Statin use after first myocardial infarction in UK men and women from 1997 to 2006: Who started and who continued treatment?

Socioeconomic deprivation and prognostic outcomes in acute coronary syndrome: A meta-analysis using multidimensional socioeconomic status indices

BACKGROUND

Low socioeconomic status (SES) is an important prognosticator amongst patients with acute coronary syndrome (ACS). This paper analysed the effects of SES on ACS outcomes.

METHODS

Medline and Embase were searched for articles reporting outcomes of ACS patients stratified by SES using a multidimensional index, comprising at least 2 of the following components: Income, Education and Employment. A comparative meta-analysis was conducted using random-effects models to estimate the risk ratio of all-cause mortality in low SES vs high SES populations, stratified according to geographical region, study year, follow-up duration and SES index.

RESULTS

A total of 29 studies comprising of 301,340 individuals were included, of whom 43.7% were classified as low SES. While patients of both SES groups had similar cardiovascular risk profiles, ACS patients of low SES had significantly higher risk of all-cause mortality (adjusted HR:1.19, 95%CI: 1.10-1.1.29, p < 0.001) compared to patients of high SES, with higher 1-year mortality (RR:1.08, 95%CI:1.03-1.13, p = 0.0057) but not 30-day mortality (RR:1.07, 95%CI:0.98-1.16, p = 0.1003). Despite having similar rates of ST-elevation myocardial infarction and non-ST-elevation ACS, individuals with low SES had lower rates of coronary revascularisation (RR:0.95, 95%CI:0.91-0.99, p = 0.0115) and had higher cerebrovascular accident risk (RR:1.25, 95%CI:1.01-1.55, p = 0.0469). Excess mortality risk was independent of region (p = 0.2636), study year (p = 0.7271) and duration of follow-up (p = 0.0604) but was dependent on the SES index used (p < 0.0001).

CONCLUSION

Low SES is associated with increased mortality post-ACS, with suboptimal coronary revascularisation rates compared to those of high SES. Concerted efforts are needed to address the global ACS-related socioeconomic inequity.

REGISTRATION AND PROTOCOL

The current study was registered with PROSPERO, ID: CRD42022334482.

Statin adherence is lower in primary than secondary prevention: A national follow-up study of new users

BACKGROUND

Maintaining adherence to statins reduces the risk of an initial cardiovascular disease (CVD) event in high-risk individuals (primary prevention) and additional CVD events following the first event (secondary prevention). The effectiveness of statin therapy is limited by the level of adherence maintained by the patient. We undertook a nationwide study to compare adherence and discontinuation in primary and secondary prevention patients.

METHODS

Dispensing data from New Zealand community pharmacies were used to identify patients who received their first statin dispensing between 2006 and 2011. The Medication Possession Ratio (MPR) and proportion who discontinued statin medication was calculated for the year following first statin dispensing for patients with a minimum of two dispensings. Adherence was defined as an MPR ≥ 0.8. Previous CVD was identified using hospital discharge records. Multivariable logistic regression was used to control for demographic and statin characteristics.

RESULTS

Between 2006 and 2011 289,666 new statin users were identified with 238,855 (82.5%) receiving the statin for primary prevention compared to 50,811 (17.5%) who received it for secondary prevention. The secondary prevention group was 1.55 (95% CI 1.51-1.59) times as likely to be adherent and 0.67 (95% CI 0.65-0.69) times as likely to discontinue statin treatment than the primary prevention group. An early gap in statin coverage increased the odds of discontinuing statin treatment.

CONCLUSION

Adherence to statin medication is higher in secondary prevention than primary prevention. Within each group, a range of demographic and treatment factors further influences adherence.

Exposure to guideline-recommended drugs after a first acute myocardial infarction in older adults: does deprivation matter?

BACKGROUND

Inequities between guideline-recommended drugs (GRD) exposure and socioeconomic status might exist. The objective was to assess the association between a material and a social deprivation index and GRD exposure following a first acute myocardial infarction (AMI) in older adults in the province of Quebec.

METHODS

We conducted a retrospective cohort study using the Quebec Integrated Chronic Disease Surveillance System. Elderly ≥66 years, hospitalized for a first AMI between January 1, 2006, and December 31, 2011 and covered by the public drug plan were identified. Exposure to GRD (i.e. simultaneous use of 1) antiplatelet, 2) beta-blocker, 3) lipid-lowering and 4) angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker drugs) was assessed 30 and 365 days following hospital discharge. Associations between deprivation index and GRD exposure were estimated with log-binomial regressions adjusting for potential confounders.

RESULTS

Exposure to GRD was 52.2% and 48.0%, 30 and 365 days after hospital discharge, respectively. No statistically significant association was observed in multivariate analysis for both time points. Thirty days post hospital discharge, adjusted prevalence ratio of non-exposure to GRD was 0.98 (95% confidence interval [CI]: 0.95-1.02) for most materially deprived vs. least deprived and 1.04 (95% CI: 0.99-1.08) for most socially deprived vs. least deprived. Similar results were observed for 365 days.

CONCLUSION

Exposure to GRD after a first urgent AMI among older adults insured by the public drug plan in the province of Quebec is relatively low. Reasons and risk groups for this low exposure should be studied to improve secondary prevention. However, results suggest equitable access to GRD, regardless of deprivation.

Patient beliefs and attitudes to taking statins: systematic review of qualitative studies

BACKGROUND

Statins are effective in preventing cardiovascular disease (CVD) events and are recommended for at-risk individuals but estimated adherence rates are low.

AIM

To describe patients' perspectives, experiences, and attitudes towards taking statins.

DESIGN AND SETTING

Systematic review of qualitative studies reporting perspectives of patients on statins.

METHOD

PsycINFO, CINAHL, Embase, MEDLINE, and PhD dissertations from inception to 6 October 2016 were searched for qualitative studies on adult patients' perspectives on statins. All text and participant quotations were extracted from each article and analysed by thematic synthesis.

RESULTS

Thirty-two studies involving 888 participants aged 22-93 years across eight countries were included. Seven themes were identified: confidence in prevention (trust in efficacy, minimising long-term catastrophic CVD, taking control, easing anxiety about high cholesterol); routinising into daily life; questioning utility (imperceptible benefits, uncertainties about pharmacological mechanisms); medical distrust (scepticism about overprescribing, pressure to start therapy); threatening health (competing priorities and risks, debilitating side effects, toxicity to body); signifying sickness (fear of perpetual dependence, losing the battle); and financial strain.

CONCLUSION

An expectation that statins could prevent CVD and being able to integrate the statin regimen in daily life facilitated acceptance of statins among patients. However, avoiding the 'sick' identity and prolonged dependence on medications, uncertainties about the pharmacological mechanisms, risks to health, side effects, costs, and scepticism about clinicians' motives for prescribing statins were barriers to uptake. Shared decision making that addresses the risks, reasons for prescribing, patient priorities, and implementing strategies to minimise lifestyle intrusion and manage side effects may improve patient satisfaction and continuation of statins.

A Systematic Review and Meta-analysis of the Factors Associated With Nonadherence and Discontinuation of Statins Among People Aged ≥65 Years

Background

Older individuals (aged ≥65 years) are commonly prescribed statins but may experience a range of barriers in adhering to therapy. The factors associated with poor statin adherence and/or discontinuation among this population have not been comprehensively reviewed.

Methods

We conducted a systematic review to identify English articles published through December 12, 2016 that reported factors associated with nonadherence and/or discontinuation of statins among older persons. Data were pooled via random-effects meta-analysis techniques.

Results

Forty-five articles reporting data from more than 1.8 million older statin users from 13 countries were included. The factors associated with increased statin nonadherence were black/non-white race (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.39-1.98), female gender (OR 1.08, 95% CI 1.03-1.13), current smoker (OR 1.12, 95% CI 1.03-1.21), higher copayments (OR 1.38, 95% CI 1.25-1.52), new user (OR 1.58, 95% CI 1.21-2.07), lower number of concurrent cardiovascular medications (OR 1.08, 95% CI 1.06-1.09), primary prevention (OR 1.49, 95% CI 1.40-1.59), having respiratory disorders (OR 1.17, 95% CI 1.12-1.23) or depression (OR 1.11, 95% CI 1.06-1.16), and not having renal disease (OR 1.09, 95% CI 1.04-1.14). The factors associated with increased statin discontinuation were lower income status (OR 1.20, 95% CI 1.06-1.36), current smoker (OR 1.14, 95% CI 1.06-1.23), higher copayment (OR 1.61, 95% CI 1.53-1.70), higher number of medications (OR 1.04, 95% CI 1.01-1.06), presence of dementia (OR 1.18, 95% CI 1.02-1.36), cancer (OR 1.22, 95% CI 1.11-1.33) or respiratory disorders (OR 1.19, 95% CI 1.05-1.34), primary prevention (OR 1.66, 95% CI 1.24-2.22), and not having hypertension (OR 1.13, 95% CI 1.07-1.20) or diabetes (OR 1.09, 95% CI 1.04-1.15).

Conclusion

Interventions that target potentially modifiable factors including financial and social barriers, patients' perceptions about disease risk as well as polypharmacy may improve statin use in the older population.

Socioeconomic inequality in medication persistence in primary and secondary prevention of coronary heart disease - A population-wide electronic cohort study

Background

Coronary heart disease (CHD) mortality in England fell by 36% between 2000 and 2007 and it is estimated that approximately 50% of the fall was due to improved treatment uptake. Marked socio-economic inequalities in CHD mortality in the United Kingdom (UK) remain, with higher age-adjusted rates in more deprived groups. Inequalities in the persistence of medication for primary and secondary prevention of CHD may contribute to the observed social gradient and we investigated this possibility in the population of Wales (UK).

Methods and findings

An electronic cohort of individuals aged over 20 (n = 1,199,342) in Wales (UK) was formed using linked data from primary and secondary care and followed for six years (2004–2010). We identified indications for medication (statins, aspirin, ACE inhibitors, clopidogrel) recommended in UK National Institute for Clinical Excellence (NICE) guidance for CHD (high risk, stable angina, stable angina plus diabetes, unstable angina, and myocardial infarction) and measured the persistence of indicated medication (time from initiation to discontinuation) across quintiles of the Welsh Index of Multiple Deprivation, an area-based measure of socio-economic inequality, using Cox regression frailty models. In models adjusted for demographic factors, CHD risk and comorbidities across 15 comparisons for persistence of the medications, none favoured the least deprived quintile, two favoured the most deprived quintile and 13 showed no significant differences.

Conclusions

During our study period (2004–2010) we found no significant evidence of socio-economic inequality in the persistence of recommended medication for primary and secondary prevention of CHD.

Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine

Failure to change risk behaviors following myocardial infarction (MI) increases the likelihood of recurrent MI and death. Lower-socioeconomic status (SES) patients are more likely to engage in high-risk behaviors prior to MI. Less well known is whether propensity to change risk behaviors after MI also varies inversely with SES. We performed a systematized literature review addressing changes in risk behaviors following MI as a function of SES. 2160 abstracts were reviewed and 44 met eligibility criteria. Behaviors included smoking cessation, cardiac rehabilitation (CR), medication adherence, diet, and physical activity (PA). For each behavior, lower-SES patients were less likely to change after MI. Overall, lower-SES patients were 2 to 4 times less likely to make needed behavior changes (OR's 0.25-0.56). Lower-SES populations are less successful at changing risk behaviors post-MI. Increasing their participation in CR/secondary prevention programs, which address multiple risk behaviors, including increasing PA and exercise, should be a priority of healthy lifestyle medicine (HLM).

Retrospective examination of lipid-lowering treatment patterns in a real-world high-risk cohort in the UK in 2014: comparison with the National Institute for Health and Care Excellence (NICE) 2014 lipid modification guidelines

BACKGROUND

In 2014, guidelines from the National Institute for Health and Care Excellence (NICE) provided updated recommendations on lipid-modifying therapy (LMT). We assessed clinical practice contemporaneous to release of these guidelines in a UK general practice setting for secondary and high-risk primary-prevention populations, and extrapolated the findings to UK nation level.

METHODS

Patients from The Health Improvement Network database with the following criteria were included: lipid profile in 2014 (index date); ≥20 years of age; ≥2 years representation in database prior to index; ≥1 statin indication either for atherosclerotic cardiovascular disease (ASCVD) or the non-ASCVD conditions high-risk diabetes mellitus and/or chronic kidney disease.

RESULTS

Overall, 183 565 patients met the inclusion criteria (n=91 479 for ASCVD, 92 086 for non-ASCVD). In those with ASCVD, 79% received statin treatment and 31% received high-intensity statin. In the non-ASCVD group, 62% were on a statin and 57% received medium-intensity or high-intensity statin. In the ASCVD and non-ASCVD cohorts, 6% and 15%, respectively, were already treated according to dosing recommendations as per updated NICE guidelines. Extrapolation to the 2014 UK population indicated that, of the 3.3 million individuals with ASCVD, 2.4 million would require statin uptitration and 680 000 would require statin initiation (31% de novo initiation, 60% reinitiation, 9% addition to non-statin LMT) to achieve full concordance with updated guidelines. Of the 3.5 million high-risk non-ASCVD individuals, 1.6 million would require statin uptitration and 1.4 million would require statin initiation (59% de novo initiation, 36% reinitiation, 5% addition to non-statin LMT).

CONCLUSIONS

A large proportion of UK individuals with ASCVD and high-risk non-ASCVD received statin treatment (79% and 62%, respectively) during the year of NICE 2014 guidelines release. Up to 94% of patients with ASCVD and 85% of high-risk non-ASCVD individuals, representing ∼3 million individuals in each group, would require statin uptitration or initiation to achieve full concordance with updated guidelines.

Time trends in the prescription of statins for the primary prevention of cardiovascular disease in the United Kingdom: a cohort study using The Health Improvement Network primary care data

Background

Statins are widely prescribed for the primary prevention of cardiovascular disease. Guidelines exist for statin prescriptions, but there is little recent analysis concerning prescription trends over time and how these vary with respect to demographic variables.

Methods and results

Using The Health Improvement Network primary care database, statin therapy initiation and statin prescription prevalence rates were calculated using data from 7,027,711 individuals across the UK for the years 1995 to 2013, overall and stratified by sex, age group, and socioeconomic deprivation level (Townsend score). Statin therapy initiation rates rose sharply from 1995 (0.51 per 1,000 person-years) up to 2006 (19.83 per 1,000 person-years) and thereafter declined (10.76 per 1,000 person-years in 2013). Males had higher initiation rates than females and individuals aged 60–85 years had higher initiation rates than younger or more elderly age groups. Initiation rates were slightly higher as social deprivation level increased, after accounting for age and sex. Prescription prevalence increased sharply from 1995 (2.36 per 1,000 person-years) to 2013 (128.03 per 1,000 person-years) with males generally having a higher prevalence rate, over time, than females. Prevalence rates over time were generally higher for older age groups but were similar with respect to social deprivation level.

Conclusion

The uptake of statins within UK primary care has increased greatly over time with statins being more commonly prescribed to older patients in general and, in recent years, males appear to have been prescribed statins at higher rates than females. After accounting for age and sex, the statin therapy initiation rate increases with the level of social deprivation.

Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review

Strong socioeconomic inequalities exist in cardiovascular mortality and morbidity. The current review aims to synthesize the current evidence on the association between socioeconomic status (SES) and access to treatment of coronary heart disease (CHD). We examined quantitative studies analyzing the relationship between SES and access to CHD treatment that were published between 1996 and 2015. Our data sources included Medline and Web of Science. Our search yielded a total of 2066 records, 57 of which met our inclusion criteria. Low SES was found to be associated with low access to coronary procedures and secondary prevention. Access to coronary procedures, especially coronary angiography, was mainly related to SES to the disadvantage of patients with low SES. However, access to drug treatment and cardiac rehabilitation was only associated with SES in about half of the studies. The association between SES and access to treatment for CHD was stronger when SES was measured based on individual-level compared to area level, and stronger for individuals living in countries without universal health coverage. Socioeconomic inequalities exist in access to CHD treatment, and universal health coverage shows only a minor effect on this relationship. Inequalities diminish along the treatment pathway for CHD from diagnostic procedures to secondary prevention. We therefore conclude that CHD might be underdiagnosed in patients with low SES. Our results indicate that there is an urgent need to improve access to CHD treatment, especially by increasing the supply of diagnostic angiographies, to reduce inequalities across different healthcare systems.

Use of Health Care System-Supplied Aspirin by Veterans With Postoperative Heart Attack or Unstable Angina

Evidence-based guidelines for the use of aspirin in secondary prevention of cardiovascular disease events are well established. Despite this, the prevalence of aspirin use for secondary prevention is suboptimal. The study aimed to determine the prevalence of aspirin use for secondary prevention of cardiovascular disease events when it is dispensed as a prescription, as is performed in the Veterans Affairs (VA) managed care system. VA patients who had undergone major surgery and experienced a postoperative myocardial infarction (MI) or unstable angina between the years 2005 and 2009 were identified from administrative databases. VA pharmacy records were used to determine whether a prescription for aspirin was filled after the postoperative MI or unstable angina. Multivariable logistic regression models estimated odd ratios of filling aspirin prescriptions for the predictors of interest. Of the 321,131 men and women veterans who underwent major surgery, 7,700 experienced a postoperative MI or unstable angina. Among those 7,700, 47% filled an aspirin prescription. Only 59% of veterans with no co-pay filled an aspirin prescription. Aspirin fills were more common in younger veterans, Blacks, Hispanics, males, hypertensive veterans, mentally ill patients, those with no co-pay and those prescribed antiplatelets/anticoagulants in addition to aspirin postoperatively. These findings suggest that the impact of dispensing aspirin as a prescription may not be significant in increasing the appropriate use of aspirin for secondary prevention.

Evaluating quality and its determinants in lipid control for secondary prevention of heart disease and stroke in primary care: a study in an inner London Borough

OBJECTIVES

To assess quality of management and determinants in lipid control for secondary prevention of cardiovascular disease (CVD) using multilevel regression models.

DESIGN

Cross-sectional study.

SETTING

Inner London borough, with a primary care registered population of 378,000 (2013).

PARTICIPANTS

48/49 participating general practices with 7869 patients on heart disease/stroke registers were included.

OUTCOME MEASURES

(1) Recording of current total cholesterol levels and lipid control according to national evidence-based standards. (2) Assessment of quality by age, sex, ethnicity, deprivation, presence of other risks or comorbidity in meeting both lipid measurement and control standards.

RESULTS

Some process standards were not met. Patients with a current cholesterol measurement >5 mmol/L were less likely to have a current statin prescription (adjusted OR=3.10; 95% CI 2.70 to 3.56). They were more likely to have clustering of other CVD risk factors. Women were significantly more likely to have raised cholesterol after adjustment for other factors (adjusted OR=1.74; 95% CI 1.53 to 1.98).

CONCLUSIONS

In this study, the key factor that explained poor lipid control in people with CVD was having no current prescription record of a statin. Women were more likely to have poorly controlled cholesterol (independent of comorbid risk factors and after adjusting for age, ethnicity, deprivation index and practice-level variation). Women with CVD should be offered statin prescription and may require higher statin dosage for improved control.

Association of Continuity of Primary Care and Statin Adherence

Purpose

Deficiencies in medication adherence are a major barrier to effectiveness of chronic condition management. Continuity of primary care may promote adherence. We assessed the association of continuity of primary care with adherence to long-term medication as exemplified by statins.

Research Design

We linked data from a prospective study of 267,091 Australians aged 45 years and over to national data sets on prescription reimbursements, general practice claims, hospitalisations and deaths. For participants having a statin dispense within 90 days of study entry, we computed medication possession ratio (MPR) and usual provider continuity index (UPI) for the subsequent two years. We used multivariate Poisson regression to calculate the relative risk (RR) and 95% confidence interval (CI) for the association between tertiles of UPI and MPR adjusted for socio-demographic and health-related patient factors, including age, gender, remoteness of residence, smoking, alcohol intake, fruit and vegetable intake, physical activity, prior heart disease and speaking a language other than English at home. We performed a comparison approach using propensity score matching on a subset of the sample.

Results

36,144 participants were eligible and included in the analysis among whom 58% had UPI greater than 75%. UPI was significantly associated with 5% increased MPR for statin adherence (95% CI 1.04–1.06) for highest versus lowest tertile. Dichotomised analysis using a cut-off of UPI at 75% showed a similar effect size. The association between UPI and statin adherence was independent of socio-demographic and health-related factors. Stratification analyses further showed a stronger association among those who were new to statins (RR 1.33, 95% CI 1.15–1.54).

Conclusions

Greater continuity of care has a positive association with medication adherence for statins which is independent of socio-demographic and health-related factors.

Initiation rates of statin therapy for the primary prevention of cardiovascular disease: an assessment of differences between countries of the UK and between regions within England

OBJECTIVES

To investigate the extent to which variation exists in the initiation rate of statin therapy for the primary prevention of cardiovascular disease between countries of the UK and between different regions within England.

DESIGN

Cohort study using data from a large UK primary care database.

SETTING UK PARTICIPANTS

4,820,885 individuals from 554 general practices during the period 2004-2012.

MAIN OUTCOME MEASURES

Rate of statin therapy initiation per 1000 person-years.

RESULTS

Relative to a fixed English rate of 1 initiation per 1000 person-years and accounting for gender, age and social deprivation level, the rate was similar for Scotland at 0.92 (95% CI 0.84 to 1.00) and rates for Northern Ireland and Wales were higher at 1.40 (95% CI 1.20 to 1.62) and 1.18 (95% CI 1.05 to 1.32), respectively. Within England, the regions could be classified into three groups with respect to statin therapy initiation rates (relative to a rate of 1 initiation per 1000 person-years for London): the South Central 0.73 (95% CI 0.64 to 0.83), South West 0.80 (95% CI 0.71 to 0.91), East of England 0.81 (95% CI 0.71 to 0.94) and South East Coast 0.83 (95% CI 0.73 to 0.95); strategic health authorities had similar low rates followed by the East Midlands 0.88 (95% CI 0.73 to 1.05), West Midlands 0.96 (95% CI 0.84 to 1.09), North East 0.96 (95% CI 0.79 to 1.16), Yorkshire and Humber 0.97 (95% CI 0.81 to 1.17) and London strategic health authorities. North West England exhibited the highest rate of statin therapy initiation of 1.16 (95% CI 1.02 to 1.31).

CONCLUSIONS

Considerable variation in the rate of statin therapy initiation was observed between the four countries of the UK and between different geographical regions within England.

Achieving lipid targets in primary care settings

Achieving low-density lipoprotein cholesterol (LDL-C) goals in clinical practice is still unsatisfactory. Furthermore, a significant residual risk remains, even after reaching LDL-C targets, in terms of both fasting and postprandial triglycerides, high-density lipoprotein cholesterol (quantity and quality) and small dense LDL particles. Statins are the first choice for treating lipid abnormalities. Other lipid-lowering agents can be administered when statins are not tolerated and if LDL-C targets are not reached. Furthermore, multifactorial treatment, including a statin, exerts several beneficial effects on cardiovascular and residual risk reduction. The role of novel developing lipid therapies in clinical practice remains to be established.

Lifestyle factors as predictors of nonadherence to statin therapy among patients with and without cardiovascular comorbidities

BACKGROUND

Easily detectable predictors of nonadherence to long-term drug treatment are lacking. We investigated the association between lifestyle factors and nonadherence to statin therapy among patients with and without cardiovascular comorbidities.

METHODS

We included 9285 participants from the Finnish Public Sector Study who began statin therapy after completing the survey. We linked their survey data with data in national health registers. We used prescription dispensing data to determine participants' nonadherence to statin therapy during the first year of treatment (defined as < 80% of days covered by filled prescriptions). We used logistic regression to estimate the association of several lifestyle factors with nonadherence, after adjusting for sex, age and year of statin initiation.

RESULTS

Of the participants without cardiovascular comorbidities (n = 6458), 3171 (49.1%) were nonadherent with their statin therapy. Obesity (adjusted odds ratio [OR] 0.86, 95% confidence interval [CI] 0.74-0.99), overweight (adjusted OR 0.88, 95% CI 0.79-0.98) and former smoking (adjusted OR 0.82, 95% CI 0.74-0.92) predicted a reduced risk of nonadherence in this group after adjustment for sex, age and year of statin initiation. Of the participants with cardiovascular comorbidities (n = 2827), 1155 (40.9%) were nonadherent. In this group, high alcohol consumption (adjusted OR 1.55, 95% CI 1.12-2.15), extreme drinking occasions (adjusted OR 1.48, 95% CI 1.11-1.97) and a cluster of 3-4 lifestyle risks (adjusted OR 1.61, 95% CI 1.15-2.27) predicted increased odds of nonadherence after adjustment for sex, age and year of statin initiation.

INTERPRETATION

People with cardiovascular comorbidities who had risky drinking behaviours or a cluster of lifestyle risks were at increased risk of nonadherence. Among individuals without cardiovascular comorbidities, information on lifestyle factors was unhelpful in identifying those at increased risk of nonadherence; that overweight, obesity and former smoking were predictors of better adherence in this group provides insight into mechanisms of adherence to preventive medication that deserve further study.

Exploration of pharmacological interventions to prevent isoproterenol-induced myocardial infarction in experimental models

High incidences of myocardial infarction associated with high morbidity and mortality, are a major concern and economic burden on industrialized nations. Persistent β-adrenergic receptor stimulation with isoproterenol leads to the development of oxidative stress, myocardial inflammation, thrombosis, platelet aggregation and calcium overload, which ultimately cause myocardial infarction. Therapeutic agents that are presently employed for the prevention and management of myocardial infarction are beta-blockers, antithrombotics, thrombolytics, statins, angiotensin converting enzyme inhibitors, angiotensin II type 1 receptor blockers, calcium channel blockers and nitrovasodilators. In spite of effective available interventions, the mortality rate of myocardial infarction is progressively increasing. Thus, there has been a regular need to develop effective therapies for the prevention and management of this insidious disease. In this review, the authors give an overview of the consequences of isoproterenol in the pathogenesis of cardiac disorders and various therapeutic possibilities to prevent these disorders.

Cholesterol levels and the association of statins with in-hospital mortality of myocardial infarction patients insights from a Chilean registry of myocardial infarction

BACKGROUND

Hypercholesterolemia is a strong risk factor for myocardial infarction (MI). There is scarce information regarding lipoprotein levels among patients with MI in Latin America as well as about the association of very early statin therapy during the course of acute MI.

HYPOTHESIS

Very early statin prescription might be associated with a reduction on in-hospital mortality in MI patients with nearly normal lipid levels.

METHODS

Prospective registry database analysis of MI patients admitted between 2001 and 2007 at a single university hospital from which demographics, treatments, clinical variables, and mortality were assessed. Patients naïve to statin therapy were divided in 2 groups, according to whether they received (group A) or did not receive (group B) statins during the first 24 hours after admission.

RESULTS

In the 1465 patients analyzed, mean plasma levels of total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol (HDL-C) were 197, 117, and 44 mg/dL, respectively, and 41.8% had HDL-C ≤40 mg/dL. Among statin naïve patients (n = 1272), 67% were classified in group A and 33% in group B. Overall in-hospital mortality was 4.1%: 1.8% in group A and 8.5% in group B. In the multivariate analysis, including propensity score for statin prescription, the odds ratio for in-hospital mortality for group A was 0.971 (95% confidence interval: 0.944-0.999, P = 0.04).

CONCLUSIONS

In the Chilean registry of MI patients, low HDL-C was the main lipid disturbance. Very early statin use after MI appears to be associated with a borderline significant and independent reduction of in-hospital mortality.

Does the use of an electronic reminder device with or without counseling improve adherence to lipid-lowering treatment? The results of a randomized controlled trial

BACKGROUND

Lipid-lowering treatment with statins has proven to be effective in reducing cardiovascular events and mortality. In daily practice, however, adherence to medication is often low and this compromises the therapeutic effect. The aim of this study was to assess the effectiveness of an electronic reminder device (ERD) with or without counseling to improve refill adherence and persistence for statin treatment in non-adherent patients.

METHODS

A multicenter, community pharmacy-based, randomized controlled trial was conducted in 24 pharmacies in the Netherlands among patients with pre-baseline refill adherence rates between 50 and 80%. Eligible patients aged 65 years or older were randomly assigned to 1 of 3 groups: (1) counseling with an ERD (n = 134), (2) ERD with a written instruction (n = 131), and a (3) control group that received the usual treatment (n = 134).

MAIN OUTCOME MEASURE

refill adherence to statin treatment for a 360-day period after inclusion (PDC360). Patients with a refill rate ≥80% were considered adherent. The effect among subgroups was also assessed.

RESULTS

There were no relevant differences at baseline. In the counseling with ERD group 54 of 130 eligible patients received the counseling with ERD. In the ERD group, 117 of 123 eligible patients received the ERD. The proportions of adherent patients in the counseling with ERD-group (69.2%) and in the ERD group (72.4%) were not higher than in the control group (64.8%). Among women using statins for secondary prevention, more patients were adherent in the ERD group (86.1%) than in the control group (52.6%) (p < 0.005). In men using statins for secondary prevention the ERD was found to have no effect.

CONCLUSION

In this randomized controlled trial, no statistically significant improvement of refill adherence was found if an ERD was used with or without counseling. However, in a subgroup of women using statins for secondary prevention the ERD did improve adherence significantly.

Statin use among older Finns stratified according to cardiovascular risk

PURPOSE

Statin use has increased in older age groups, although there is little evidence for the benefits of statin therapy in the elderly, especially in low-risk persons. The aim of this paper is to describe recent trends in the prevalence and incidence of statin use among the Finnish older population, according to the person's estimated cardiovascular (CV) event risk.

METHODS

We conducted a register study covering the whole community-dwelling population of Finland, aged >70 years in 2000-2008 (N = 883,051). Data on reimbursed purchases of statins, antidiabetic and CV drugs, and pre-existing CV diseases were retrieved from comprehensive national registers. We stratified each person into low, moderate or high CV risk category, and according to age (70-74, 75-79, and >80 years) and sex.

RESULTS

Between 2000 and 2008, the age-sex-standardized prevalence of statin use tripled from 12.2 % to 38.7 % (rate ratio 3.0, 95 % CI 3.0-3.1), and the incidence almost doubled (from 3.7 % to 6.8 %; rate ratio 1.8, 95 % CI 1.8-1.9). The prevalence and incidence of statin use were consistently highest among high-risk persons. The greatest relative increases were observed in persons aged >80 years and in those at low risk; however, the proportion of statin users at low CV risk remained the same (∼7 % of all users).

CONCLUSIONS

Statin prescribing is shifting towards older age groups. A substantial increase in prevalence and incidence was seen across all risk categories, but the channeling of statin use towards high-risk persons remained unchanged.