Primary care providers should prescribe aspirin to prevent cardiovascular disease based on benefit−risk ratio, not age

Recent guidelines restricted aspirin (ASA) in primary prevention of cardiovascular disease (CVD) to patients <70 years old and more recent guidance to <60.In the most comprehensive prior meta-analysis, the Antithrombotic Trialists Collaboration reported a significant 12% reduction in CVD with similar benefit−risk ratios at older ages. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four trials were added to an updated meta-analysis.ASA produced a statistically significant 13% reduction in CVD with 95% confidence limits (0.83 to 0.92) with similar benefits at older ages in each of the trials.Primary care providers should make individual decisions whether to prescribe ASA based on benefit−risk ratio, not simply age. When the absolute risk of CVD is >10%, benefits of ASA will generally outweigh risks of significant bleeding. ASA should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit such as statins, which are, at the very least, additive to ASA. Our perspective is that individual clinical judgements by primary care providers about prescription of ASA in primary prevention of CVD should be based on our evidence-based solution of weighing all the absolute benefits and risks rather than age. This strategy would do far more good for far more patients as well as far more good than harm in both developed and developing countries. This new and novel strategy for primary care providers to consider in prescribing ASA in primary prevention of CVD is the same as the general approach suggested by Professor Geoffrey Rose decades ago.

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Abstract P720: Primary Stroke Prevention by Primary Care Providers: An Unmet Need

Stroke ◽

10.1161/str.52.suppl_1.p720 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Raymond Reichwein ◽

Alicia Richardson ◽

Cesar Velasco

Keyword(s):

Risk Factors ◽

Primary Care ◽

Primary Prevention ◽

Care Setting ◽

Stroke Risk ◽

Primary Care Setting ◽

Primary Care Providers ◽

Large Vessel ◽

Care Providers ◽

Stroke Risk Factors

Introduction: The majority of patients who present with acute ischemic stroke (AIS) have known stroke risk factors which are not optimally managed. It has been suggested that a CHADS-VASC score can assist with primary prevention by calculating future stroke risk. This however, has not been widely adapted in the primary care setting. Methods: From 2018-2019, 686 AIS patients were included in retrospective analysis. Data elements included: historical stroke risk factors, historical CHADS-VASC score, antiplatelet/anticoagulant use at time of presentation, discharge location, and mRS. Results: Of the 686 AIS patients, 77% were age > 60, and 52% were male. Etiology subtypes were small vessel/lacunar 20%, large vessel 22%, cardioembolic 20%, undetermined 31% (cryptogenic 15%), and other determined 5%. On presentation, the majority of patients had 2 or more stroke risk factors and a calculated historical CHADS-VASC score > 2 (Table 1). Over half of the patients with large vessel or small vessel/lacunar etiology were not on any antiplatelets and 53% of patients with known history of atrial fibrillation weren’t on anticoagulants. Forty-nine percent of patients had a mRS > 3 at discharge. Conclusion: Patients with several stroke risk factors are sub optimally managed by primary care providers. Primary prevention education for PCPs in management of higher stroke risk individuals and additional analysis of the CHADS-VASC tool for this setting is needed. If widely adapted, this tool may prevent strokes by providing adequate risk reduction in the primary care setting.

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A systematic review and meta-analysis of community and primary-care-based hepatitis C testing and treatment services that employ direct acting antiviral drug treatments

BMC Health Services Research ◽

10.1186/s12913-019-4635-7 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 15

Author(s):

Andrew Radley ◽

Emma Robinson ◽

Esther J. Aspinall ◽

Kathryn Angus ◽

Lex Tan ◽

...

Keyword(s):

Primary Care ◽

Hepatitis C ◽

Meta Analysis ◽

Antiviral Drug ◽

Sustained Viral Response ◽

Primary Care Providers ◽

Care Providers ◽

Hcv Treatment ◽

Direct Acting Antiviral ◽

Direct Acting

Abstract Background Direct Acting Antiviral (DAAs) drugs have a much lower burden of treatment and monitoring requirements than regimens containing interferon and ribavirin, and a much higher efficacy in treating hepatitis C (HCV). These characteristics mean that initiating treatment and obtaining a virological cure (Sustained Viral response, SVR) on completion of treatment, in non-specialist environments should be feasible. We investigated the English-language literature evaluating community and primary care-based pathways using DAAs to treat HCV infection. Methods Databases (Cinahl; Embase; Medline; PsycINFO; PubMed) were searched for studies of treatment with DAAs in non-specialist settings to achieve SVR. Relevant studies were identified including those containing a comparison between a community and specialist services where available. A narrative synthesis and linked meta-analysis were performed on suitable studies with a strength of evidence assessment (GRADE). Results Seventeen studies fulfilled the inclusion criteria: five from Australia; two from Canada; two from UK and eight from USA. Seven studies demonstrated use of DAAs in primary care environments; four studies evaluated integrated systems linking specialists with primary care providers; three studies evaluated services in locations providing care to people who inject drugs; two studies evaluated delivery in pharmacies; and one evaluated delivery through telemedicine. Sixteen studies recorded treatment uptake. Patient numbers varied from around 60 participants with pathway studies to several thousand in two large database studies. Most studies recruited less than 500 patients. Five studies reported reduced SVR rates from an intention-to-treat analysis perspective because of loss to follow-up before the final confirmatory SVR test. GRADE assessments were made for uptake of HCV treatment (medium); completion of HCV treatment (low) and achievement of SVR at 12 weeks (medium). Conclusion Services sited in community settings are feasible and can deliver increased uptake of treatment. Such clinics are able to demonstrate similar SVR rates to published studies and real-world clinics in secondary care. Stronger study designs are needed to confirm the precision of effect size seen in current studies. Prospero: CRD42017069873.

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Primary Care Providers Can Help Prevent Cardiovascular Disease in Children—And Their Parents

The Journal of Pediatrics ◽

10.1016/j.jpeds.2011.12.042 ◽

2012 ◽

Vol 160 (4) ◽

pp. 539-540

Author(s):

Reginald L. Washington

Keyword(s):

Cardiovascular Disease ◽

Primary Care ◽

Primary Care Providers ◽

Care Providers

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Abstract P379: Features to Increase Primary Care Provider Referrals to Intensive Behavioral Counseling for Cardiovascular Disease Prevention

Circulation ◽

10.1161/circ.141.suppl_1.p379 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Author(s):

John D Omura ◽

Kathleen B Watson ◽

Fleetwood V Loustalot ◽

Janet E Fulton ◽

Susan A Carlson

Keyword(s):

Physical Activity ◽

Cardiovascular Disease ◽

Primary Care ◽

At Risk ◽

Task Force ◽

Primary Care Providers ◽

Care Providers ◽

Behavioral Counseling ◽

Patients At Risk ◽

Risk Patients

Background: The US Preventive Services Task Force recommends adults with certain cardiovascular disease (CVD) risk factors be offered or referred to intensive behavioral counseling to promote a healthful diet and physical activity for CVD prevention. However, only 1 in 12 primary care providers (PCPs) currently follow this recommendation. This study assessed system and programmatic features PCPs reported would increase their likelihood of referring patients at risk for CVD to intensive behavioral counseling and whether this varied by the percentage of at-risk patients with whom they discuss physical activity. Methods: DocStyles 2018, a web-based panel survey of PCPs, assessed the percentage of at-risk patients with whom PCPs discuss physical activity and the degree to which select features would increase their likelihood of referring to intensive behavioral counseling. Results: Overall, 60.8% of PCPs discussed physical activity with most of their at-risk patients; 21.8% did so with many and 17.4% with few or some. The proportion of PCPs identifying features as increasing their likelihood of referring to intensive behavioral counseling by a great extent ranged from 24.1% for an automated referral in electronic health records, 35.3% for patient progress reports, 41.5% for the program being accredited or evidence-based, to 67.2% for the program having no cost to the patient (Table). These proportions increased for each feature as the percentage of at-risk patients with whom they discuss physical activity increased. Conclusion: PCPs identified programmatic features (i.e. being accredited and of no cost) as having the greatest influence on their likelihood of referring patients at risk for CVD to intensive behavioral counseling, although this varied by the percentage of at-risk patients with whom they discuss physical activity. Findings suggest that the effectiveness of strategies to improve behavioral counseling referrals by PCPs may depend on their current physical activity counseling practices.

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Primary Care Providers’ Awareness of Physical Activity-Related Intensive Behavioral Counseling Services for Cardiovascular Disease Prevention

American Journal of Health Promotion ◽

10.1177/0890117118784226 ◽

2018 ◽

Vol 33 (2) ◽

pp. 208-216 ◽

Cited By ~ 1

Author(s):

John D. Omura ◽

Kathleen B. Watson ◽

Fleetwood Loustalot ◽

Janet E. Fulton ◽

Susan A. Carlson

Keyword(s):

Physical Activity ◽

Cardiovascular Disease ◽

Primary Care ◽

At Risk ◽

Primary Care Providers ◽

The United States ◽

Counseling Services ◽

Care Providers ◽

Behavioral Counseling ◽

Local Services

Purpose: The US Preventive Services Task Force recommends that adults at risk for cardiovascular disease (CVD) be offered or referred to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. We assessed primary care providers’ (PCPs) awareness of local physical activity-related behavioral counseling services, whether this awareness was associated with referring eligible patients, and the types and locations of services to which they referred. Design: Cross-sectional survey. Setting: Primary care providers practicing in the United States. Subjects: 1256 respondents. Measures: DocStyles 2016 survey assessing PCPs’ awareness of and referral to physical activity-related behavioral counseling services. Analysis: Calculated prevalence and adjusted odds ratios (aORs). Results: Overall, 49.9% of PCPs were aware of local services. Only 12.6% referred many or most of their at-risk patients and referral was associated with awareness of local services (aOR = 2.81, [95% confidence interval: 1.85-4.25]). Among those referring patients, services ranged from a health-care worker within their practice or group (25.4%) to an organized program in a medical facility (41.2%). Primary care providers most often referred to services located outside their practice or group (58.1%). Conclusion: About half of PCPs were aware of local behavioral counseling services, and referral was associated with awareness. Establishing local resources and improving PCPs’ awareness of them, especially using community–clinical linkages, may help promote physical activity among adults at risk for CVD.

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Primary care providers' physical activity counseling and referral practices and barriers for cardiovascular disease prevention

Preventive Medicine ◽

10.1016/j.ypmed.2017.12.030 ◽

2018 ◽

Vol 108 ◽

pp. 115-122 ◽

Cited By ~ 13

Author(s):

John D. Omura ◽

Moriah P. Bellissimo ◽

Kathleen B. Watson ◽

Fleetwood Loustalot ◽

Janet E. Fulton ◽

...

Keyword(s):

Physical Activity ◽

Cardiovascular Disease ◽

Primary Care ◽

Disease Prevention ◽

Primary Care Providers ◽

Cardiovascular Disease Prevention ◽

Care Providers ◽

Physical Activity Counseling ◽

Activity Counseling ◽

Referral Practices

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Associations between statins and adverse events in primary prevention of cardiovascular disease: systematic review with pairwise, network, and dose-response meta-analyses

BMJ ◽

10.1136/bmj.n1537 ◽

2021 ◽

pp. n1537

Author(s):

Ting Cai ◽

Lucy Abel ◽

Oliver Langford ◽

Genevieve Monaghan ◽

Jeffrey K Aronson ◽

...

Keyword(s):

Systematic Review ◽

Cardiovascular Disease ◽

Primary Prevention ◽

Adverse Events ◽

Dose Response ◽

Odds Ratio ◽

Absolute Risk ◽

Meta Analysis ◽

Risk Difference ◽

Prevention Of Cardiovascular Disease

Abstract Objective To assess the associations between statins and adverse events in primary prevention of cardiovascular disease and to examine how the associations vary by type and dosage of statins. Design Systematic review and meta-analysis. Data sources Studies were identified from previous systematic reviews and searched in Medline, Embase, and the Cochrane Central Register of Controlled Trials, up to August 2020. Review methods Randomised controlled trials in adults without a history of cardiovascular disease that compared statins with non-statin controls or compared different types or dosages of statins were included. Main outcome measures Primary outcomes were common adverse events: self-reported muscle symptoms, clinically confirmed muscle disorders, liver dysfunction, renal insufficiency, diabetes, and eye conditions. Secondary outcomes included myocardial infarction, stroke, and death from cardiovascular disease as measures of efficacy. Data synthesis A pairwise meta-analysis was conducted to calculate odds ratios and 95% confidence intervals for each outcome between statins and non-statin controls, and the absolute risk difference in the number of events per 10 000 patients treated for a year was estimated. A network meta-analysis was performed to compare the adverse effects of different types of statins. An E max model based meta-analysis was used to examine the dose-response relationships of the adverse effects of each statin. Results 62 trials were included, with 120 456 participants followed up for an average of 3.9 years. Statins were associated with an increased risk of self-reported muscle symptoms (21 trials, odds ratio 1.06 (95% confidence interval 1.01 to 1.13); absolute risk difference 15 (95% confidence interval 1 to 29)), liver dysfunction (21 trials, odds ratio 1.33 (1.12 to 1.58); absolute risk difference 8 (3 to 14)), renal insufficiency (eight trials, odds ratio 1.14 (1.01 to 1.28); absolute risk difference 12 (1 to 24)), and eye conditions (six trials, odds ratio 1.23 (1.04 to 1.47); absolute risk difference 14 (2 to 29)) but were not associated with clinically confirmed muscle disorders or diabetes. The increased risks did not outweigh the reduction in the risk of major cardiovascular events. Atorvastatin, lovastatin, and rosuvastatin were individually associated with some adverse events, but few significant differences were found between types of statins. An E max dose-response relationship was identified for the effect of atorvastatin on liver dysfunction, but the dose-response relationships for the other statins and adverse effects were inconclusive. Conclusions For primary prevention of cardiovascular disease, the risk of adverse events attributable to statins was low and did not outweigh their efficacy in preventing cardiovascular disease, suggesting that the benefit-to-harm balance of statins is generally favourable. Evidence to support tailoring the type or dosage of statins to account for safety concerns before starting treatment was limited. Systematic review registration PROSPERO CRD42020169955.

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