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Nanna MG, Nelson AJ, Haynes K, Shambhu S, Eapen Z, Cziraky MJ, Calvert SB, Pagidipati NJ, Granger CB. Lipid-lowering treatment among older patients with atherosclerotic cardiovascular disease. J Am Geriatr Soc 2023; 71:1243-1249. [PMID: 36538393 PMCID: PMC10089944 DOI: 10.1111/jgs.18172] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/10/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The contemporary uptake of lipid-lowering therapies (LLT), including more intensive treatment with high-intensity statins and non-statin LLT, among U.S. older adults (≥75 years old) with ASCVD is unknown. METHODS In this multicenter retrospective cohort study of a large geographically diverse sample of commercially insured U.S. older adults with ASCVD, we assessed treatment with LLT. Secondary measures included LDL-C above target ≥70 mg/dl, persistence and adherence to therapy. RESULTS Treatment with statins, high-intensity statins, ezetimibe, and PCSK9 inhibitors was assessed in 194,503 older adults (49.9% female) with known ASCVD on January 31st, 2019. 49.3% of older adults with ASCVD were on any statin, with 16.6% receiving a high-intensity statin and 32.7% on low-or moderate-intensity statins. Treatment with ezetimibe (2.4%) or PCSK9 inhibitors (0.24%) was rare and 62.6% of the overall cohort had an LDL-C above target at ≥70 mg/dl. Patients on high-intensity statins were more frequently male, had a diagnosis of coronary artery disease, and were more frequently seen by a cardiologist compared with those on low-or moderate-intensity statins and untreated individuals (p < 0.0001). The majority of older adults on high-intensity statins remained on therapy at 12 months (91.9%) and 85.7% had ≥75% adherence to treatment. CONCLUSIONS Less than half of eligible older adults with ASCVD are on statins and only a minority of patients are receiving more intensive lipid-lowering to improve outcomes.
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Affiliation(s)
- Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Zubin Eapen
- Element Science, San Francisco, California, USA
| | | | - Sara B Calvert
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Clinical Trials Transformation Initiative, Durham, North Carolina, USA
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Mansi ET, Banks S, Littman AJ, Weiss NS. Association between sociodemographic factors and cholesterol-lowering medication use in U.S. adults post-myocardial infarction. PLoS One 2023; 18:e0281607. [PMID: 36758062 PMCID: PMC9910652 DOI: 10.1371/journal.pone.0281607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/26/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Cholesterol-lowering medications offer effective secondary prevention after myocardial infarction (MI). Our objective was to evaluate the association between sociodemographic factors and cholesterol-lowering medication use in high-risk adults. METHODS We conducted an analysis using weighted data from 31,408 participants in the 2017 and 2019 Behavioral Risk Factor Surveillance Systems cross-sectional surveys, who had a self-reported history of MI and high blood cholesterol. The sociodemographic factors evaluated were sex, age, race and ethnicity, annual household income, education level, relationship status, and reported healthcare coverage. We estimated the weighted prevalence of medication use, and weighted prevalence differences (with 95% confidence intervals) across categories, adjusting for sex, age group, healthcare coverage, smoking status, hypertension, and diabetes. RESULTS AND DISCUSSION Overall, 83% of survey participants with a self-reported history of both MI and high blood cholesterol reported currently using a cholesterol-lowering medication. The prevalence of use was only 61% in those without self-reported healthcare coverage, compared to 85% of those with healthcare coverage (adjusted prevalence difference of -20%; 95% CI: -25% to -14%). Use of cholesterol-lowering medication was relatively low in younger adults and higher in older adults, leveling off after age 65 years. The proportion of Native Hawaiian or Pacific Islanders who were using a cholesterol-lowering medication was relatively low, but otherwise there was little variation by race and ethnicity. Household income, education level, and relationship status were weakly or not associated with medication use. CONCLUSIONS Knowledge of characteristics of persons who are relatively less likely to be adherent with cholesterol-lowering medications for secondary prevention may be useful to policymakers and healthcare providers involved in the long-term treatment of MI patients. Policy makers might consider a reduced cost prescription coverage for persons without current healthcare coverage who have sustained an MI to reduce future cardiovascular morbidity and mortality.
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Affiliation(s)
- Elizabeth T. Mansi
- School of Public Health, University of Washington, Seattle, Washington, United States of America
- Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
- * E-mail:
| | - Samantha Banks
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Alyson J. Littman
- School of Public Health, University of Washington, Seattle, Washington, United States of America
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States of America
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services, Seattle, Washington, United States of America
| | - Noel S. Weiss
- School of Public Health, University of Washington, Seattle, Washington, United States of America
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Liu L, Ding X, Han Y, Lv J. Effects and Safety of Sacubitril/Valsartan for Patients with Myocardial Infarction: A Systematic Review and Meta-Analysis. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7840852. [PMID: 35035857 PMCID: PMC8754592 DOI: 10.1155/2022/7840852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/19/2021] [Accepted: 11/27/2021] [Indexed: 11/17/2022]
Abstract
Patients who develop heart failure (HF) after an acute myocardial infarction (AMI) are at higher risk of adverse fatal and nonfatal outcomes. Studies have shown sacubitril/valsartan can further reduce the risk of cardiovascular death or hospitalization for heart failure by 20% compared with enalapril. At the same time, its tolerance and safety are better. However, the current evidence regarding the efficacy of sacubitril/valsartan in patients with heart failure after acute myocardial infarction is controversial. To assess the effect of sacubitril/valsartan on heart failure after acute myocardial infarction, we conducted a systematic review of the literature and a meta-analysis of existing randomized clinical trials. Meta-analysis of randomized controlled trails is used where data are collected from PubMed, the Cochrane library, Embase, and Web of Science. Data about sacubitril/valsartan were available from 5 studies. Forest plots showed that the sacubitril/valsartan group had a 299% higher value of sacubitril/valsartan to the control group (MD = 2.99%, 95% CI: 2.01, 3.96, I 2 = 78%, P < 0.00001, Figure 2), and the difference was statistically significant. Forest plots showed that the sacubitril/valsartan group had a 531% lower value of LVEF to the control group (MD = -5.31%, 95% CI: -7.36, -3.26, I 2 = 91%, P < 0.00001, Figure 2), and the difference was statistically significant. Forest plots showed that the sacubitril/valsartan group had a 133% lower value of NT-proBNP to the control group (MD = -1.33%, 95% CI: -1.54, -1.12, I 2 = 96%, P < 0.00001, Figure 3). Forest plots showed that the sacubitril/valsartan group had a 49% lower risk of heart failure to the control group (MD = 0.49, 95% CI: 0.27, 0.89, I 2 = 0%, P=0.02, Figure 3). The patients in experimental showed an obviously lower OR of MACE (OR = 0.47, 95% CI: 0.27, 0.82, P=0.007, Figure 3). The data were statistically significant. We have observed that for patients with heart failure after acute myocardial infarction, early administration of sacubitril/valsartan can significantly reduce the incidence of heart rate, left ventricular ejection fraction, NT-proBNP, and MACE. Our meta-analysis suggests that taking sacubitril/valsartan is relatively safe and effective, especially if started early after acute myocardial infarction.
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Affiliation(s)
- Lang Liu
- General Hospital of Ningxia Medical University, Yinchuan City 750000, China
| | - Xiaofang Ding
- General Hospital of Ningxia Medical University, Yinchuan City 750000, China
| | - Yaxiang Han
- General Hospital of Ningxia Medical University, Yinchuan City 750000, China
| | - Jianfeng Lv
- Affiliated RenHe Hospital of China, Three Gorges University Second Clinical Medical College of China Three Gorges University, Yichang City 443000, China
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Hsu B, Korda RJ, Lindley RI, Douglas KA, Naganathan V, Jorm LR. Use of health and aged care services in Australia following hospital admission for myocardial infarction, stroke or heart failure. BMC Geriatr 2021; 21:538. [PMID: 34635068 PMCID: PMC8504055 DOI: 10.1186/s12877-021-02519-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular diseases (CVD), including myocardial infarction (MI), stroke and heart failure (HF) are the leading cause of death amongst the older population worldwide. The aim of this study is to investigate trajectories of use of health and aged care services after hospital admission for MI, stroke or HF among community-dwelling people not previously receiving aged care services. METHODS The study population comprised people aged 65+ years from the 45 and Up Study with linked records for hospital stays, aged care services and deaths for the period 2006-14. Among those with an index hospital admission for MI, stroke or HF, we developed Sankey plots to describe and visualize sequences and trajectories of service use (none, re-hospitalization, community care, residential care, death) in the 12 months following discharge. We used Cox proportional hazards models to estimate hazard ratios (HRs), for commencing community care and entering residential care (and the other outcomes) within 3, 6 and 12 months, compared to a matched group without MI, stroke or HF. RESULTS Two thousand six hundred thirty-nine, two thousand five hundred and two thousand eight hundred seventy-three people had an index hospitalization for MI, stroke and HF, respectively. Within 3 months of hospital discharge, 16, 32 and 29%, respectively, commenced community care (multivariable-adjusted HRs: 1.26 (95%CI:1.18-1.35), 1.53 (95%CI:1.44-1.64) and 1.39 (95%CI:1.32-1.48)); and 7, 18 and 14%, respectively, entered residential care (HRs: 1.25 (95%CI:1.12-1.41), 2.65 (95%CI:2.42-2.91) and 1.50 (95%CI:1.37-1.65)). Likewise, 26, 15 and 28%, respectively, were rehospitalized within 3 months following discharge (multivariable-adjusted HRs: 4.78 (95%CI:4.31-5.32), 3.26 (95%CI:2.91-3.65) and 4.94 (95%CI:4.47-5.46)). CONCLUSIONS Older people hospitalized for major CVD may be vulnerable to transition-related risks and have poor health trajectories, thus emphasizing the value of preventing such events and care strategies targeted towards this at-risk group.
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Affiliation(s)
- Benjumin Hsu
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia. .,School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
| | - Rosemary J Korda
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australia
| | - Richard I Lindley
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kirsty A Douglas
- ANU Medical School, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Repatriation Hospital and University of Sydney, Sydney, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia
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Mack DS, Hume AL, Tjia J, Lapane KL. National Trends in Statin Use among the United States Nursing Home Population (2011-2016). Drugs Aging 2021; 38:427-439. [PMID: 33694105 PMCID: PMC8102363 DOI: 10.1007/s40266-021-00844-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Little is known about trends in statin use in United States (US) nursing homes. OBJECTIVES The aim of this study was to describe national trends in statin use in nursing homes and evaluate the impact of the introduction of generic statins, safety warnings, and guideline recommendations on statin use. METHODS This study employed a repeated cross-sectional prevalence design to evaluate monthly statin use in long-stay US nursing home residents enrolled in Medicare fee-for-service using the Minimum Data Set 3.0 and Medicare Part D claims between April 2011 and December 2016. Stratified by age (65-75 years, ≥ 76 years), analyses estimated trends and level changes with 95% confidence intervals (CI) following statin-related events (the availability of generic statins, American Heart Association/American College of Cardiology guideline updates, and US FDA safety warnings) through segmented regression models corrected for autocorrelation. RESULTS Statin use increased from April 2011 to December 2016 (65-75 years: 38.6-43.3%; ≥ 76 years: 26.5% to 30.0%), as did high-intensity statin use (65-75 years: 4.8-9.5%; ≥ 76 years: 2.3-4.5%). The introduction of generic statins yielded little impact on the prevalence of statins in nursing home residents. Positive trend changes in high-intensity statin use occurred following national guideline updates in December 2011 (65-75 years: β = 0.16, 95% CI 0.09-0.22; ≥ 76 years: β = 0.09, 95% CI 0.06-0.12) and November 2013 (65-75 years: β = 0.11, 95% CI 0.09-0.13; ≥ 76 years: β = 0.04, 95% CI 0.03-0.05). There were negative trend changes for any statin use concurrent with FDA statin safety warnings in March 2012 among both age groups (65-75 years: β trend change = - 0.06, 95% CI - 0.10 to - 0.02; ≥ 76 years: β trend change = - 0.05, 95% CI - 0.08 to - 0.01). The publication of the results of a statin deprescribing trial yielded a decrease in any statin use among the ≥ 76 years age group (β level change = - 0.25, 95% CI - 0.48 to - 0.09; β trend change = - 0.03, 95% CI - 0.04 to - 0.01), with both age groups observing a positive trend change with high-intensity statins (65-75 years: β = 0.11, 95% CI 0.02-0.21; ≥ 76 years: β = 0.05, 95% CI 0.01-0.09). CONCLUSION Overall, statin use in US nursing homes increased from 2011 to 2016. Guidelines and statin-related events appeared to impact use in the nursing home setting. As such, statin guidelines and messaging should provide special consideration for nursing home populations, who may have more risk than benefit from statin pharmacotherapy.
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Affiliation(s)
- Deborah S Mack
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, 01605, MA, USA
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Anne L Hume
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Jennifer Tjia
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, 01605, MA, USA
| | - Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, 01605, MA, USA.
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Spencer-Bonilla G, Chung S, Sarraju A, Heidenreich P, Palaniappan L, Rodriguez F. Statin Use in Older Adults with Stable Atherosclerotic Cardiovascular Disease. J Am Geriatr Soc 2021; 69:979-985. [PMID: 33410499 PMCID: PMC8049971 DOI: 10.1111/jgs.16975] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/14/2020] [Accepted: 11/14/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND/OBJECTIVES Older adults (>75 years of age) represent two-thirds of atherosclerotic cardiovascular disease (ASCVD) deaths. The 2013 and 2018 American multi-society cholesterol guidelines recommend using at least moderate intensity statins for older adults with ASCVD. We examined annual trends and statin prescribing patterns in a multiethnic population of older adults with ASCVD. DESIGN Retrospective longitudinal study using electronic health record (EHR) data from 2007 to 2018. SETTING A large multi-specialty health system in Northern California. PARTICIPANTS A total of 24,651 adults older than 75 years with ASCVD. MEASUREMENTS Statin prescriptions for older adults with known ASCVD were trended over time. Multivariable regression models were used to identify predictors of statin prescription (logistic) after controlling for relevant demographic and clinical factors. RESULTS The study cohort included 24,651 patients older than 75 years; 48% were women. Although prescriptions for moderate/high intensity statins increased over time for adults over 75, fewer than half of the patients (45%) received moderate/high intensity statins in 2018. Women (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.74, 0.80), patients who had heart failure (OR = 0.69; 95% CI = 0.65, 0.74), those with dementia (OR = 0.88; 95% CI = 0.82, 0.95) and patients who were underweight (OR = 0.64; 95% CI = 0.57, 0.73) were less likely to receive moderate/high intensity statins. CONCLUSIONS Despite increasing prescription rates between 2007 and 2018, guideline-recommended statins remained underused in older adults with ASCVD, with more pronounced disparities among women and those with certain comorbidities. Future studies are warranted to examine reasons for statin underuse in older adults with ASCVD.
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Affiliation(s)
| | - Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Ashish Sarraju
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - Paul Heidenreich
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
- Division of Cardiovascular Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Latha Palaniappan
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
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Underprescription of medications in older adults: causes, consequences and solutions-a narrative review. Eur Geriatr Med 2021; 12:453-462. [PMID: 33709336 DOI: 10.1007/s41999-021-00471-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/10/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE Under-prescription is defined as the omission of a medication that is indicated for the treatment of a condition or a disease, without any valid reason for not prescribing it. The aim of this review is to provide an updated overview of under-prescription, summarizing the available evidence concerning its prevalence, causes, consequences and potential interventions to reduce it. METHODS A PubMed search was performed, using the following keywords: under-prescription; under-treatment; prescribing omission; older adults; polypharmacy; cardiovascular drugs; osteoporosis; anticoagulant. The list of articles was evaluated by two authors who selected the most relevant of them. The reference lists of retrieved articles were screened for additional pertinent studies. RESULTS Although several pharmacological therapies are safe and effective in older patients, under-prescription remains widespread in the older population, with a prevalence ranging from 22 to 70%. Several drugs are underused, including cardiovascular, oral anticoagulant and anti-osteoporotic drugs. Many factors are associated with under-prescription, e.g. multi-morbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. Under-prescription is associated with negative consequences, such as higher risk of cardiovascular events, worsening disability, hospitalization and death. The implementation of explicit criteria for under-prescription, the use of the comprehensive geriatric assessment by geriatricians, and the involvement of a clinical pharmacist seem to be promising options to reduce under-prescription. CONCLUSION Under-prescription remains widespread in the older population. Further studies should be performed, to provide a better comprehension of this phenomenon and to confirm the efficacy of corrective interventions.
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Alcusky M, Baek J, Tjia J, McManus DD, Lapane KL. Geographic Variation in Anticoagulant Use and Resident, Nursing Home, and County Characteristics Associated With Treatment Among US Nursing Home Residents. J Am Med Dir Assoc 2021; 22:164-172.e9. [PMID: 33357746 PMCID: PMC8092949 DOI: 10.1016/j.jamda.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population. DESIGN A repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016. SETTING AND PARTICIPANTS Secondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded. METHODS Multilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated. RESULTS Among 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation. CONCLUSIONS AND IMPLICATIONS In this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.
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Affiliation(s)
- Matthew Alcusky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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9
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Zullo AR, Riester MR, Erqou S, Wu WC, Rudolph JL, Steinman MA. Comparative Effectiveness of Angiotensin II Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors in Older Nursing Home Residents After Myocardial Infarction: A Retrospective Cohort Study. Drugs Aging 2020; 37:755-766. [PMID: 32808250 PMCID: PMC7530043 DOI: 10.1007/s40266-020-00791-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Evidence regarding differences in outcomes between angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) among older nursing home (NH) residents after acute myocardial infarction (AMI) is limited. OBJECTIVES The purpose of our study was to estimate the post-AMI effects of ARBs versus ACEIs on mortality, rehospitalization, and functional decline outcomes in this important population. METHODS This retrospective cohort study used national Medicare claims linked to Minimum Data Set assessments. The study population included individuals aged ≥ 65 years who resided in a US NH ≥ 30 days, were hospitalized for AMI between May 2007 and March 2010, and returned to the NH. We compared 90-day mortality, rehospitalization, and functional decline outcomes between ARB and ACEI users with inverse-probability-of-treatment-weighted binomial and multinomial logistic regression models. RESULTS Of the 2765 NH residents, 270 (9.8%) used ARBs and 2495 (90.2%) used ACEIs. The mean age of ARB versus ACEI users was 82.3 versus 82.7 years, respectively. No marked differences existed between ARB and ACEI users for mortality [odds ratio (OR) 1.18; 95% confidence interval (CI) 0.78-1.79], rehospitalization (OR 1.22; 95% CI 0.90-1.65), or functional decline (OR 1.23; 95% CI 0.88-1.74). In subgroup analyses, ARBs were associated with increased mortality and rehospitalization in individuals with moderate to severe cognitive impairment and with increased rehospitalization in those aged < 85 years. CONCLUSIONS Our findings align with prior data and suggest that clinicians can prescribe either ARBs or ACEIs post-AMI for secondary prevention in NH residents, although the subgroup findings merit further scrutiny and replication. Providers should consider factors such as patient preferences, class-specific adverse events, and costs when prescribing.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA. .,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA. .,Department of Pharmacy, Rhode Island Hospital, Providence, RI, USA.
| | | | - Sebhat Erqou
- Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Wen-Chih Wu
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - James L Rudolph
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA, USA
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Alcusky M, McManus DD, Hume AL, Fisher M, Tjia J, Lapane KL. Changes in Anticoagulant Utilization Among United States Nursing Home Residents With Atrial Fibrillation From 2011 to 2016. J Am Heart Assoc 2020; 8:e012023. [PMID: 31046504 PMCID: PMC6512099 DOI: 10.1161/jaha.119.012023] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Nursing home residents with atrial fibrillation are at high risk for ischemic stroke and bleeding events. The most recent national estimate (2004) indicated less than one third of this high‐risk population was anticoagulated. Whether direct‐acting oral anticoagulant (DOAC) use has disseminated into nursing homes and increased anticoagulant use is unknown. Methods and Results A repeated cross‐sectional design was used to estimate the point prevalence of oral anticoagulant use on July 1 and December 31 of calendar years 2011 to 2016 among Medicare fee‐for‐service beneficiaries with atrial fibrillation residing in long‐stay nursing homes. Nursing home residence was determined using Minimum Data Set 3.0 records. Medicare Part D claims for apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin were identified and point prevalence was estimated by determining if the supply from the most recent dispensing covered each point prevalence date. A Cochran‐Armitage test was performed for linear trend in prevalence. On December 31, 2011, 42.3% of 33 959 residents (median age: 85; Q1 79, Q3 90) were treated with an oral anticoagulant, of whom 8.6% used DOACs. The proportion receiving treatment increased to 47.8% of 37 787 residents as of December 31, 2016 (P<0.01); 48.2% of 18 054 treated residents received DOACs. Demographic and clinical characteristics of residents using DOACs and warfarin were similar in 2016. Half of the 8734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016. Conclusions Increases in anticoagulant use among US nursing home residents with atrial fibrillation coincided with declining warfarin use and increasing DOAC use.
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Affiliation(s)
- Matthew Alcusky
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - David D. McManus
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Anne L. Hume
- Department of Pharmacy PracticeCollege of PharmacyUniversity of Rhode IslandKingstonRI
| | - Marc Fisher
- Department of NeurologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Jennifer Tjia
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Kate L. Lapane
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
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11
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Zullo AR, Mogul A, Corsi K, Shah NR, Lee SJ, Rudolph JL, Wu WC, Dapaah-Afriyie R, Berard-Collins C, Steinman MA. Association Between Secondary Prevention Medication Use and Outcomes in Frail Older Adults After Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020; 12:e004942. [PMID: 31002274 DOI: 10.1161/circoutcomes.118.004942] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Secondary prevention medications are often not prescribed to frail, older adults following acute myocardial infarction, potentially because of the absence of data to support use, perceived lack of benefit, and concern over possible harms. We examined the effect of using more guideline-recommended medications after myocardial infarction on mortality, rehospitalization, and functional decline in the frailest and oldest segment of the US population-long-stay nursing home residents. Methods and Results We conducted a retrospective cohort study of nursing home residents aged ≥65 years using 2007 to 2010 national US Minimum Data Set clinical assessment data and Medicare claims. Exposure was the number of secondary prevention medications (antiplatelets, β-blockers, statins, and renin-angiotensin-aldosterone system inhibitors) initiated after myocardial infarction. Outcomes were 90-day death, rehospitalization, and functional decline. We compared outcomes for new users of 2 versus 1 and 3 or 4 versus 1 medications using the inverse probability of treatment-weighted odds ratios with 95% CI. The cohort comprised 4787 residents, with a total of 509 death, 820 functional decline, and 1226 rehospitalization events. Compared with individuals who initiated 1 medication, mortality odds ratios were 0.98 (95% CI, 0.79-1.22) and 0.74 (95% CI, 0.57-0.97) for users of 2 and 3 or 4 medications, respectively. Rehospitalization odds ratios were 1.00 (95% CI, 0.85-1.17) for 2 and 0.97 (95% CI, 0.8-1.17) for 3 or 4 medications. Functional decline odds ratios were 1.04 (95% CI, 0.85-1.28) for 2 and 1.12 (95% CI, 0.89-1.40) for 3 or 4 medications. In a stability analysis excluding antiplatelet drugs from the exposure definition, more medication use was associated with functional decline. Conclusions Use of more guideline-recommended medications after myocardial infarction was associated with decreased mortality in older, predominantly frail adults, but no difference in rehospitalization. Results for functional decline from the main and stability analyses were discordant and did not rule out an increased risk associated with more medication use.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.,Department of Epidemiology (A.R.Z., W.-C.W.), Brown University School of Public Health, Providence, RI.,Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.).,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI (A.R.Z., J.L.R.)
| | - Amanda Mogul
- Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.).,Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY (A.M.)
| | - Katherine Corsi
- Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.).,Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (K.C.)
| | - Nishant R Shah
- Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.,Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI (N.R.S., W.-C.W.)
| | - Sei J Lee
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco (M.A.S., S.J.L.)
| | - James L Rudolph
- Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI (A.R.Z., J.L.R.)
| | - Wen-Chih Wu
- Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.,Department of Epidemiology (A.R.Z., W.-C.W.), Brown University School of Public Health, Providence, RI.,Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI (N.R.S., W.-C.W.)
| | - Ruth Dapaah-Afriyie
- Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.)
| | - Christine Berard-Collins
- Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.)
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco (M.A.S., S.J.L.)
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12
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Zullo AR, Ofori-Asenso R, Wood M, Zuern A, Lee Y, Wu WC, Rudolph JL, Liew D, Steinman MA. Effects of Statins for Secondary Prevention on Functioning and Other Outcomes Among Nursing Home Residents. J Am Med Dir Assoc 2020; 21:500-507.e8. [PMID: 32144051 PMCID: PMC7127965 DOI: 10.1016/j.jamda.2020.01.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/11/2020] [Accepted: 01/18/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Studies examining the effects of statins after acute myocardial infarction (AMI) excluded frail older adults, especially nursing home (NH) residents, and few examined functional outcomes. Older NH residents may benefit less from statins and be particularly susceptible to adverse drug events like myopathy-related functional decline. We evaluated the effects of statins on 1-year functional decline, rehospitalization, and death in NH residents. DESIGN We conducted a retrospective cohort study using 2007-2010 linked national data from Minimum Data Set (MDS) assessments, Medicare claims, and Online Survey Certification and Reporting System records. SETTING AND PARTICIPANTS We included US NH residents 65 years and older who were statin nonusers, were hospitalized for AMI between May 2007 and March 2010, and returned to the NH. MEASURES Outcomes were functional decline, death, and rehospitalization in the first year after post-AMI NH admission. New statin users were 1:1 propensity-score matched to nonusers to adjust for 92 characteristics. We estimated hazard ratios (HRs) and restricted mean survival time differences with 95% confidence intervals (CIs) comparing individuals who did vs did not initiate statin therapy after AMI hospitalization. RESULTS Propensity-score matching yielded a cohort of 5440 residents. Mean age was 83 years and 69% were female. Statin use was associated with a reduction in mortality (HR 0.80, 95% CI 0.73-0.87), corresponding to a mean of 15.9 (95% CI 9.9-22.0) days of extended life expectancy. No overall differences in rehospitalization (HR 1.06, 95% CI 0.98-1.14) or functional decline (HR 1.00, 95% CI 0.88-1.14) were observed. CONCLUSIONS AND IMPLICATIONS Statins may reduce 1-year mortality by 20% without affecting function among older NH residents who wish to live longer after AMI. During shared decision making with these patients or their representatives, clinicians should consider communicating that the average benefit of statins is 16 days of additional survival over 1 year.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI; Department of Epidemiology, Brown University School of Public Health, Providence, RI; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; Department of Pharmacy, Rhode Island Hospital, Providence, RI.
| | - Richard Ofori-Asenso
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marci Wood
- Department of Pharmacy, Rhode Island Hospital, Providence, RI
| | - Allison Zuern
- Department of Pharmacy, Rhode Island Hospital, Providence, RI
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Wen-Chih Wu
- Department of Epidemiology, Brown University School of Public Health, Providence, RI; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI
| | - James L Rudolph
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI
| | - Danny Liew
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA
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13
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Viscogliosi G, Donfrancesco C, Lo Noce C, Vanuzzo D, Carle F, Giampaoli S, Palmieri L. Prevalence and Correlates of Statin Underuse for Secondary Prevention of Cardiovascular Disease in Older Adults 65-79 Years of Age: The Italian Health Examination Survey 2008-2012. Rejuvenation Res 2020; 23:394-400. [PMID: 32008438 DOI: 10.1089/rej.2019.2268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Limited data are available on the prevalence and correlates of statin use for secondary cardiovascular (CV) prevention in the older adult population. We used data of older adults (65-79 years) with established atherosclerotic CV disease from the cross-sectional Italian Health Examination Survey 2008-2012 to address this issue. Lifestyles, CV risk factors, chronic diseases, and therapies were assessed using standardized procedures. A comprehensive geriatric assessment was performed to evaluate cognitive function, disability in basic activities of daily living/instrumental activities of daily living, mobility, and polypharmacy. Multiple regression analyses were performed to identify independent correlates of statin use. A total of 392 participants (mean age 72.1 ± 4.4 years, 61.5% men) were considered for this analysis. Coronary heart disease was identified in 67.1% of participants, cerebrovascular disease in 23.5%, and peripheral artery disease (PAD) in 18.1%. One hundred ninety (48.5%) were statin users. By multiple regression analysis, functional disability (odds ratio [OR] = 0.81; 95% confidence interval [CI] = 0.71-0.92; p = 0.002), cognitive impairment (OR = 0.87; 95% CI = 0.78-0.98; p = 0.018), and polypharmacy (OR = 0.86; 95% CI = 0.75-0.98; p = 0.035) predicted statin nonuse, whereas having hypertension (OR = 1.19; 95% CI = 1.05-1.34; p = 0.005), diabetes mellitus (OR = 1.14; 95% CI = 1.03-1.27; p = 0.013), or a previous myocardial revascularization (OR = 1.31; 95% CI = 1.16-1.48; p < 0.001) predicted statin use. Significant interaction terms were observed between cerebrovascular disease, PAD, cognitive impairment, and disability in predicting statin nonuse. Statin underuse in older adults aged 65-79 years with CV disease, and thus suboptimal secondary CV prevention, is highly prevalent despite current guidelines and recommendations. Common geriatric conditions are associated with statin nonuse. Such results support the need for improving the awareness of statin treatment for secondary CV prevention.
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Affiliation(s)
- Giovanni Viscogliosi
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy.,Department of Epidemiology, Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Chiara Donfrancesco
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy
| | - Cinzia Lo Noce
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy
| | - Diego Vanuzzo
- Department of Cardiology, National Association Hospital Cardiologists, Florence, Italy
| | - Flavia Carle
- Department of Epidemiology, Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Simona Giampaoli
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy
| | - Luigi Palmieri
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy
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14
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Jokanovic N, Kautiainen H, Bell JS, Tan ECK, Pitkälä KH. Change in Prescribing for Secondary Prevention of Stroke and Coronary Heart Disease in Finnish Nursing Homes and Assisted Living Facilities. Drugs Aging 2019; 36:571-579. [PMID: 30949985 DOI: 10.1007/s40266-019-00656-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND One quarter of residents in long-term care facilities (LTCFs) have a diagnosis of CHD or stroke and over half use at least one preventative cardiovascular medication. There have been no studies that have investigated the longitudinal change in secondary preventative cardiovascular medication use in residents in LTCFs over time. OBJECTIVE The aim of this study was to investigate the change in cardiovascular medication use among residents with coronary heart disease (CHD) and prior stroke in nursing homes (NHs) and assisted living facilities (ALFs) in Finland over time, and whether this change differs according to dementia status. METHODS Three comparable cross-sectional audits of cardiovascular medication use among residents aged 65 years and over with CHD or prior stroke in NHs in 2003 and 2011 and ALFs in 2007 and 2011 were compared. Logistic regression analyses adjusted for gender, age, mobility, cancer and length of stay were performed to examine the effect of study year, dementia and their interaction on medication use. RESULTS Cardiovascular medication use among residents with CHD (NHs: 89% vs 70%; ALFs: 89% vs 84%) and antithrombotic medication use among residents with stroke (NHs: 72% vs 63%; ALFs: 78% vs 69%) declined between 2003 and 2011 in NHs and 2007 and 2011 in ALFs. Decline in the use of diuretics, nitrates and digoxin were found in both groups and settings. Cardiovascular medication use among residents with CHD and dementia declined in NHs (88% [95% CI 85-91] in 2003 vs 70% [95% CI 64-75] in 2011) whereas there was no change among people without dementia. There was no change in cardiovascular medication use among residents with CHD in ALFs with or without dementia over time. Antithrombotic use was lower in residents with dementia compared with residents without dementia in NHs (p < 0.001) and ALFs (p = 0.026); however, the interaction between dementia diagnosis and time was non-significant. CONCLUSIONS The decline in cardiovascular medication use in residents with CHD and dementia suggests Finnish physicians are adopting a more conservative approach to the management of cardiovascular disease in the NH population.
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Affiliation(s)
- Natali Jokanovic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia. .,Pharmacy Department, Alfred Hospital, Melbourne, Australia.
| | - Hannu Kautiainen
- Department of General Practice and Unit of Primary Health Care, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Edwin C K Tan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Aging Research Centre, Department of Neurobiology, Care Sciences and Society, Karolinska Institute and Stockholm University, Stockholm, Sweden
| | - Kaisu H Pitkälä
- Department of General Practice and Unit of Primary Health Care, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
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15
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Lanham D, Ali S, Davis D, Rawle MJ. Beta-Blockers for the Secondary Prevention of Myocardial Infarction in People with Dementia: A Systematic Review. J Alzheimers Dis 2019; 71:1105-1114. [PMID: 31476156 PMCID: PMC6839460 DOI: 10.3233/jad-190503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: Cardiovascular disease remains the most common cause of death in industrialized countries. The use of beta-blockers is well established as a secondary prevention of myocardial infarction. However, little is known about the benefits of beta-blockers for people living with dementia. Objective: To evaluate the use of beta-blockers in people with dementia who have had a myocardial infarction, in order to identify associations between medication use, mortality, re-infarction and functional decline. Methods: We searched for all studies (randomized trials, observational cohorts) reporting beta-blocker use in populations with both dementia and previous myocardial infarction. Relevant keywords were used in Medline, Embase, and Web of Science up to October 2018. Titles and abstracts were independently screened by two reviewers. Quality of eligible studies was assessed using the Newcastle-Ottawa Scale. PRISMA recommendations were followed throughout. Results: Two observational studies were included, representing 10,992 individuals in a community setting and 129,092 individuals from a hospital record-linkage study. One showed use of beta-blockers reduced all-cause mortality (HR 0.74 (95% CI 0.64– 0.86) alongside evidence for an increased rate of functional decline in individuals aged≥65 with moderate to severe cognitive impairment (OR 1.34 (95% CI 1.11– 1.61)). The second study did not find an association between beta-blocker use and mortality in the population living with dementia. Conclusion: There is insufficient evidence to support use of beta-blockers to persons living with dementia. A single study provides limited evidence that beta-blockers improve survival rates but with associated detrimental effects on functional status in nursing home residents with cognitive impairment. Decisions to continue beta-blockers in persons living with dementia should be made on an individual basis.
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Affiliation(s)
- David Lanham
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Sana Ali
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
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16
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Zullo AR, Olean M, Berry SD, Lee Y, Tjia J, Steinman MA. Patient-Important Adverse Events of β-blockers in Frail Older Adults after Acute Myocardial Infarction. J Gerontol A Biol Sci Med Sci 2019; 74:1277-1281. [PMID: 30137259 PMCID: PMC6625583 DOI: 10.1093/gerona/gly191] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We evaluated the burden of adverse events caused by β-blocker use after acute myocardial infarction (AMI) in frail, older nursing home (NH) residents. METHODS This retrospective cohort study used national Medicare claims linked to Minimum Data Set assessments. The study population was individuals aged ≥65 years who resided in a U.S. NH for ≥30 days, had a hospitalized AMI between May 2007 and March 2010, and returned to the NH. Exposure was new use of β-blockers versus nonuse post-AMI. Orthostasis, general hypotension, falls, dizziness, syncope, and breathlessness outcomes were measured over 90 days of follow-up. Odds ratios (ORs) with 95% confidence intervals (CIs) for outcomes were estimated using multinomial logistic regression models after 1:1 propensity score-matching of β-blocker users to nonusers. RESULTS Among the 10,992 NH propensity score-matched residents with an AMI, the mean age was 84 years and 70.9% were female. β-blocker users were more likely than nonusers to be hospitalized for hypotension (OR = 1.20, 95% CI 1.03-1.39) or experience breathlessness (OR = 1.10, 95% CI 1.01-1.20) after AMI. With the exception of falls, other outcome estimates, though imprecise, were compatible with a potential elevated risk of orthostasis (OR = 1.14, 95% CI 0.96-1.35), syncope, (OR = 1.24, 95% CI 0.55-2.77), and dizziness (OR = 1.28, 95% CI 0.82-1.99) among β-blocker users. CONCLUSIONS Considered alongside prior evidence that β-blockers may worsen functional outcomes in NH residents with poor baseline functional and cognitive status, our results suggest that providers should exercise caution when prescribing for these vulnerable groups, balancing the mortality benefit against the potential for causing adverse events.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Rhode Island
- Department of Pharmacy, Rhode Island Hospital, Providence
| | - Matthew Olean
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Department of Pharmacy, Rhode Island Hospital, Providence
- University of Rhode Island College of Pharmacy, Kingston
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Jennifer Tjia
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center
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17
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Zullo AR, Hersey M, Lee Y, Sharmin S, Bosco E, Daiello LA, Shah NR, Mor V, Boscardin WJ, Berard-Collins CM, Dore DD, Steinman MA. Outcomes of "diabetes-friendly" vs "diabetes-unfriendly" β-blockers in older nursing home residents with diabetes after acute myocardial infarction. Diabetes Obes Metab 2018; 20:2724-2732. [PMID: 29952104 PMCID: PMC6231977 DOI: 10.1111/dom.13451] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/20/2018] [Accepted: 06/24/2018] [Indexed: 12/11/2022]
Abstract
AIMS To assess whether nursing home (NH) residents with type 2 diabetes mellitus (T2D) preferentially received "T2D-friendly" (vs "T2D-unfriendly") β-blockers after acute myocardial infarction (AMI), and to evaluate the comparative effects of the two groups of β-blockers. MATERIALS AND METHODS This new-user retrospective cohort study of NH residents with AMI from May 2007 to March 2010 used national data from the Minimum Data Set and Medicare system. T2D-friendly β-blockers were those hypothesized to increase peripheral glucose uptake through vasodilation: carvedilol, nebivolol and labetalol. Primary outcomes were hospitalizations for hypoglycaemia and hyperglycaemia in the 90 days after AMI. Secondary outcomes were functional decline, death, all-cause re-hospitalization and fracture hospitalization. We compared outcomes using binomial and multinomial logistic regression models after propensity score matching. RESULTS Of 2855 NH residents with T2D, 29% initiated a T2D-friendly β-blocker vs 24% of 6098 without T2D (P < 0.001). For primary outcomes among residents with T2D, T2D-friendly vs T2D-unfriendly β-blockers were associated with a reduction in hospitalized hyperglycaemia (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.21-0.97), but unassociated with hypoglycaemia (OR 2.05, 95% CI 0.82-5.10). For secondary outcomes, T2D-friendly β-blockers were associated with a greater rate of re-hospitalization (OR 1.26, 95% CI 1.01-1.57), but not death (OR 1.06, 95% CI 0.85-1.32), functional decline (OR 0.91, 95% CI 0.70-1.19), or fracture (OR 1.69, 95% CI 0.40-7.08). CONCLUSIONS In older NH residents with T2D, T2D-friendly β-blocker use was associated with a lower rate of hospitalization for hyperglycaemia, but a higher rate of all-cause re-hospitalization.
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Affiliation(s)
- Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Department of Pharmacy, Rhode Island Hospital, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Michelle Hersey
- Department of Pharmacy, Rhode Island Hospital, Providence, RI
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Sadia Sharmin
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Elliott Bosco
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Lori A. Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Nishant R. Shah
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | | | - David D. Dore
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Optum Epidemiology, Boston, MA
| | - Michael A. Steinman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
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