Family history of cardiovascular disease and influence on statin therapy persistence

Purpose

Persistence to statins is low, presumably due to lack of perception of risk. Having a close relative suffering from cardiovascular disease (CVD) might increase persistence to statins. We investigated whether family history of CVD influences the discontinuation of statin treatment.

Methods

A population-based cohort study was performed. Swedish registers on dispensed drugs, hospitalization and cause of death were linked to the Multi-generation Register. Incident statin users 20–72 years of age were identified between 2006 and 2007 and followed until 30 June 2009. Family history of CVD was defined as the presence of relatives with a previous cardiovascular event. Cox regression was used to study discontinuation and estimate the effect of the family history of CVD, adjusting for gender, age, education, income, healthcare provider, prevention’s type, birth’s country and residence’s county. Stratified analysis by type and severity of cardiovascular event was performed.

Results

A total of 86,002 patients were enrolled; 61.5 % had a family history of CVD. Discontinuation of statin therapy was not associated with family history of CVD (HR: 0.98; 95 % CI:0.96–1.01), except for patients with a family history of death from myocardial infarction (MI) (HR: 0.95 95 % CI:0.92–0.98). Young age, foreign background, low income, and statin for primary prevention and for secondary prevention when prescribed by a general practitioner were associated with higher risk of statin discontinuation.

Conclusions

Having relatives suffering from CVD did not consistently influence the persistence to statin treatment. A family history of death from MI had a slight significant positive effect on statin persistence, though not clinically relevant.     

Implementation of a Pharmacist-Led Clinic for Hypertensive Patients in Primary Care – A Pilot Study

Objectives:To implement a pharmacist-led Hypertension Management Clinic in one general medical practice. To evaluate the impact of the clinic on blood pressure (BP) control and prevention of coronary heart disease (CHD). Method:A total of 242 patients attended the pharmacist-led hypertension clinic over a 10-month period. Lifestyle and drug therapy alterations were implemented to achieve British Hypertension Society (BHS) target level BP. A sub-group of 160 patients were used to compare BP control in the clinic setting against that with the general practitioner (GP). Assessment was made of 10-year CHD risk in patients with no artherosclerotic disease. Patients with underlying artherosclerotic disease were prescribed statins, and antiplatelet drugs where indicated. Main outcome measures:Changes in numbers of hypertensive patients meeting the BHS target level BP. Changes in prescribing of antiplatelet agents and statins for primary and secondary prevention of artherosclerosis. Results:In 206 patients with established hypertension, the number achieving target level BPs increased from 74 (36%) pre-clinic to 174 (85%) post-clinic; P < 0.001 chi-squared test. After attending the clinic, for 5 months 74 patients (80%) achieved target level BP in the clinic compared with 27 (40%) with standard GP care; P < 0.001 chi-squared test. Of 188 patients assessed for primary prevention therapy, 126 (67%) required treatment with aspirin and 37 (20%) with a statin. Post-clinic 101 (80%) received aspirin compared with 17 (13%) pre-clinic and 34 (92%) received a statin in comparison with 4 (11%) pre-clinic; both P < 0.001 chi-squared test.A total of 52 (96%) of 54 patients received an antiplatelet agent for secondary prevention of artherosclerosis compared with 40 patients (74%) pre-clinic. Thirty six of 54 patients required a statin for secondary prevention. Thirty five patients (97%) received a statin compared with 23 (64%) pre-clinic; both P < 0.01 chi-squared test. Conclusion:Implementation of a pharmacist-led clinic improved blood pressure control and appropriate prescribing of antiplatelet agents and statins for primary prevention of CHD and secondary prevention of artherosclerosis.     

Managing hyperlipidemia: current and future roles of HMG-CoA reductase inhibitors.

The current and future roles of statins as antilipemic agents for the prevention and management of coronary artery disease (CAD) are reviewed. Therapy with hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) substantially reduces total cholesterol and low-density-lipoprotein (LDL) cholesterol concentrations. Large clinical trials have documented the efficacy of statin therapy for both primary and secondary prevention of CAD. Nevertheless, many eligible patients are either untreated or inadequately treated with these agents. In one study, 61% of patients with documented CAD were not treated with a lipid-lowering agent. Large percentages of high-risk patients receiving such agents are not meeting cholesterol goals set by the National Cholesterol Education Program (NCEP). Populations at increased risk for coronary events include patients with diabetes, women, the elderly, and patients with established CAD. Comparative studies have not shown any one agent as clearly superior to the others. Future possibilities for statin use include early treatment of hypercholesterolemia and acute coronary syndromes consistent with guidelines established by NCEP. Many clinicians now believe that an aggressive approach to lowering LDL cholesterol may yield even greater reductions in coronary events. Treatment may reduce the risk of recurrent ischemic events when initiated within 96 hours of hospitalization for acute myocardial infarction or unstable angina and continued for up to four months. Another use may be the management of atherosclerotic cerebrovascular disease. Closer attention to potential adverse effects will be necessary before any expansion in statin use. Statins are highly effective for improving cardiovascular outcomes in high-risk patients but are frequently underused. Pharmacists can help extend the benefits of statins to more patients.     

Persistence of atorvastatin and simvastatin among patients with and without prior cardiovascular diseases: a US managed care study

ABSTRACT

Background: In clinical practice, persistence with statin therapy is poor. While little is known about relative persistence to specific statins, previous studies have observed greater persistence in patients who achieve greater degrees of lipid lowering. Identification of statin therapies which improve patient persistence has the potential to improve the quality of patient care and clinical outcomes. Therefore, we assessed patient persistence with atorvastatin and simvastatin in primary and secondary prevention patients enrolled in managed care.

Methods: New statin users aged ≥18 years, both with and without prior cardiovascular (CV) events within the 12 month pre-treatment period, were identified from a large national database of managed care patients. Patients initiated atorvastatin or simvastatin therapy from January 1, 2003 to September 30, 2005 and were continuously enrolled in a covered plan for at least 12 months before and after initiation of statin therapy. Subanalyses of patients ≥65 years were also conducted. Measures of interest included demographic and clinical characteristics of the study samples and persistence of statin utilization over the 1-year follow-up period. Persistence was defined as the number of days a patient remained on treatment in the first year following their index date, measured from the date of first fill to study end or the date of discontinuation.

Results: A total of 129 764 atorvastatin users and 45 558 simvastatin users without prior CV events were included in the study. For those patients with prior CV events, a total of 6888 atorvastatin users and 4443 simvastatin users were included in the study. Median persistence in patients without prior CV events was 50 days longer for patients initiating therapy with atorvastatin than simvastatin (207 vs. 157 days, p < 0.0001) and after adjusting for confounding factors, those treated with atorvastatin were 15% less likely to discontinue therapy during the first year than those treated with simvastatin (HR = 0.85; 95% CI 0.84, 0.86; p < 0.001). In secondary prevention patients median persistence was 85 days longer in atorvastatin patients than simvastatin patients (266 vs. 181 days, p < 0.0001) and atorvastatin patients were 22% less likely to discontinue therapy (HR = 0.78; 95% CI 0.75, 0.82; p < 0.001). Persistence was worse in the elderly patients, but the relative difference between atorvastatin and simvastatin was similar to the overall patient population.

Conclusions: In patients with and without prior CV disease, persistence is generally poor, even worse in the elderly, but significantly better for atorvastatin patients than simvastatin patients (p < 0.001). Further studies are required to determine whether this is due to differences in cost, effectiveness, side-effects, or other attributes of the statins.

Study limitations: Differences in persistence could be, in part, due to unmeasured confounders although all available variables were adjusted in multivariate analyses. Additionally, the claims database lacks some clinical data such as lipid levels, limiting assessments of statin efficacy, and does not include any reasons for discontinuation of therapy.     

Prescribing behaviour according to Dutch and European guidelines on the management of hypercholesterolaemia (1992-1999)

BACKGROUND: The success of the full implementation of a new guideline may depend on the observed discrepancy between daily medical practice developed before the release of the guideline and new treatment recommendations issued by the guideline. AIM: To assess whether the initiation of statin treatment for primary prevention of cardiovascular disease in an elderly population was in agreement with guidelines. METHODS: Data were obtained from the Rotterdam Study, a prospective population-based cohort study consisting of 7983 subjects aged>or=55 years. In the period 1992-1999, all patients starting statins for primary prevention were selected. Treatment eligibility was established according to Dutch guidelines based on considerations of cost effectiveness (1998) and European guidelines based on clinical effectiveness (1998 and 2003). RESULTS: Only 5.7% [95% confidence interval (CI) 3.1, 8.3] of the 299 subjects starting statins for primary prevention met the eligibility criteria of the Dutch guidelines. Most patients (92.0%, 95% CI 88.9, 95.1) met the criteria of the 2003 European guidelines. Patients who did not meet any eligibility criteria were female and had one or less cardiovascular risk factor, except for two patients with total cholesterol levels<5 mmol l-1 prior to start of statin therapy. CONCLUSIONS: The use of statins was in agreement with the most recent European guidelines in over 90% of elderly patients who started statins for primary prevention, but in only 6% of these patients according to the Dutch guidelines. As long as existing guidelines are as discrepant as they are now, variation in agreement between physicians' prescribing and guideline recommendations is unavoidable.     

Current practice in the treatment of hyperlipidaemias

Primary and secondary prevention trials for coronary heart disease (CHD) in hyperlipidaemic or so-called 'normolipidaemic' patients with drugs affecting lipid metabolism have clearly confirmed that even slight alterations in lipoprotein metabolism are major risk factors for CHD. The global cardiovascular risk must be determined before deciding to treat patients with drugs affecting lipid metabolism. Screening for dyslipidaemia consists of determining cholesterol (C), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C) and triglyceride (TG) plasma levels and the decision to treat depends mainly on LDL-C plasma levels. Furthermore, secondary dyslipidaemia must be diagnosed and primary disease must be adequately treated. There are four classes of available lipid-regulating drugs: HMG-CoA reductase inhibitors (statins), bile acid sequestrants (resins), peroxisome proliferator-activated receptor-alpha (PPAR- alpha) activators (fibrates) and nicotinic acid. All four will be discussed in this review. Clinical trials have shown that drugs improving lipid metabolism reduce CHD relative risk from 24% (secondary prevention) to 37% (primary prevention) and the absolute risk from 2% (primary prevention) to 8.5% (secondary prevention). These studies indicate that the number of patients needed to be treated to economise one clinical event ranges from 12 (secondary prevention) to 50 (primary prevention). Clinical trials are currently testing the hypothesis that 'lower LDL-C is better'.     

Meta‐analysis of the role of high‐dose statins administered prior to percutaneous coronary intervention in reducing major adverse cardiac events in patients with coronary artery disease

1. There is considerable evidence regarding the efficacy of statins for the primary and secondary prevention of coronary artery disease (CAD). However, due to lack of sufficient evidence, there is still doubt whether high‐dose statin therapy prior to percutaneous coronary intervention (PCI) is beneficial. In the present study, we performed a meta‐analysis to evaluate the effect of preoperative high‐dose statin therapy on the incidence of major adverse cardiac events (MACE) after successful PCI. 2. Trials were retrieved through Medline (1980–2009) and the reference files limited to English‐language articles. Data were abstracted using a standardized protocol and a meta‐analysis was performed. 3. Five studies of a total 1789 patients with CAD qualified for analysis. Administration of high‐dose statins in CAD patients before PCI was associated with a significant reduction in MACE 30 days after the procedure. The incidence of MACE in the high‐dose statin group (6.98%) was significantly lower than that in the placebo group (14.77%), with an odds ratio (OR) of 0.43 (95% confidence interval (CI) 0.31–0.59; P < 0.00001). The incidence of post‐PCI increases in creatine kinase MB in the high‐dose statin and placebo groups was 9.20%vs 18.83%, respectively (OR 0.43; 95% CI 0.33–0.58; P < 0.00001), whereas the incidence of increases in troponin I was 30.13%vs 44.53%, respectively (OR 0.53; 95% CI 0.43–0.67; P < 0.00001), respectively. 4. In conclusion, high‐dose statin therapy before PCI provides a significant benefit over placebo in preventing post‐PCI MACE. Findings from the present analysis strongly support a strategy of routine loading of high‐dose statins before interventional therapy.     

Current practice in the treatment of hyperlipidaemias

Primary and secondary prevention trials for coronary heart disease (CHD) in hyperlipidaemic or so-called ‘normolipidaemic’ patients with drugs affecting lipid metabolism have clearly confirmed that even slight alterations in lipoprotein metabolism are major risk factors for CHD. The global cardiovascular risk must be determined before deciding to treat patients with drugs affecting lipid metabolism. Screening for dyslipidaemia consists of determining cholesterol (C), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C) and triglyceride (TG) plasma levels and the decision to treat depends mainly on LDL-C plasma levels. Furthermore, secondary dyslipidaemia must be diagnosed and primary disease must be adequately treated. There are four classes of available lipid-regulating drugs: HMG-CoA reductase inhibitors (statins), bile acid sequestrants (resins), peroxisome proliferator-activated receptor-α (PPAR-α) activators (fibrates) and nicotinic acid. All four will be discussed in this review. Clinical trials have shown that drugs improving lipid metabolism reduce CHD relative risk from 24% (secondary prevention) to 37% (primary prevention) and the absolute risk from 2% (primary prevention) to 8.5% (secondary prevention). These studies indicate that the number of patients needed to be treated to economise one clinical event ranges from 12 (secondary prevention) to 50 (primary prevention). Clinical trials are currently testing the hypothesis that ‘lower LDL-C is better’.     

Five-year follow-up of drug utilization for secondary prevention in coronary artery disease

Objective Despite the availability of various prevention guidelines on coronary artery disease, secondary prevention practice utilizing aspirin, beta-blockers, angiotensin converting enzyme inhibitors and statins still can be sub-optimal. In this study, we aimed to assess the guideline adherence of secondary prevention prescribing and the continuity of adherence for a 5-year period in a small cohort of patients angiographically diagnosed to have coronary artery disease. Method In this prospective study, 73 patients who were angiographically diagnosed to have CAD were followed up for 5 years. The baseline demographic and clinical data were collected just before angiography. The baseline drug data were collected at the day of discharge. The fifth year data were taken from the patients via face-to-face consultations or phone interviews. Results The ‘initial prescribing rate’ at discharge was found to be 82% for aspirin, 49% for statins, 44% for ACE inhibitors and 55% for beta-blockers. ‘Continuity of prescribing’ for 5 years was 45% for aspirin, 26% for statins, 17% for ACE inhibitors and 20% for beta-blockers. Conclusions Besides the sub-optimal prescribing of secondary prevention drugs, absence of continuity of prescribing seems to be a challenging issue in pharmaceutical care of coronary artery disease patients.