odds of premature atherosclerotic cardiovascular disease. Patients with systemic lupus erythematosus (OR: 3.06, 95% CI: 2.38-3.93) and rheumatoid arthritis (OR: 2.39, 95% CI: 1.85-3.08) also had a higher likelihood of extremely premature atherosclerotic cardiovascular disease. CONCLUSION Patients with systemic lupus erythematosus and rheumatoid arthritis carry higher odds of both premature and extremely premature atherosclerotic cardiovascular disease. Future studies are needed to understand the rheumatic disease-specific factors behind the development and progression of clinical atherosclerotic cardiovascular disease in these young patients.
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Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Tex; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Angela Gupta
- Department of Medicine, University Hospitals Cleveland Medical Center, and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David J Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Tex
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Anurag Mehta
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Ga
| | | | - Michelle T Lee
- Department of Medicine, University of Texas Health Science Center, Houston
| | - Khurram Nasir
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Tex
| | - Zainab Samad
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, Tex
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Tex; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Tex; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex.
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20
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Ahmed ST, Akeroyd JM, Mahtta D, Street R, Slagle J, Navar AM, Stone NJ, Ballantyne CM, Petersen LA, Virani SS. Shared Decisions: A Qualitative Study on Clinician and Patient Perspectives on Statin Therapy and Statin-Associated Side Effects. J Am Heart Assoc 2020; 9:e017915. [PMID: 33170055 PMCID: PMC7763718 DOI: 10.1161/jaha.120.017915] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/06/2020] [Indexed: 01/14/2023]
Abstract
Background Despite guideline recommendations and clinical trial data suggesting benefit, statin therapy use in patients with atherosclerotic cardiovascular disease remains suboptimal. The aim of this study was to understand clinician and patient views on statin therapy, statin-associated side effects (SASEs), SASE management, and communication around statin risks and benefits. Methods and Results We conducted qualitative interviews of patients with atherosclerotic cardiovascular disease who had SASEs (n=17) and clinicians who regularly prescribe statins (n=20). We used directed content analysis, facilitated by Atlas.ti software, to develop and revise codebooks for clinician and patient interviews. The most relevant codes were "pile sorted" into 5 main topic domains: (1) SASEs vary in severity, duration, and time of onset; (2) communication practices by clinicians around statins and SASEs are variable and impacted by clinician time limitations and patient preconceived notions of SASEs; (3) although a "trial and error" approach to managing SASEs may be effective in allowing clinicians to keep patients with atherosclerotic cardiovascular disease on a statin, it can be frustrating for patients; (4) outside sources, such as the media, internet, social networks, and social circles, influence patients' perceptions and often impact the risk benefit discussion; and (5) a decision aid would be beneficial in facilitating clinician decision-making around SASEs and discussion of SASEs with the patients. Conclusions Statin use among patients with atherosclerotic cardiovascular disease remains suboptimal because of various patient- and clinician-related factors. The development of a decision aid to facilitate discussion of SASEs, clinician decision-making, and SASE management may improve statin use in this high-risk population.
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Affiliation(s)
- Sarah T. Ahmed
- Health Policy, Quality and Informatics ProgramMichael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and SafetyHoustonTX
- Section of Health Services ResearchDepartment of MedicineBaylor College of MedicineHoustonTX
| | - Julia M. Akeroyd
- Health Policy, Quality and Informatics ProgramMichael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and SafetyHoustonTX
- Section of Health Services ResearchDepartment of MedicineBaylor College of MedicineHoustonTX
| | - Dhruv Mahtta
- Health Policy, Quality and Informatics ProgramMichael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and SafetyHoustonTX
- Section of Health Services ResearchDepartment of MedicineBaylor College of MedicineHoustonTX
| | - Richard Street
- Section of Cardiovascular ResearchDepartment of MedicineBaylor College of MedicineHoustonTX
- Department of CommunicationTexas A&M UniversityCollege StationTX
| | - Jason Slagle
- Center for Research and Innovation in Systems SafetyDepartment of AnesthesiologyVanderbilt University School of MedicineNashvilleTN
- Geriatric Research, Education and Clinical CenterTennessee Valley Healthcare SystemDepartment of Veterans AffairsNashvilleTN
| | - Ann Marie Navar
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Neil J. Stone
- Northwestern University Feinberg School of MedicineChicagoIL
| | - Christie M. Ballantyne
- Section of Cardiovascular ResearchDepartment of MedicineBaylor College of MedicineHoustonTX
- Section of CardiologyMichael E. DeBakey Veterans Affairs Medical CenterHoustonTX
| | - Laura A. Petersen
- Health Policy, Quality and Informatics ProgramMichael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and SafetyHoustonTX
- Section of Health Services ResearchDepartment of MedicineBaylor College of MedicineHoustonTX
| | - Salim S. Virani
- Health Policy, Quality and Informatics ProgramMichael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and SafetyHoustonTX
- Section of Health Services ResearchDepartment of MedicineBaylor College of MedicineHoustonTX
- Section of Cardiovascular ResearchDepartment of MedicineBaylor College of MedicineHoustonTX
- Section of CardiologyMichael E. DeBakey Veterans Affairs Medical CenterHoustonTX
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21
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Mahtta D, Ramsey DJ, Al Rifai M, Nasir K, Samad Z, Aguilar D, Jneid H, Ballantyne CM, Petersen LA, Virani SS. Evaluation of Aspirin and Statin Therapy Use and Adherence in Patients With Premature Atherosclerotic Cardiovascular Disease. JAMA Netw Open 2020; 3:e2011051. [PMID: 32816031 PMCID: PMC7441361 DOI: 10.1001/jamanetworkopen.2020.11051] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Studies on the use of and adherence to secondary prevention therapies in patients with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD) are lacking. OBJECTIVE To evaluate and compare aspirin use, any statin use, high-intensity statin use, and statin adherence among patients with premature or extremely premature ASCVD compared with patients with nonpremature ASCVD. DESIGN, SETTING, AND PARTICIPANTS This multicenter cross-sectional study used the clinical and administrative data sets of the US Department of Veterans Affairs (VA) to identify adult patients with at least 1 primary care visit in the VA health care system between October 1, 2014, and September 30, 2015. The study cohort comprised patients with ASCVD (ischemic heart disease, peripheral arterial disease, or ischemic cerebrovascular disease) who were enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. Patients with missing data for date of birth or sex and those with limited life expectancy were excluded. Data were analyzed from November 1, 2019, to January 1, 2020. EXPOSURES Premature (the first ASCVD event occurred at age <55 years for men and age <65 years for women) vs nonpremature (the first ASCVD event occurred at age ≥55 years for men or age ≥65 years for women) ASCVD and extremely premature (the first ASCVD event occurred at age <40 years) vs nonpremature ASCVD. MAIN OUTCOMES AND MEASURES The primary outcomes were aspirin use, any statin use, high-intensity statin use, and statin adherence (measured by proportion of days covered [PDC] ≥0.8). RESULTS Of the 1 248 158 patients identified, 135 703 (10.9%) had premature ASCVD (mean [SD] age, 49.6 [5.8] years; 116 739 men [86.0%]), 1 112 455 (89.1%) had nonpremature ASCVD (mean [SD] age, 69.6 [8.9] years; 1 104 318 men [99.3%]), and 7716 (0.6%) had extremely premature ASCVD (mean [SD] age, 34.2 [4.3] years; 6576 men [85.2%]). Patients with premature ASCVD vs those with nonpremature ASCVD had lower rates of aspirin use (96 468 [71.1%] vs 860 726 [77.4%]; P < .001) and any statin use (98 908 [72.9%] vs 894 931 [80.5%]; P < .001); had a statin PDC of 0.8 or higher (57 306 [57.9%] vs 644 357 [72.0%]; P < .001); and a higher rate of high-intensity statin use (49 354 [36.4%] vs 332 820 [29.9%]; P < .001). Similarly, patients with extremely premature ASCVD were less likely to use aspirin (odds ratio [OR], 0.27; 95% CI, 0.26-0.29), any statin (OR, 0.25; 95% CI, 0.24-0.27), or high-intensity statin (OR, 0.78; 95% CI, 0.74-0.82) and to be statin adherent (OR, 0.44; 95% CI, 0.41-0.47). CONCLUSIONS AND RELEVANCE In this study, patients with premature or extremely premature ASCVD appeared to be less likely to use aspirin or statins and to adhere to statin therapy. This finding warrants further investigation into premature ASCVD and initiatives, including clinician and patient education, to better understand and mitigate the disparities in medication use and adherence.
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Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality and Informatics Program, Health Services Research and Development, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David J. Ramsey
- Health Policy, Quality and Informatics Program, Health Services Research and Development, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Khurram Nasir
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Zainab Samad
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - David Aguilar
- Division of Cardiology, University of Texas Health Science Center McGovern Medical School, Houston
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Christie M. Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Laura A. Petersen
- Health Policy, Quality and Informatics Program, Health Services Research and Development, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Salim S. Virani
- Health Policy, Quality and Informatics Program, Health Services Research and Development, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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22
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Alameddine R, Seifeddine S, Ishak H, Antoun J. Improving statin prescription through the involvement of nurses in the provision of ASCVD score: a quality improvement initiative in primary care. Postgrad Med 2020; 132:479-484. [PMID: 32276565 DOI: 10.1080/00325481.2020.1755146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES This study compares two methods of providing CVD risk score on the percentage of appropriate statin therapy for primary prevention of CVD in family medicine clinics, according to the American Heart Association guidelines. METHODS Participants were non-diabetic patients aged 40 to 75 with a recently ordered low-density lipoprotein (LDL) level, not on statin therapy and free of CVD. The first intervention is passive with a display of the score on the EMR in the vital signs section and lasted for three months. The second intervention is collaborative where the nurses calculate the risk score and displayed it to the physician along with therapy recommendations. Electronic health records were reviewed to randomly select medical charts of eligible patients. RESULTS 162 charts were randomly selected out of 547 eligible charts and included in the analysis, including 60 charts for the baseline group. Among moderate-risk patients, the percentage of appropriate statin initiation was 0% at baseline and after intervention 1; yet it increased to (33.3% [7.5-70.1, 95% CI]) after intervention 2. Among high risk patients, percentage of appropriate statin initiation was 9.1% [0.1-41.3, 95% CI], 11.1% [1.4, 34.7, 95% CI] and 28.6% [8.4, 58.1, 95% CI] during baseline, intervention 1 and intervention 2, respectively. CONCLUSION The provision of the CVD risk score alone as clinical decision support is not enough to improve statin initiation for primary prevention. The nurse collaboration can improve guideline-concordant statin initiation.
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Affiliation(s)
- Reina Alameddine
- Department of Family Medicine, American University of Beirut , Beirut, Lebanon
| | - Suzan Seifeddine
- Department of Family Medicine, American University of Beirut , Beirut, Lebanon
| | - Hala Ishak
- Department of Family Medicine, American University of Beirut , Beirut, Lebanon
| | - Jumana Antoun
- Department of Family Medicine, American University of Beirut , Beirut, Lebanon
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