Factors Associated with Disparities in Appropriate Statin Therapy in an Outpatient Inner City Population

Lipid-lowering therapies are essential for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The aim of this study is to identify discrepancies between cholesterol management guidelines and current practice with a focus on statin treatment in an underserved population based in a large single urban medical center. Among 1042 reviewed records, we identified 464 statin-eligible patients. Age was 61.0 ± 10.4 years and 53.9% were female. Most patients were black (47.2%), followed by Hispanic (45.7%) and white (5.0%). In total, 82.1% of patients were prescribed a statin. An appropriate statin was not prescribed in 32.4% of statin-eligible patients who qualified based only on a 10-year ASCVD risk of ≥7.5%. After adjustment for gender and health insurance status, appropriate statin treatment was independently associated with age >55 years (OR = 4.59 (95% CI 1.09–16.66), p = 0.026), hypertension (OR = 2.38 (95% CI 1.29–4.38), p = 0.005) and chronic kidney disease (OR = 3.95 (95% CI 1.42–14.30), p = 0.017). Factors independently associated with statin undertreatment were black race (OR = 0.42 (95% CI 0.23–0.77), p = 0.005) and statin-eligibility based solely on an elevated 10-year ASCVD risk (OR = 0.14 (95% CI 0.07–0.25), p < 0.001). Hispanic patients were more likely to be on appropriate statin therapy when compared to black patients (86.8% vs. 77.2%). Statin underprescription is seen in approximately one out of five eligible patients and is independently associated with black race, younger age, fewer comorbidities and eligibility via 10-year ASCVD risk only. Hispanic patients are more likely to be on appropriate statin therapy compared to black patients.

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Factors Associated with Disparities in Appropriate Statin Therapy in an Outpatient Inner City Population

10.1101/2020.08.14.20174185 ◽

2020 ◽

Author(s):

Giselle Alexandra Suero Abreu ◽

Aris Karatasakis ◽

Sana Rashid ◽

Maciej Tysarowski ◽

Analise Y Douglas ◽

...

Keyword(s):

Statin Therapy ◽

Statin Treatment ◽

Blood Cholesterol ◽

Lipid Lowering ◽

Atherosclerotic Cardiovascular Disease ◽

Care Clinic ◽

Black Race ◽

Black Patients ◽

Hispanic Patients ◽

Ascvd Risk

Introduction: Appropriate lipid-lowering therapies are essential for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The aim of this study is to identify discrepancies between cholesterol management guidelines and current practice in an underserved population, with a focus on statin treatment. Methods: We reviewed the records of 1,042 consecutive patients seen between August 2018 and August 2019 in an outpatient academic primary care clinic. Eligibility for statin and other lipid-lowering therapies was determined based on the 2018 American Heart Association and American College of Cardiology (AHA/ACC) guideline on the management of blood cholesterol. Results: Among 464 statin-eligible patients, age was 61.1 +/- 10.4 years and 53.9% were female. Most patients were Black (47.2%), followed by Hispanic (45.7%), and White (5.0%). Overall, 82.1% of patients were prescribed a statin. Statin-eligible patients who qualified based only on a 10-year ASCVD risk > 7.5% were less likely to be prescribed a statin (32.8%, p<0.001). After adjustment for gender and health insurance status, appropriate statin treatment was independently associated with age > 55 years (OR = 4.59 [95% CI 1.09 - 16.66], p = 0.026), hypertension (OR = 2.38 [95% CI 1.29 - 4.38], p = 0.005) and chronic kidney disease (OR = 3.95 [95% CI 1.42 - 14.30], p = 0.017). Factors independently associated with statin undertreatment were Black race (OR = 0.42 [95% CI 0.23 - 0.77], p = 0.005), and statin-eligibility based solely on an elevated 10-year ASCVD risk (OR = 0.14 [95% CI 0.07 - 0.25], p < 0.001). Hispanic patients were more likely to be on appropriate statin therapy when compared to Black patients (86.8% vs 77.2%). Conclusion: Statin underprescription is seen in approximately one out of five eligible patients, and is independently associated with Black race, younger age, fewer comorbidities, and eligibility via 10-year ASCVD risk only. Hispanic patients are more likely to be on appropriate statin therapy compared to Black patients.

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Abstract 16936: Implications of the 2013 ACC/AHA Cholesterol Guidelines for Adults in Contemporary Cardiovascular Practice: Insights from the NCDR® PINNACLE Registry®

Circulation ◽

10.1161/circ.130.suppl_2.16936 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Thomas Maddox ◽

William Borden ◽

Fengming Tang ◽

Salim Virani ◽

William Oetgen ◽

...

Keyword(s):

Statin Therapy ◽

Current Practice ◽

Risk Group ◽

National Registry ◽

Lipid Lowering ◽

Fixed Dose ◽

Atherosclerotic Cardiovascular Disease ◽

Ascvd Risk ◽

Cholesterol Guidelines ◽

Testing Patterns

Background: In a significant update, the 2013 ACC/AHA cholesterol guidelines recommend fixed-dose statin therapy for those at risk and do not recommend non-statin therapies or treatment to target LDL-C levels, limiting the need for repeated LDL-C testing. We examined the implications of these updated guidelines on current lipid treatment and testing patterns in a national registry of cardiology practices. Methods: Using NCDR® PINNACLE Registry® data from 2008 to 2012, we assessed current practice patterns as a function of the 2013 cholesterol guidelines. Lipid-lowering therapies and LDL-C testing patterns by patient risk group (atherosclerotic cardiovascular disease (ASCVD), diabetes, off-treatment LDL-C ≥190mg/dL, or an estimated 10-year ASCVD risk ≥7.5%) were described. Results: Among a cohort of 1,174,545 patients, 1,129,205 (96.1%) were statin-eligible (91.2% ASCVD, 6.6% diabetes, 0.3% off-treatment LDL-C ≥190mg/dL, 1.9% estimated 10-year ASCVD risk ≥7.5%). 377,311 (32.4%) patients were not receiving statin therapy and 259,143 (22.6%) were receiving non-statin therapies. 20.8% patients had 2 or more LDL-C assessments during the study period, and 7.0% had more than 4 assessments. Conclusions: In U.S. cardiovascular practices, 32.4% of statin-eligible patients, as defined by the 2013 ACC/AHA cholesterol guidelines, were not currently receiving them. In addition, 22.6% were receiving non-statin lipid-lowering therapies and 20.8% had repeated LDL-C testing. Achieving concordance with the new cholesterol guidelines would result in significant increases in statin use, as well as significant reductions in non-statin therapies and laboratory testing.

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Abstract 10426: One Year Impact of the 2013 Cholesterol Guidelines on Patterns of Lipid Lowering Treatment

Circulation ◽

10.1161/circ.132.suppl_3.10426 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Josephine N Tran ◽

Tzu Chun Kao ◽

Toros Caglar ◽

Karen M Stockl ◽

Heidi C Lew ◽

...

Keyword(s):

Statin Therapy ◽

High Intensity ◽

Arterial Disease ◽

Statin Treatment ◽

Lipid Lowering ◽

High Dose ◽

Atherosclerotic Cardiovascular Disease ◽

Patients With Diabetes ◽

Cholesterol Guidelines ◽

One Year

Background: In 2013, national organizations issued new cholesterol guidelines to emphasize evidence-based treatment with moderate- to high-dose statins for patients at high risk for atherosclerotic cardiovascular disease (ASCVD), which includes coronary heart disease, stroke, and peripheral arterial disease. Whether these new guidelines have influenced patterns of treatment one year after their dissemination is unknown. Methods: Using pharmacy and medical claims from a large U.S. health insurance organization, we identified 610,535 adult patients with ASCVD (n=301,440) or diabetes mellitus (n=309,095) and examined statin treatment rates before and one year after the new cholesterol guidelines. Among patients receiving statins post-guidelines, we also evaluated whether patients were treated with guideline-recommended intensity of statin therapy. A standardized difference (SD) of at least 10% was required to declare the effect size meaningful. Results: Overall, there was no change in statin treatment rates for patients with ASCVD (48.0% before guidelines vs. 47.3% after, SD [1.4]) or diabetes (50% vs. 51.5% after, SD [2.4]). Statin initiation rates among patients not on statins pre-guidelines were 10.1% in patients with ASCVD and 14.3% in patients with diabetes, and these gains were offset by 13.0% and 12.2% statin discontinuation rates among ASCVD and diabetes patients, respectively. Among patients taking statins one year post-guidelines, 80% of patients with ASCVD and < 75 years of age were not on guideline-recommended high-intensity statin therapy, whereas >75% of patients with ASCVD and >75 years of age or patients with diabetes were on moderate- or high-intensity statin treatment. Conclusion: One year after dissemination of the new 2013 cholesterol guidelines, overall treatment rates with statins among patients with ASCVD and diabetes have not changed appreciably, and many patients remain either untreated or under-treated. Character Count: 1683

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Patients Living With HIV Are Less Likely to Receive Appropriate Statin Therapy for Cardiovascular Disease Risk Reduction

Journal of Pharmacy Practice ◽

10.1177/0897190021999790 ◽

2021 ◽

pp. 089719002199979

Author(s):

Roshni P. Emmons ◽

Nicholas V. Hastain ◽

Todd A. Miano ◽

Jason J. Schafer

Keyword(s):

Cardiovascular Disease ◽

Logistic Regression ◽

Statin Therapy ◽

Risk Reduction ◽

Blood Cholesterol ◽

Control Group ◽

Atherosclerotic Cardiovascular Disease ◽

Ascvd Risk ◽

Living With Hiv ◽

To Receive

Background: Recent studies suggest that statins are underprescribed in patients living with HIV (PLWH) at risk for atherosclerotic cardiovascular disease (ASCVD), but none have assessed if eligible patients receive the correct statin and intensity compared to uninfected controls. Objectives: The primary objective was to determine whether statin-eligible PLWH are less likely to receive appropriate statin therapy compared to patients without HIV. Methods: This retrospective study evaluated statin eligibility and prescribing among patients in both an HIV and internal medicine clinic at an urban, academic medical center from June-September 2018 using the American College of Cardiology/American Heart Association guideline on treating blood cholesterol to reduce ASCVD risk. Patients were assessed for eligibility and actual treatment with appropriate statin therapy. Characteristics of patients appropriately and not appropriately treated were compared with chi-square testing and predictors for receiving appropriate statin therapy were determined with logistic regression. Results: A total of 221/300 study subjects were statin-eligible. Fewer statin-eligible PLWH were receiving the correct statin intensity for their risk benefit group versus the uninfected control group (30.2% vs 67.0%, p < 0.001). In the multivariable logistic regression analysis, PLWH were significantly less likely to receive appropriate statin therapy, while those with polypharmacy were more likely to receive appropriate statin therapy. Conclusion: Our study reveals that PLWH may be at a disadvantage in receiving appropriate statin therapy for ASCVD risk reduction. This is important given the heightened risk for ASCVD in this population, and strategies that address this gap in care should be explored.

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Statin Use With the ATP III Guidelines Compared to the 2013 ACC/AHA Guidelines in HIV Primary Care Patients

Journal of Pharmacy Practice ◽

10.1177/0897190015611774 ◽

2016 ◽

Vol 30 (1) ◽

pp. 64-69 ◽

Cited By ~ 5

Author(s):

Pansy Elsamadisi ◽

Agnes Cha ◽

Elise Kim ◽

Safia Latif

Keyword(s):

Statin Therapy ◽

Retrospective Chart Review ◽

Population Based ◽

Risk Scores ◽

Atherosclerotic Cardiovascular Disease ◽

Laboratory Test Results ◽

Hiv Primary Care ◽

Cholesterol Guidelines ◽

Level Of Agreement ◽

Statin Use

Background: The 2013 Cholesterol Guidelines include a new atherosclerotic cardiovascular disease (ASCVD) risk calculator that determines the 10-year risk of coronary heart disease and/or stroke. The applicability of this calculator and its predecessor, the Framingham risk score (FRS) in Adult Treatment Panel (ATP) III, has been limited in patients with HIV. The objective of this study was to compare the risk scores of ASCVD and FRS in the initiation of statin therapy in patients with HIV. Methods: We conducted a retrospective chart review of patients with HIV on statin therapy from October 1, 2013, to April 1, 2014. Data collection included patient demographics, pertinent laboratory test results, and medication list. The primary end point evaluated the level of agreement between the guidelines. Results: Of 155 patients who met the inclusion criteria, 116 were treated similarly with both guidelines. This showed a moderate level of agreement ( P < .001). Forty-eight of 86 patients requiring statins were placed on the correct intensity statin using the 2013 guidelines. Regardless of which guideline, a majority of patients required statin therapy. Conclusion: A moderate agreement was found between both guidelines in terms of statin use when applied to an HIV patient population. Based on the 2013 guidelines and taking into account drug interactions with antiretrovirals, 44.2% of the patients were treated with an incorrect statin intensity.

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Inequities in Aortic Stenosis and Aortic Valve Replacement Between Black/African‐American, White, and Hispanic Residents of Maryland

Journal of the American Heart Association ◽

10.1161/jaha.120.017487 ◽

2021 ◽

Author(s):

Matthew J. Czarny ◽

Rani K. Hasan ◽

Wendy S. Post ◽

Matthews Chacko ◽

Stefano Schena ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Surgical Aortic Valve Replacement ◽

Black Race ◽

Transcatheter Aortic Valve ◽

Black Patients ◽

Hispanic Patients ◽

White Patients

Background Racial and ethnic inequities exist in surgical aortic valve replacement for aortic stenosis (AS), and early studies have suggested similar inequities in transcatheter aortic valve replacement. Methods and Results We performed a retrospective analysis of the Maryland Health Services Cost Review Commission inpatient data set from 2016 to 2018. Black patients had half the incidence of any inpatient AS diagnosis compared with White patients (incidence rate ratio [IRR], 0.50; 95% CI, 0.48–0.52; P <0.001) and Hispanic patients had one fourth the incidence compared with White patients (IRR, 0.25; 95% CI, 0.22–0.29; P <0.001). Conversely, the incidence of any inpatient mitral regurgitation diagnosis did not differ between White and Black patients (IRR, 1.00; 95% CI, 0.97–1.03; P =0.97) but was significantly lower in Hispanic compared with White patients (IRR, 0.36; 95% CI, 0.33–0.40; P <0.001). After multivariable adjustment, Black race was associated with a lower incidence of surgical aortic valve replacement (IRR, 0.67; 95% CI, 0.55–0.82 P <0.001 relative to White race) and transcatheter aortic valve replacement (IRR, 0.77; 95% CI, 0.65–0.90; P =0.002) among those with any inpatient diagnosis of AS. Hispanic patients had a similar rate of surgical aortic valve replacement and transcatheter aortic valve replacement compared with White patients. Conclusions Hospitalization with any diagnosis of AS is less common in Black and Hispanic patients than in White patients. In hospitalized patients with AS, Black race is associated with a lower incidence of both surgical aortic valve replacement and transcatheter aortic valve replacement compared with White patients, whereas Hispanic patients have a similar incidence of both. The reasons for these inequities are likely multifactorial.

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Lower is better: ezetimibe and PCSK9 inhibition join the mainstream of lipid‑lowering therapy

Reviews in Health Care ◽

10.7175/rhc.v7i1.1263 ◽

2016 ◽

Vol 7 (1) ◽

pp. 17-25

Author(s):

Cezary Wójcik

Keyword(s):

Statin Therapy ◽

Heart Association ◽

Lipid Lowering ◽

Atherosclerotic Cardiovascular Disease ◽

Lipid Lowering Therapy ◽

Pcsk9 Inhibitors ◽

Level Of Evidence ◽

Cholesterol Guidelines ◽

Pcsk9 Inhibition ◽

Current Guidelines

The focus of 2013 cholesterol guidelines to prevent atherosclerotic cardiovascular disease (ASCVD) released by American College of Cardiology (ACC) and American Heart Association (AHA) is the administration of high intensity statin therapy to specific four groups of patients, which were found to benefit the most from such therapy. They no longer promote achieving specific LDL-C goals with a combination therapy involving statins and other drugs, as advocated by the former ATP-III guidelines as well as current guidelines of European Atherosclerosis Society, International Atherosclerosis Society or National Lipid Association. Such approach has been dictated by the strict reliance on randomized controlled trials as the only acceptable level of evidence. However, since publication of the 2013 ACC/AHA guidelines, cardiovascular benefits of ezetimibe added to statin therapy have been established. Moreover, the advent of PCSK9 inhibitors, providing a powerful supplement and/or alternative to statin therapy, further complicates the therapeutic horizon in dyslipdiemias. It is very likely that a new set of ACC/AHA guidelines will be published in 2016, with a return of specific LDL-C and Non-HDL-C goals of therapy as well as integration of drugs other than statins. As the treatment of dyslipidemias becomes more complex, the need for the subspecialty of clinical lipidology to be officially recognized becomes more evident.

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Abstract 05: Assessing Population Impact of Statin Treatment for Primary Prevention of Atherosclerotic Cardiovascular Diseases in US

Circulation ◽

10.1161/circ.131.suppl_1.05 ◽

2015 ◽

Vol 131 (suppl_1) ◽

Author(s):

Quanhe Yang ◽

Yuna Zhong ◽

Catheen Gillespie ◽

Robert Merritt ◽

Barbara Bowman ◽

...

Keyword(s):

Primary Prevention ◽

Adverse Effects ◽

Randomized Clinical Trials ◽

Statin Treatment ◽

Population Based ◽

Number Needed To Treat ◽

Atherosclerotic Cardiovascular Disease ◽

Population Impact ◽

New Guidelines ◽

Statin Use

Introduction: American College of Cardiology/American Heart Association (ACC/AHA) new cholesterol treatment guidelines recommend consideration of statin treatment for a larger proportion of population for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). It is important to assess the population impact of statin treatment under these new guidelines. Hypothesis: We assessed the hypothesis that increased statin use for the primary prevention of ASCVD might be accompanied by adverse effects among population. Methods: We used 2010 US Census, Multiple Cause Mortality, Third National Health and Nutrition Examination Survey Linked Mortality File (NHANES III 1988-2006, n=7095) and NHANES 2005-2010 (n=3178) participants 40-75 years of age to estimate prevalence of statin use, annual ASCVD deaths prevented and excess adverse effects by age, sex, and race/ethnicity if everyone followed updated guidelines. Results: Among 33.0 million adults aged 40-75 years meeting new guidelines for primary prevention of ASCVD (12.4 million with diabetes and 20.6 without diabetes but with a predicted 10-year ASCVD risk ≥7.5% and 70 ≤ low-density lipoprotein (LDL) ≤189 mg/dL), 26.9% (8.8 million) were on statins, indicating an additional 24.2 million potentially eligible for statin treatment (7.7 million with diabetes and 16.5 million without). Among the 7.7 million with diabetes, assuming 100% statin use, expected annual ASCVD deaths prevented were 2,514 (95% CI 592-4,142) and number-needed-to-treat (NNT) was 3,063 (1,860-13,017). The additional cases of myopathy based on estimates from randomized clinical trials (RCT) was 482 (0-2239) and number-needed-to-harm (NNH) was 15,992 (3,440-∞), and was 11,801 (9,251-14,916) and NNH 653 (516-833) based on estimates from population-based studies. Among 16.5 million without diabetes, ASCVD deaths prevented were 5,425 (1,276-8,935) with NNT 3,039 (1,845-12,914). The additional diabetes cases were 16,406 (4,922-26,250) with NNH 1,005 (628-3,349). Additional cases of myopathy was 1,030 (0-4,791) with NNH 15,996 3,441-∞) based on RCT estimates, and 24,302 (19,363-30,292) with NNH 678 (544-851) for population-based studies. ASCVD deaths prevented increased with age and >70% of ASCVD deaths prevented would occur among adults aged ≥60 years. Conclusions: Under ACC/AHA new guidelines for primary prevention of ASCVD by statin, assuming all those eligible took a statin, up to 12.6% of annual ASCVD deaths could be prevented, but could be accompanied by additional cases of diabetes and myopathy.

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Prognostic impact of cascade screening for familial hypercholesterolemia on cardiovascular events

European Heart Journal ◽

10.1093/ehjci/ehaa946.2983 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

H Tada ◽

H Okada ◽

A Nomura ◽

A Nohara ◽

M Yamagishi ◽

...

Keyword(s):

Risk Factors ◽

Familial Hypercholesterolemia ◽

Cardiovascular Events ◽

Lipid Lowering ◽

Funding Source ◽

Atherosclerotic Cardiovascular Disease ◽

Prognostic Impact ◽

Cascade Screening ◽

Ascvd Risk ◽

The Impact

Abstract Background Early diagnosis and timely treatment for the patients with familial hypercholesterolemia (FH) can substantially lower the risk of atherosclerotic cardiovascular disease (ASCVD). In this sense, cascade screening could be one of the most useful options. However, few data exist regarding the impact of cascade screening for FH on the reduction of risk of ASCVD events. Objectives We aimed to evaluate the prognostic impact of cascade screening for FH. Methods We retrospectively investigated the health records of 1,050 patients with clinically diagnosed FH, including probands and their relatives who were cascade-screened. We used Cox models that were adjusted for established ASCVD risk factors to assess the association between cascade screening and major adverse cardiovascular events (MACE). The median period of follow-up was 12.3 years (interquartile range [IQR] = 9.1–17.5 years), and MACE included death from any causes or hospitalization due to ASCVD events. Results During the observation period, 246 participants experienced MACE. The mean age of patients identified through cascade screening was 18-years younger than that of the probands (38.7 yr vs. 57.0 yr, P<0.001), with a lower proportion of ASCVD risk factors. Interestingly, patients identified through cascade screening under milder lipid-lowering therapies were at reduced risk for MACE (hazard ratio [HR] = 0.36; 95% CI = 0.22 to 0.60; P<0.001) when compared with the probands, even after adjusting for those known risk factors. Conclusions The identification of patients with FH via cascade screening appeared to result in better prognoses. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Scientific research grants from the Ministry of Education, Science and Culture of Japan (no. 16K19394, 18K08064, and 19K08575)

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New Approaches for the Prevention and Treatment of Cardiovascular Disease: Focus on Lipoproteins and Inflammation

Annual Review of Medicine ◽

10.1146/annurev-med-100119-013612 ◽

2020 ◽

Vol 72 (1) ◽

Author(s):

Aliza Hussain ◽

Christie M. Ballantyne

Keyword(s):

Cardiovascular Disease ◽

Statin Therapy ◽

Low Density Lipoprotein ◽

Density Lipoprotein ◽

Annual Review ◽

Publication Date ◽

Atherosclerotic Cardiovascular Disease ◽

Substantial Progress ◽

Ascvd Risk ◽

Made In

Although numerous trials have convincingly shown benefits of statin therapy in both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), most showed relative risk reductions of 25–40%, and thus many individuals continue to have ASCVD events despite statin therapy. Substantial progress has been made in developing therapies that address the residual risk for ASCVD despite statin therapy. In this review, we summarize progress of currently available therapies along with therapies under development that further reduce low-density lipoprotein cholesterol and apolipoprotein B–containing lipoproteins, reduce lipoprotein(a), reduce ASCVD events in patients with high triglycerides, and directly target inflammation to reduce ASCVD risk. Expected final online publication date for the Annual Review of Medicine, Volume 72 is January 27, 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

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