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Omar Khader A, van Trier T, van der Brug S, Liem AH, Groenemeijer BE, Schut A, Jorstad HT, Martens FMAC, Alings MAMW. Effects of a stepwise, structured LDL-C lowering strategy in patients post-acute coronary syndrome. Neth Heart J 2024; 32:206-212. [PMID: 38277062 DOI: 10.1007/s12471-023-01851-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/27/2024] Open
Abstract
OBJECTIVE Low-density lipoprotein cholesterol (LDL-C) lowering constitutes a cornerstone of secondary prevention of atherosclerotic cardiovascular disease (ASCVD), yet a considerable number of patients do not achieve guideline-recommended LDL‑C targets. The 2016 European guidelines recommended titration of LDL‑C lowering medication in a set number of steps, starting with oral medication. We aimed to investigate the effects of this stepwise approach in post-acute coronary syndrome (ACS) patients. METHODS In a multicentre, prospective, non-randomised trial, we evaluated a three-step strategy aiming to reduce LDL‑C to ≤ 1.8 mmol/l in post-ACS patients with prior ASCVD and/or diabetes mellitus. Steps, undertaken every 4-6 weeks, included: 1) start high-intensity statin (HIST); 2) addition of ezetimibe; 3) addition of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i). The primary outcome was the proportion of patients achieving LDL-C ≤ 1.8 mmol/l after Steps 1 and 2 (using oral medications alone). Secondary outcomes examined the prevalence of meeting the target throughout all steps ( https://onderzoekmetmensen.nl/nl/trial/21157 ). RESULTS Out of 999 patients, 84% (95% confidence intervals (CI): 81-86) achieved the LDL‑C target using only statin and/or ezetimibe. In an intention-to-treat analysis, the percentages of patients meeting the LDL‑C target after each step were 69% (95% CI: 67-72), 84% (95% CI: 81-86), and 87% (95% CI: 85-89), respectively. There were protocol deviations for 23, 38 and 23 patients at each respective step. CONCLUSION Through stepwise intensification of lipid-lowering therapy, 84% of very high-risk post-ACS patients achieved an LDL‑C target of ≤ 1.8 mmol/l with oral medications alone. Addition of PCSK9i further increased this rate to 87% (95% CI: 85-89).
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Affiliation(s)
- Aaram Omar Khader
- Amphia Hospital, Breda, The Netherlands.
- Cardiovascular Institute, Thorax Center, Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands.
| | - Tinka van Trier
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - An-Ho Liem
- Franciscus Gasthuis, Rotterdam, The Netherlands
- WCN (Workgroup Cardiology Centres Netherlands), Utrecht, The Netherlands
| | - Bjorn E Groenemeijer
- WCN (Workgroup Cardiology Centres Netherlands), Utrecht, The Netherlands
- Gelre Hospitals Apeldoorn, Apeldoorn, The Netherlands
| | - Astrid Schut
- WCN (Workgroup Cardiology Centres Netherlands), Utrecht, The Netherlands
| | - Harald T Jorstad
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Fabrice M A C Martens
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
- WCN (Workgroup Cardiology Centres Netherlands), Utrecht, The Netherlands
- Deventer Hospital, Deventer, The Netherlands
| | - Marco A M W Alings
- Amphia Hospital, Breda, The Netherlands
- WCN (Workgroup Cardiology Centres Netherlands), Utrecht, The Netherlands
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Franchi C, Rossio R, Mandelli S, Ardoino I, Nobili A, Peyvandi F, Mannucci PM. Statins, ACE/ARBs drug use, and risk of pneumonia in hospitalized older patients: a retrospective cohort study. Intern Emerg Med 2024; 19:689-696. [PMID: 38353881 DOI: 10.1007/s11739-023-03528-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/30/2023] [Indexed: 04/24/2024]
Abstract
The aims of this study is to evaluate the association between angiotensin-converting enzyme inhibitor (ACE-I), angiotensin II receptor blocker (ARBs) and/or statin use with the risk of pneumonia, as well as and with in-hospital and short-term outpatient mortality in hospitalized older patients with pneumonia. Patients aged 65 years or older hospitalized in internal medicine and/or geriatric wards throughout Italy and enrolled in the REPOSI (REgistro Politerapuie SIMI-Società Italiana di Medicina Interna) register from 2010 to 2019 were screened to assess the diagnosis of pneumonia and classified on whether or not they were prescribed with at least one drug among ACE-I, ARBs, and/or statins. Further study outcomes were mortality during hospital stay and at 3 months after hospital discharge. Among 5717 cases included (of whom 18.0% with pneumonia), 2915 (51.0%) were prescribed at least one drug among ACE-I, ARBs, and statins. An inverse association was found between treatment with ACE-I or ARBs and pneumonia (OR = 0.79, 95% CI 0.65-0.95). A higher effect was found among patients treated with ACE-I or ARBs in combination with statins (OR = 0.67, 95% CI 0.52-0.85). This study confirmed in the real-world setting that these largely used medications may reduce the risk of pneumonia in older people, who chronically take them for cardiovascular conditions.
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Affiliation(s)
- Carlotta Franchi
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, Italy.
| | - Raffaella Rossio
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sara Mandelli
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Ilaria Ardoino
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Alessandro Nobili
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Ardoino I, Mandelli S, Baviera M, Rossio R, Nobili A, Mannucci PM, Franchi C. Antidiabetic Drug Prescription Pattern in Hospitalized Older Patients with Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2607. [PMID: 36767972 PMCID: PMC9915986 DOI: 10.3390/ijerph20032607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/24/2023] [Accepted: 01/28/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To describe the prescription pattern of antidiabetic and cardiovascular drugs in a cohort of hospitalized older patients with diabetes. METHODS Patients with diabetes aged 65 years or older hospitalized in internal medicine and/or geriatric wards throughout Italy and enrolled in the REPOSI (REgistro POliterapuie SIMI-Società Italiana di Medicina Interna) registry from 2010 to 2019 and discharged alive were included. RESULTS Among 1703 patients with diabetes, 1433 (84.2%) were on treatment with at least one antidiabetic drug at hospital admission, mainly prescribed as monotherapy with insulin (28.3%) or metformin (19.2%). The proportion of treated patients decreased at discharge (N = 1309, 76.9%), with a significant reduction over time. Among those prescribed, the proportion of those with insulin alone increased over time (p = 0.0066), while the proportion of those prescribed sulfonylureas decreased (p < 0.0001). Among patients receiving antidiabetic therapy at discharge, 1063 (81.2%) were also prescribed cardiovascular drugs, mainly with an antihypertensive drug alone or in combination (N = 777, 73.1%). CONCLUSION The management of older patients with diabetes in a hospital setting is often sub-optimal, as shown by the increasing trend in insulin at discharge, even if an overall improvement has been highlighted by the prevalent decrease in sulfonylureas prescription.
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Affiliation(s)
- Ilaria Ardoino
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Sara Mandelli
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Marta Baviera
- Laboratory of Cardiovascular Prevention, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Raffaella Rossio
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alessandro Nobili
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Carlotta Franchi
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
- Italian Institute For Planetary Health (IIPH), 20156 Milan, Italy
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Bertolotti M, Franchi C, Lancellotti G, Mandelli S, Mussi C. Predicting hospital readmissions in older patients with heart failure with advanced bioinformatics tools: focus on the role of vulnerability and frailty. Intern Emerg Med 2022; 17:2403-2405. [PMID: 36149527 PMCID: PMC9652160 DOI: 10.1007/s11739-022-03099-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/05/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Marco Bertolotti
- Division of Geriatrics, Department of Biomedical, Metabolic and Neural Sciences and Center for Gerontological Evaluation and Research, Ospedale Civile di Baggiovara, Università di Modena e Reggio Emilia, Via Giardini, 1355, 41026, Modena, MO, Italy.
| | - Carlotta Franchi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Giulia Lancellotti
- Division of Geriatrics, Department of Biomedical, Metabolic and Neural Sciences and Center for Gerontological Evaluation and Research, Ospedale Civile di Baggiovara, Università di Modena e Reggio Emilia, Via Giardini, 1355, 41026, Modena, MO, Italy
| | - Sara Mandelli
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Chiara Mussi
- Division of Geriatrics, Department of Biomedical, Metabolic and Neural Sciences and Center for Gerontological Evaluation and Research, Ospedale Civile di Baggiovara, Università di Modena e Reggio Emilia, Via Giardini, 1355, 41026, Modena, MO, Italy
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Franchi C, Ludergnani M, Merlino L, Nobili A, Fortino I, Leoni O, Ardoino I. Multiple Medication Adherence and Related Outcomes in Community-Dwelling Older People on Chronic Polypharmacy: A Retrospective Cohort Study on Administrative Claims Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5692. [PMID: 35565087 PMCID: PMC9099923 DOI: 10.3390/ijerph19095692] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 02/01/2023]
Abstract
Poor medication adherence compromises treatment efficacy and adversely affects patients' clinical outcomes. This study aims to assess (1) multiple medication adherence to the most common drug classes chronically prescribed to older people, (2) the factors associated, and (3) the clinical outcomes. This retrospective cohort study included 122,655 community-dwelling patients aged 65-94 years old, newly exposed to chronic polypharmacy, and recorded in the Lombardy Region (northern Italy) administrative database from 2016 to 2018. Multiple medication adherence was assessed for drugs for diabetes, antithrombotics, antihypertensives, statins, and bisphosphonates, by calculating the daily polypharmacy possession ratio (DPPR). One-year mortality, nursing home, emergency department (ED), and hospital admission rates were calculated for 2019. The most prescribed drugs were antihypertensives (89.0%). The mean (std.dev) DPPR was 82.9% (15.6). Being female (OR = 0.85, 95%CI: 0.84-0.86), age ≥85 years (OR = 0.77, 95%CI: 0.76-0.79), and multimorbidity (≥4 diseases, OR = 0.88, 95%CI: 0.86-0.90) were associated with lower medication adherence. A higher DPPR was associated with clinical outcomes-in particular, improved survival (HR = 0.93 for 10/100-point increase, 95%CI: 0.92-0.94) and lower incidence in nursing home admissions (SDHR = 0.95, 95%CI: 0.93-0.97). Adherence to the most common chronic drugs co-prescribed to the older population was high. Better multiple medication adherence was associated with better clinical outcomes.
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Affiliation(s)
- Carlotta Franchi
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy; (A.N.); (I.A.)
| | - Monica Ludergnani
- Direzione Sanitaria—Centro Cardiologico Monzino (I.R.C.C.S.), 20138 Milan, Italy; (M.L.); (L.M.)
| | - Luca Merlino
- Direzione Sanitaria—Centro Cardiologico Monzino (I.R.C.C.S.), 20138 Milan, Italy; (M.L.); (L.M.)
| | - Alessandro Nobili
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy; (A.N.); (I.A.)
| | - Ida Fortino
- Directorate General for Health, Lombardy Region, 20124 Milan, Italy; (I.F.); (O.L.)
| | - Olivia Leoni
- Directorate General for Health, Lombardy Region, 20124 Milan, Italy; (I.F.); (O.L.)
| | - Ilaria Ardoino
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy; (A.N.); (I.A.)
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