1
|
Brown CJ, Chang LS, Hosomura N, Malmasi S, Morrison F, Shubina M, Lan Z, Turchin A. Assessment of Sex Disparities in Nonacceptance of Statin Therapy and Low-Density Lipoprotein Cholesterol Levels Among Patients at High Cardiovascular Risk. JAMA Netw Open 2023; 6:e231047. [PMID: 36853604 PMCID: PMC9975905 DOI: 10.1001/jamanetworkopen.2023.1047] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
IMPORTANCE Many patients at high cardiovascular risk-women more commonly than men-are not receiving statins. Anecdotally, it is common for patients to not accept statin therapy recommendations by their clinicians. However, population-based data on nonacceptance of statin therapy by patients are lacking. OBJECTIVES To evaluate sex disparities in nonacceptance of statin therapy and assess their association with low-density lipoprotein (LDL) cholesterol control. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted from January 1, 2019, to December 31, 2022, of statin-naive patients with atherosclerotic cardiovascular disease, diabetes, or LDL cholesterol levels of 190 mg/dL (to convert to millimoles per liter, multiply by 0.0259) or more who were treated at Mass General Brigham between January 1, 2000, and December 31, 2018. EXPOSURE Recommendation of statin therapy by the patient's clinician, ascertained from the combination of electronic health record prescription data and natural language processing of electronic clinician notes. MAIN OUTCOMES AND MEASURES Time to achieve an LDL cholesterol level of less than 100 mg/dL. RESULTS Of 24 212 study patients (mean [SD] age, 58.8 [13.0] years; 12 294 women [50.8%]), 5308 (21.9%) did not accept the initial recommendation of statin therapy. Nonacceptance of statin therapy was more common among women than men (24.1% [2957 of 12 294] vs 19.7% [2351 of 11 918]; P < .001) and was similarly higher in every subgroup in the analysis stratified by comorbidities. In multivariable analysis, female sex was associated with lower odds of statin therapy acceptance (0.82 [95% CI, 0.78-0.88]). Patients who did vs did not accept a statin therapy recommendation achieved an LDL cholesterol level of less than 100 mg/dL over a median of 1.5 years (IQR, 0.4-5.5 years) vs 4.4 years (IQR, 1.3-11.1 years) (P < .001). In a multivariable analysis adjusted for demographic characteristics and comorbidities, nonacceptance of statin therapy was associated with a longer time to achieve an LDL cholesterol level of less than 100 mg/dL (hazard ratio, 0.57 [95% CI, 0.55-0.60]). CONCLUSIONS AND RELEVANCE This cohort study suggests that nonacceptance of a statin therapy recommendation was common among patients at high cardiovascular risk and was particularly common among women. It was associated with significantly higher LDL cholesterol levels, potentially increasing the risk for cardiovascular events. Further research is needed to understand the reasons for nonacceptance of statin therapy by patients and to develop methods to ensure that all patients receive optimal therapy in accordance with their preferences and priorities.
Collapse
Affiliation(s)
- C. Justin Brown
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
- Pharmacy Department, Tufts Medical Center, Boston, Massachusetts
| | - Lee-Shing Chang
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Naoshi Hosomura
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Shervin Malmasi
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Amazon.com Inc, Seattle, Washington
| | - Fritha Morrison
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Maria Shubina
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Zhou Lan
- Harvard Medical School, Boston, Massachusetts
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander Turchin
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
2
|
Gynnild MN, Hageman SHJ, Spigset O, Lydersen S, Saltvedt I, Dorresteijn JAN, Visseren FLJ, Ellekjær H. Use of lipid-lowering therapy after ischaemic stroke and expected benefit from intensification of treatment. Open Heart 2022; 9:openhrt-2022-001972. [PMID: 35459718 PMCID: PMC9036470 DOI: 10.1136/openhrt-2022-001972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/05/2022] [Indexed: 12/27/2022] Open
Abstract
Objectives Elevated low-density lipoprotein cholesterol (LDL-C) increases the risk of recurrent cardiovascular disease (CVD) events. We examined use of lipid-lowering therapy (LLT) following ischaemic stroke, and estimated benefits from guideline-based up-titration of LLT. Methods The Norwegian COgnitive Impairment After STroke (Nor-COAST) study, a multicentre prospective cohort study, collected data on LLT use, dose intensity and LDL-C levels for 462 home-dwelling patients with ischaemic stroke. We used the Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health (SMART-REACH) model to estimate the expected benefit of up-titrating LLT. Results At discharge, 92% received LLT (97% statin monotherapy). Patients with prestroke dementia and cardioembolic stroke aetiology were less likely to receive LLT. Older patients (coefficient −3 mg atorvastatin per 10 years, 95% CI −6 to −0.5) and women (coefficient −5.1 mg atorvastatin, 95% CI −9.2 to −0.9) received lower doses, while individuals with higher baseline LDL-C, ischaemic heart disease and large artery stroke aetiology received higher dose intensity. At 3 months, 45% reached LDL-C ≤1.8 mmol/L, and we estimated that 81% could potentially reach the target with statin and ezetimibe, resulting in median 5 (IQR 0–12) months of CVD-free life gain and median 2% 10-year absolute risk reduction (IQR 0–4) with large interindividual variation. Conclusion Potential for optimisation of conventional LLT use exists in patients with ischaemic stroke. Awareness of groups at risk of undertreatment and objective estimates of the individual patient’s benefit of intensification can help personalise treatment decisions and reduce residual cholesterol risk. Trial registration number NCT02650531.
Collapse
Affiliation(s)
- Mari Nordbø Gynnild
- Department of Neuromedicine and Movement Science, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Trondheim, Norway .,Department of Stroke, Clinic of Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Trondheim, Norway.,Department of Geriatrics, Clinic of Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | | | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Trondheim, Norway.,Department of Stroke, Clinic of Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| |
Collapse
|
3
|
Zhu J, Ma M, Fang J, Bao J, Dong S, Chen N, Guo Y, He L. Prestroke statin use enhances collateralization in acute ischemic stroke patients. Restor Neurol Neurosci 2020; 38:311-321. [PMID: 32925118 DOI: 10.3233/rnn-201012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Statin therapy has been shown to be effective in the prevention of ischemic stroke. In addition, recent studies have suggested that prior statin therapy could lower the initial stroke severity and improve stroke functional outcomes in the event of stroke. It was speculated that prestroke statin use may enhance collateral circulation and result in favorable functional outcomes. OBJECTIVE The aim of the study was to investigate the association of prestroke statin use with leptomeningeal collaterals and to determine the association of prestroke statin use with stroke severity and functional outcome in acute ischemic stroke patients. METHODS We prospectively and consecutively enrolled 239 acute ischemic stroke patients with acute infarction due to occlusion of the middle cerebral artery within 24 h in the neurology department of West China Hospital from May 2011 to April 2017. Computed tomographic angiography (CTA) imaging was performed for all patients to detect middle cerebral artery thrombus; regional leptomeningeal collateral score (rLMCS) was used to assess the degree of collateral circulation; the National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission; the modified Rankin scale (mRS) was used to measure outcome at 90 days; and premorbid medications were recorded. Univariate and multivariate analyses were performed. RESULTS Overall, 239 patients met the inclusion criteria. Fifty-four patients used statins, and 185 did not use statins before stroke onset. Prestroke statin use was independently associated with good collateral circulation (rLMCS > 10) (odds ratio [OR], 4.786; 95% confidence interval [CI], 1.195-19.171; P = 0.027). Prestroke statin use was not independently associated with lower stroke severity (NIHSS score≤14) (OR, 1.955; 95% CI, 0.657-5.816; p = 0.228), but prestroke statin use was independently associated with favorable outcome (mRS score≤2) (OR, 3.868; 95% CI, 1.325-11.289; P = 0.013). CONCLUSIONS Our findings suggest that prestroke statin use was associated with good leptomeningeal collaterals and clinical outcomes in acute ischemic stroke (AIS) patients presenting with occlusion of the middle cerebral artery. However, clinical studies should be conducted to verify this claim.
Collapse
Affiliation(s)
- Jiaying Zhu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, CD, China.,Department of Emergency, Gui Zhou provincial People's Hospital, Guiyang, GY, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, CD, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, CD, China
| | - Jiajia Bao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, CD, China
| | - Shuju Dong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, CD, China
| | - Ning Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, CD, China
| | - Yijia Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, CD, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, CD, China
| |
Collapse
|
4
|
Vitturi BK, Gagliardi RJ. Effects of statin therapy on outcomes of ischemic stroke: a real-world experience in Brazil. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:461-467. [PMID: 32627806 DOI: 10.1590/0004-282x20200027] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/17/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Statin therapy has become one of the most important advances in stroke secondary prevention. OBJECTIVE To provide evidence from real-world data for evaluating detailed associations between secondary prevention of stroke and statin use in Brazil. METHODS We conducted a prospective cohort study including consecutive patients diagnosed with an ischemic stroke. Subjects were classified into non-statin, simvastatin 20 mg, simvastatin 40 mg, and high-potency statin groups. We also registered the onset of statin therapy, previous use of statins, the adherence to medication, and if there was discontinuation of the therapy. After two years, the functional outcome, stroke recurrence, major cardiovascular events, and mortality were assessed. RESULTS Among the 513 patients included in our cohort, there were 96 (18.7%) patients without statins, 169 (32.9%) with simvastatin 20 mg, 202 (39.3%) with simvastatin 40 mg, and 46 (9.0%) with high-potency statins. Patients without statins were at increased risk of stroke recurrence and worse functional outcomes. Concerning etiology, evidence of beneficial use of statins was observed in cases of large-artery atherosclerosis, small-vessel occlusion, and stroke of undetermined cause. Those who presented poor adherence to statins or discontinuation of the treatment had worse prognosis after stroke whereas the early onset of statins use was associated with better outcomes. Patients with simvastatin 40 mg and high-potency statins presented the best functional recovery throughout the follow-up. CONCLUSIONS Statins play an important role in the treatment of ischemic stroke, preventing stroke recurrence and cardiovascular events, and improving functional performance.
Collapse
Affiliation(s)
- Bruno Kusznir Vitturi
- Santa Casa de São Paulo, School of Medical Sciences, Department of Neurology, São Paulo SP, Brazil
| | - Rubens José Gagliardi
- Santa Casa de São Paulo, School of Medical Sciences, Department of Neurology, São Paulo SP, Brazil
| |
Collapse
|
5
|
Tate MJ, Shugart RM, Moraney RA, Brechtel LE, Blum B, Thomas I Nathaniel. Gender and functional outcomes in prestroke depressive patients treated with thrombolytic therapy. FUTURE NEUROLOGY 2020. [DOI: 10.2217/fnl-2019-0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aim: This study investigated the clinical factors associated with functional ambulatory outcomes and gender differences in prestroke depressive patients. Materials & methods: Clinical risk factors associated with improved functional outcomes with recombinant tissue plasminogen activator-treated cohorts were determined using binary logistic regression. Results: In the adjusted analysis, improvement in ambulation was associated with male patients that had higher National Institute of Health stroke scale score (p = 0.04), a stroke history (p = 0.026), lower serum creatinine levels (p = 0.049) and were taking cholesterol reducing medication (p = 0.014). Improvement in females was associated with taking antidepressants (p = 0.027) and having lower National Institute of Health stroke scale score (p = 0.002). Conclusion: Our findings indicate gender disparities between male and female prestroke depressive patients.
Collapse
Affiliation(s)
- Mandy J Tate
- University of South Carolina School of Medicine Greenville, 607 Grove Rd, Greenville, SC 29605, USA
| | - Rachel M Shugart
- University of South Carolina School of Medicine Greenville, 607 Grove Rd, Greenville, SC 29605, USA
| | - Robyn A Moraney
- University of South Carolina School of Medicine Greenville, 607 Grove Rd, Greenville, SC 29605, USA
| | - Leanne E Brechtel
- University of South Carolina School of Medicine Greenville, 607 Grove Rd, Greenville, SC 29605, USA
| | - Brice Blum
- University of South Carolina School of Medicine Greenville, 607 Grove Rd, Greenville, SC 29605, USA
| | - Thomas I Nathaniel
- University of South Carolina School of Medicine Greenville, 607 Grove Rd, Greenville, SC 29605, USA
| |
Collapse
|
6
|
Yeo SH, Toh MPHS, Lee SH, Seet RCS, Wong LY, Yau WP. Temporal Trends and Patient Characteristics Associated With Drug Utilisation After
First-Ever Stroke: Insights From Chronic Disease Registry Data in Singapore. ANNALS ACADEMY OF MEDICINE SINGAPORE 2020. [DOI: 10.47102/annals-acadmedsg.2019196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Data on drug utilisation among stroke patients of Asian ethnicities are
lacking. The objectives of the study were to examine the temporal trends and patient
characteristics associated with prescription of thrombolytic, antithrombotic and statin
medications among patients with first-ever stroke. Materials and Methods: First-ever
ischaemic and haemorrhagic stroke patients admitted to 2 Singapore tertiary hospitals
between 2010‒2014 were included. Data were extracted from the National Healthcare
Group Chronic Disease Management System. Association between drug utilisation and
admission year, as well as characteristics associated with drug use, were explored using multivariable logistic regression. Results: There was an increasing trend in the combined use of all 3 guideline medications in ischaemic stroke patients (P<0.001) ―specifically thrombolytic agents (P <0.001), oral antithrombotics (P = 0.002) and statins (P = 0.003) at discharge. Among antithrombotics, the use of clopidogrel (P <0.001) and aspirinclopidogrel (P <0.001) had increased, whereas prescription of dipyridamole (P <0.001) and aspirin-dipyridamole (P <0.001) had declined. For statins, the increase in atorvastatin prescription (P <0.001) was accompanied by decreasing use of simvastatin (P <0.001). Age, ethnicity and certain comorbidities (hyperlipidaemia, atrial fibrillation and chronic kidney disease) were associated with the combined use of all 3 guideline medications (P <0.05). In haemorrhagic stroke, prescription of statins at discharge were comparatively lower. Conclusion: This study reveals changes in prescription behaviour over time in a multiethnic Asian population with first-ever stroke. Patient characteristics including younger age, Malay ethnicity and certain comorbidities (i.e. hyperlipidaemia, atrial fibrillation) were associated with the combined use of all 3 guideline medications among ischaemic stroke patients.
Key words: Antithrombotics, Asian, Statins, Thrombolytic agents
Collapse
Affiliation(s)
| | - Matthias Paul HS Toh
- National Healthcare Group, Singapore.National University of Singapore, Singapore
| | - Sze Haur Lee
- National Neuroscience Institute (Tan Tock Seng Hospital Campus), Singapore
| | - Raymond CS Seet
- National University of Singapore, Singapore. National University Health System, Singapore
| | | | | |
Collapse
|
7
|
Yeo SH, Yau WP. Temporal Trends and Predictors of Drug Utilization and Outcomes in First-Ever Stroke Patients: A Population-Based Study Using the Singapore Stroke Registry. CNS Drugs 2019; 33:791-815. [PMID: 31313138 DOI: 10.1007/s40263-019-00648-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Drug utilization and outcomes research in multi-ethnic Asian stroke populations is lacking. OBJECTIVES Our objective was to examine temporal trends and predictors of drug utilization and outcomes in a multi-ethnic Asian stroke population. METHODS This registry-based study included ischemic and hemorrhagic first-ever stroke patients hospitalized between 2009 and 2016. Utilization of medications included in-hospital thrombolytic agents, early antithrombotics (antiplatelets, anticoagulants) within 48 h of admission, and antithrombotics and statins at discharge. Outcomes analyzed were in-hospital all-cause mortality; 28-day, 90-day, and 1-year case fatality (CF); and discharge destination. RESULTS Of the 36,615 included patients, 81.6% had ischemic stroke and 18.4% had hemorrhagic stroke (15.5% intracerebral hemorrhage [ICH] and 2.8% subarachnoid hemorrhage [SAH]). For ischemic stroke, the combined use of all three guideline medications (in-hospital thrombolytic therapy, as well as antithrombotics and statins at discharge) increased (P = 0.006). Being on the stroke pathway was associated with prescription of all three guideline medications in ischemic stroke. Decreasing trends for in-hospital mortality, 28-day, 90-day, and 1-year CF and proportion of patients discharged home without rehabilitation appointment were observed in ischemic stroke (P < 0.05) but not in ICH or SAH (apart from 28-day CF). Ischemic stroke patients who received guideline medications were less likely to die or be discharged to nursing homes and chronic sick hospitals. Hemorrhagic stroke patients prescribed statins at discharge were less likely to have 28-day and 1-year CF. CONCLUSIONS Prescription of secondary stroke preventive medications (particularly in ischemic stroke) was associated with more favorable outcomes, highlighting the importance of physician adherence to evidence-based pharmacotherapy.
Collapse
Affiliation(s)
- See-Hwee Yeo
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Republic of Singapore
| | - Wai-Ping Yau
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Republic of Singapore.
| |
Collapse
|
8
|
Ní Chróinín D, Ní Chróinín C, Akijian L, Callaly EL, Hannon N, Kelly L, Marnane M, Merwick Á, Sheehan Ó, Horgan G, Duggan J, Kyne L, Dolan E, Murphy S, Williams D, Kelly PJ. Suboptimal lipid management before and after ischaemic stroke and TIA-the North Dublin Population Stroke Study. Ir J Med Sci 2018; 187:739-746. [PMID: 29368282 DOI: 10.1007/s11845-018-1739-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/02/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few population-based studies have assessed lipid adherence to international guidelines for primary and secondary prevention in stroke/transient ischaemic attack (TIA) patients. AIMS This study aims to evaluate adherence to lipid-lowering therapy (LLT) guidelines amongst patients with ischaemic stroke/TIA. METHODS Using hot and cold pursuit methods from multiple hospital/community sources, all stroke and TIA cases in North Dublin City were prospectively ascertained over a 1-year period. Adherence to National Cholesterol Education Programme (NCEP) III guidelines, before and after index ischaemic stroke/TIA, was assessed. RESULTS Amongst 616 patients (428 ischaemic stroke, 188 TIA), total cholesterol was measured following the qualifying event in 76.5% (471/616) and low-density lipoprotein (LDL) in 60.1% (370/616). At initial stroke/TIA presentation, 54.1% (200/370) met NCEP III LDL goals. Compliance was associated with prior stroke (odds ratio [OR] 2.19, p = 0.02), diabetes (OR 1.91, p = 0.04), hypertension (OR 1.57, p = 0.03), atrial fibrillation (OR 1.78, p = 0.01), pre-event LLT (OR 2.85, p < 0.001) and higher individual LDL goal (p = 0.001). At stroke/TIA onset, 32.7% (195/596) was on LLT. Nonetheless, LDL exceeded individual NCEP goal in 29.2% (56/192); 21.6% (53/245) warranting LLT was not on treatment prior to stroke/TIA onset. After index stroke/TIA, 75.9% (422/556) was on LLT; 15.3% (30/196) meeting NCEP III criteria was not prescribed a statin as recommended. By 2 years, actuarial survival was 72.8% and 11.9% (59/497) experienced stroke recurrence. No association was observed between initial post-event target adherence and 2-year outcomes. CONCLUSIONS In this population-based study, LLT recommended by international guidelines was under-used, before and after index stroke/TIA. Strategies to improve adherence are needed.
Collapse
Affiliation(s)
- Danielle Ní Chróinín
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland.
| | | | - Layan Akijian
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Elizabeth L Callaly
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Niamh Hannon
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Lisa Kelly
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Michael Marnane
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Áine Merwick
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Órla Sheehan
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Gillian Horgan
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Joseph Duggan
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Lorraine Kyne
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - Eamon Dolan
- Stroke and Hypertension Unit, Connolly Memorial Hospital, Dublin, Ireland
| | - Seán Murphy
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| | - David Williams
- Department of Geriatric and Stroke Medicine, Beaumont Hospital/RCSI, Dublin 9, Ireland
| | - Peter J Kelly
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital/University College Dublin at Dublin Academic Medical Centre, Dublin 7, Ireland
| |
Collapse
|
9
|
Secondary CV Prevention in South America in a Community Setting: The PURE Study. Glob Heart 2016; 12:305-313. [PMID: 27773540 DOI: 10.1016/j.gheart.2016.06.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 06/11/2016] [Accepted: 06/15/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Despite the availability of evidence-based therapies, there is no information on the use of medications for the secondary prevention of cardiovascular disease in urban and rural community settings in South America. OBJECTIVES This study sought to assess the use, and its predictors, of effective secondary prevention therapies in individuals with a history of coronary heart disease (CHD) or stroke. METHODS In the PURE (Prospective Urban Rural Epidemiological) study, we enrolled 24,713 individuals from South America ages 35 to 70 years from 97 rural and urban communities in Argentina, Brazil, Chile, and Colombia. We assessed the use of proven therapies with standardized questionnaires. We report estimates of drug use at national, community, and individual levels and the independent predictors of their utilization through a multivariable analysis model. RESULTS Of 24,713 individuals, 910 had a self-reported CHD event (at a median of 5 years earlier) and 407 had stroke (6 years earlier). The proportions of individuals with CHD who received antiplatelet medications (30.1%), beta-blockers (34.2%), angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers (36.0%), or statins (18.0%) were low; with even lower proportions among stroke patients (antiplatelets 24.3%, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers 37.6%, statins 9.8%). A substantial proportion of patients did not receive any proven therapy (CHD 31%, stroke 54%). A minority of patients received either all 4 (4.1%) or 3 proven therapies (3.3%). Male sex, age >60 years, better education, more wealth, urban location, diabetes, and obesity were associated with higher rates of medication use. In a multivariable model, markers of wealth had the largest impact in secondary prevention. CONCLUSIONS There are large gaps in the use of proven medications for secondary prevention of cardiovascular disease in South America. Strategies to improve the sustained use of these medications will likely reduce cardiovascular disease burden substantially.
Collapse
|
10
|
Bembenek JP, Karlinski M, Kurkowska-Jastrzebska I, Czlonkowska A. Changes in pre-hospital management of vascular risk factors among patients admitted due to recurrent stroke in Poland from 1995 to 2013. Arch Med Sci 2016; 12:754-9. [PMID: 27482236 PMCID: PMC4947623 DOI: 10.5114/aoms.2016.60963] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/01/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of this study was to investigate long-term trends in secondary stroke prevention through management of vascular risk factors directly before hospital admission for recurrent stroke. MATERIAL AND METHODS This is a retrospective registry-based analysis of consecutive recurrent acute stroke patients from a highly urbanized area (Warsaw, Poland) admitted to a single stroke center between 1995 and 2013 with previous ischemic stroke. We compared between four consecutive time periods: 1995-1999, 2000-2004, 2005-2009 and 2010-2013. RESULTS During the study period, 894 patients with recurrent strokes were admitted (18% of all strokes), including 867 with previous ischemic stroke (our study group). Among those patients, the proportion of recurrent ischemic strokes (88.1% to 93.9%) (p = 0.319) and males (44% to 49.7%) (p = 0.5) remained stable. However, there was a rising trend in patients' age (median age of 73, 74, 76 and 77 years, respectively). There was also an increase in the use of antihypertensives (from 70.2% to 83.8%) (p = 0.013), vitamin K antagonists (from 4.8% to 15.6%) (p = 0.012) and statins (from 32.5% to 59.4%) (p < 0.001). Nonetheless, 21% of patients did not receive any antithrombotic prophylaxis. Tobacco smoking pattern remained unchanged. CONCLUSIONS Our data indicate a clear overall improvement of secondary stroke prevention. However, persistent use of antithrombotic drugs and tobacco smoking after the first ischemic stroke is constantly suboptimal.
Collapse
Affiliation(s)
- Jan P. Bembenek
- Department of Neurophysiology, Institute of Psychiatry and
Neurology, Warsaw, Poland
| | - Michał Karlinski
- 2 Department of Neurology, Institute of Psychiatry and
Neurology, Warsaw, Poland
| | - Iwona Kurkowska-Jastrzebska
- 2 Department of Neurology, Institute of Psychiatry and
Neurology, Warsaw, Poland
- Department of Experimental and Clinical Pharmacology, Medical
University of Warsaw, Warsaw, Poland
| | - Anna Czlonkowska
- 2 Department of Neurology, Institute of Psychiatry and
Neurology, Warsaw, Poland
- Department of Experimental and Clinical Pharmacology, Medical
University of Warsaw, Warsaw, Poland
| |
Collapse
|
11
|
Karmali KN, Lee JY, Brown T, Persell SD. Predictors of cholesterol treatment discussions and statin prescribing for primary cardiovascular disease prevention in community health centers. Prev Med 2016; 88:176-81. [PMID: 27090436 PMCID: PMC5040465 DOI: 10.1016/j.ypmed.2016.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/05/2016] [Accepted: 04/12/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although cholesterol guidelines emphasize cardiovascular disease (CVD) risk to guide primary prevention, predictors of statin use in practice are unknown. We aimed to identify factors associated with a cholesterol treatment discussion and statin prescribing in a high-risk population. METHODS We used data from a trial conducted among participants in community health centers without CVD or diabetes and a 10-year coronary heart disease (CHD) risk≥10%. Cholesterol treatment discussion was assessed at 6months and statin prescription at 1year. We used logistic regressions to identify factors associated with each outcome. RESULTS We analyzed 646 participants (89% male, mean age 60±9.5years). Cholesterol treatment discussion occurred in 19% and statin prescription in 12% of participants. Ten-year CHD risk was not associated with treatment discussion (OR 1.11 per 1 SD increase, 95% CI 0.91-1.33) but was associated with statin prescription (OR 1.41 per 1 SD increase, 95% CI 1.13-1.75) in unadjusted models. After adjusting for traditional CVD risk factors that contribute to CHD risk, low-density lipoprotein cholesterol (LDL-C) was independently associated with statin prescription (OR 1.82 per 1 SD increase, 95% CI 1.66-1.99). Antihypertensive medication use was independently associated with both cholesterol treatment discussion (OR 3.68, 95% CI 2.35-5.75) and statin prescription (OR 3.98, 95% CI 3.30-4.81). Other drivers of CVD risk (age, smoking, and systolic blood pressure) were not associated with statin use. CONCLUSIONS Single risk factor management strongly influences cholesterol treatment discussions and statin prescribing patterns. Interventions that promote risk-based statin utilization are needed. TRIAL REGISTRATION Clinicaltrials.gov.: NCT01610609.
Collapse
Affiliation(s)
- Kunal N Karmali
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ji-Young Lee
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.
| |
Collapse
|