Treating Dyslipidemias in the Primary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults with Diabetes Mellitus

Aspirin is the cornerstone of the antithrombotic management of patients with established atherosclerotic cardiovascular disease, but major guidelines provide conflicting recommendations for its use in primary prevention. Findings from recent randomized trials totaling >47 000 patients called into question the net clinical benefits of aspirin in primary prevention for 3 key populations: patients with diabetes mellitus, community-dwelling elderly individuals, and patients without diabetes mellitus who are at intermediate risk for atherosclerotic events. In the context of increasing emphasis on the use of other treatments for primary prevention in patients with moderate-high future risk of developing atherosclerotic cardiovascular disease, the efficacy and safety of aspirin for primary prevention has become uncertain. Key unresolved questions regarding the role of aspirin in primary prevention include the optimal drug formulation, dosing schedule, weight-based dose selection, and interplay between sex and treatment response. In the current era, most patients without established atherosclerotic cardiovascular disease should not be prescribed aspirin. Rather, aggressive management of comorbidities tailored to the expected cardiovascular risk needs to be emphasized. In this context, informed shared decision making between clinicians and patients regarding the use of aspirin for primary prevention of cardiovascular events is a suitable and laudable approach. In this article, we revisit the role of aspirin for the primary prevention of cardiovascular diseases by critically reviewing the key scientific literature, highlight key areas of uncertainties for future research, and propose a decisional framework for clinicians to support prescription of aspirin in primary prevention.

Download Full-text

Coronary Artery Calcium for the Allocation of GLP-1RA for Primary Prevention of Atherosclerotic Cardiovascular Disease

JACC Cardiovascular Imaging ◽

10.1016/j.jcmg.2020.12.024 ◽

2021 ◽

Author(s):

Miguel Cainzos-Achirica ◽

Kershaw V. Patel ◽

Renato Quispe ◽

Parag H. Joshi ◽

Amit Khera ◽

...

Keyword(s):

Cardiovascular Disease ◽

Coronary Artery ◽

Primary Prevention ◽

Coronary Artery Calcium ◽

Atherosclerotic Cardiovascular Disease

Download Full-text

Statin Use in Older Adults with Stable Atherosclerotic Cardiovascular Disease

Journal of the American Geriatrics Society ◽

10.1111/jgs.16975 ◽

2021 ◽

Author(s):

Gabriela Spencer‐Bonilla ◽

Sukyung Chung ◽

Ashish Sarraju ◽

Paul Heidenreich ◽

Latha Palaniappan ◽

...

Keyword(s):

Cardiovascular Disease ◽

Older Adults ◽

Atherosclerotic Cardiovascular Disease ◽

Statin Use

Download Full-text

Role of coronary artery calcium score in the primary prevention of cardiovascular disease

BMJ ◽

10.1136/bmj.n776 ◽

2021 ◽

pp. n776

Author(s):

Khurram Nasir ◽

Miguel Cainzos-Achirica

Keyword(s):

Cardiovascular Disease ◽

Coronary Artery ◽

Primary Prevention ◽

Coronary Artery Calcium ◽

Calcium Score ◽

Coronary Plaque ◽

Preventive Therapy ◽

Atherosclerotic Cardiovascular Disease ◽

International Studies

Abstract First developed in 1990, the Agatston coronary artery calcium (CAC) score is an international guideline-endorsed decision aid for further risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease. This review discusses key international studies that have informed this 30 year journey, from an initial coronary plaque screening paradigm to its current role informing personalized shared decision making. Special attention is paid to the prognostic value of a CAC score of zero (the so called “power of zero”), which, in a context of low estimated risk thresholds for the consideration of preventive therapy with statins in current guidelines, may be used to de-risk individuals and thereby inform the safe delay or avoidance of certain preventive therapies. We also evaluate current recommendations for CAC scoring in clinical practice guidelines around the world, and past and prevailing barriers for its use in routine patient care. Finally, we discuss emerging approaches in this field, with a focus on the potential role of CAC informing not only the personalized allocation of statins and aspirin in the general population, but also of other risk-reduction therapies in special populations, such as individuals with diabetes and people with severe hypercholesterolemia.

Download Full-text

Association between refill adherence to lipid-lowering medications and the risk of cardiovascular disease and mortality in Swedish patients with type 2 diabetes mellitus: a nationwide cohort study

BMJ Open ◽

10.1136/bmjopen-2017-020309 ◽

2018 ◽

Vol 8 (3) ◽

pp. e020309 ◽

Cited By ~ 7

Author(s):

Sofia Axia Karlsson ◽

Christel Hero ◽

Ann-Marie Svensson ◽

Stefan Franzén ◽

Mervete Miftaraj ◽

...

Keyword(s):

Diabetes Mellitus ◽

Type 2 Diabetes ◽

Cardiovascular Disease ◽

Type 2 Diabetes Mellitus ◽

Primary Prevention ◽

Secondary Prevention ◽

Exposure Period ◽

Lipid Lowering ◽

Refill Adherence

ObjectivesTo analyse the association between refill adherence to lipid-lowering medications, and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes mellitus.DesignCohort study.SettingNational population-based cohort of Swedish patients with type 2 diabetes mellitus.Participants86 568 patients aged ≥18 years, registered with type 2 diabetes mellitus in the Swedish National Diabetes Register, who filled at least one prescription for lipid-lowering medication use during 2007–2010, 87% for primary prevention.Exposure and outcome measuresRefill adherence of implementation was assessed using the medication possession ratio (MPR), representing the proportion of days with medications on hand during an 18-month exposure period. MPR was categorised by five levels (≤20%, 21%–40%, 41%–60%, 61%–80% and >80%). Patients without medications on hand for ≥180 days were defined as non-persistent. Risk of CVD (myocardial infarction, ischaemic heart disease, stroke and unstable angina) and mortality by level of MPR and persistence was analysed after the exposure period using Cox proportional hazards regression and Kaplan-Meier, adjusted for demographics, socioeconomic status, concurrent medications and clinical characteristics.ResultsThe hazard ratios for CVD ranged 1.33–2.36 in primary prevention patients and 1.19–1.58 in secondary prevention patients, for those with MPR ≤80% (p<0.0001). The mortality risk was similar regardless of MPR level. The CVD risk was 74% higher in primary prevention patients and 33% higher in secondary prevention patients, for those who were non-persistent (p<0.0001). The mortality risk was 6% higher in primary prevention patients and 18% higher in secondary prevention patients, for non-persistent patients (p<0.0001).ConclusionsHigher refill adherence to lipid-lowering medications was associated with lower risk of CVD in primary and secondary prevention patients with type 2 diabetes mellitus.

Download Full-text