Statin Prescription for Patients With Atherosclerotic Cardiovascular Disease from National Survey Data

Atherosclerotic Cardiovascular Disease Primary and Secondary Prevention in Latino Subgroups

BACKGROUND

Studies assessing equity in the prevention of atherosclerotic cardiovascular disease (ASCVD) for Latinos living in the USA collectively yield mixed results. Latino persons are diverse in many ways that may influence cardiovascular health. The intersection of Latino nativity and ASCVD prevention is understudied.

OBJECTIVE

To determine whether disparities in ASCVD screening, detection, and prescribing differ for US Latinos by country of birth.

DESIGN

A retrospective cohort design utilizing 2014-2020 electronic health record data from a network of 320 community health centers across 12 states. Analyses occurred October 1, 2022, to September 30, 2023.

PARTICIPANTS

Non-Hispanic White and Latino adults age 20-75 years, born in Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, and the USA.

EXPOSURES

Ethnicity and country of birth.

MAIN MEASURES

Outcome measures included prevalence of statin eligibility, of having insufficient data to establish eligibility, odds of having a documented statin prescription, and rates of statin prescriptions and refills. We used covariate-adjusted logistic and generalized estimating equations logistic and negative binomial regressions to generate absolute and relative measures.

KEY RESULTS

Among 108,672 adults, 23% (n = 25,422) were statin eligible for primary or secondary prevention of ASCVD using American College of Cardiology/American Heart Association guidelines. Latinos, born in and outside the USA were more likely eligible than Non-Hispanic White patients were (US-born Latino OR = 1.55 (95% CI = 1.37-1.75); non-US-born Latino OR = 1.63 (95% CI = 1.34-1.98)). The eligibility criteria that was met differed by ethnicity and nativity. Latinos overall were less likely missing data to establish eligibility and differences were again observed by specific non-US country of origin. Among those eligible, we observed no statistical difference in statin prescribing between US-born Latinos and non-Hispanic White persons; however, disparities varied by specific non-US country of origin.

CONCLUSION

Efforts to improve Latino health in the USA will require approaches for preventing and reversing cardiovascular risk factors, and statin initiation that are Latino subgroup specific.

The Global Burden of premature cardiovascular disease, 1990-2019

Aims

Premature cardiovascular disease (pCVD) definition varies in literature, with age cut-offs ranging from 50-65 years. While there is some literature available on pCVD in North America, comprehensive data on its global burden is still lacking which hinders the development of efficient strategies for early detection and prevention. In this study we aimed to investigate the global trends in pCVD related morbidity and mortality from 1990 to 2019.

Methods

The 1990-2019 Global Burden of Disease (GBD) database was utilized to examine global trends in cardiovascular disease-related total mortality, mortality rates, and Disability-Adjusted Life Years (DALYs) within individuals aged 15-49 years. The findings were further analyzed based on factors such as age, sex, and Socio-Demographic Index (SDI).

Results

From 1990 to 2019, the number of global annual pCVD deaths increased by 25%, from 992,067 (95% UI 1,042,261 - 946,383) to 1,241,484 (95% UI 1,339,193 -1,146,252). The rate of associated mortality decreased by 13%. Metabolic conditions were the most significant risk factors for pCVD mortality. Ischemic heart disease and stroke are the leading causes of death across all age groups. pCVD mortality presented progressive widening between high and low SDI regions. Additionally, sex-specific disparities in CVD mortality were significantly greater in the premature age group as compared to all-age groups.

Conclusion

pCVD is an increasingly significant global cause of morbidity and mortality that disproportionately affects males and individuals living in less privileged regions. Furthermore, ischemic heart disease and stroke were identified as the main drivers of pCVD global burden.

Use of bempedoic acid for LDL cholesterol lowering and cardiovascular risk reduction: a consensus document from the Italian study group on atherosclerosis, thrombosis and vascular biology

The clinical benefit of LDL cholesterol (LDL-C) lowering for cardiovascular disease prevention is well documented. This paper from the Italian Study Group on Atherosclerosis, Thrombosis and Vascular Biology summarizes current recommendations for treatment of hypercholesterolemia, barriers to lipid-lowering therapy implementation and tips to overcome them, as well as available evidence on the efficacy and safety of bempedoic acid. We also report an updated therapeutic algorithm for pharmacological LDL-C lowering in view of the introduction of bempedoic acid in clinical practice.

Racial, ethnic, and language differences in screening measures for statin therapy following a major guideline change

Atherosclerotic cardiovascular disease (ASCVD) disproportionally affects racial and ethnic minority populations. Statin prescribing guidelines changed in 2013 to improve ASCVD prevention. It is unknown whether risk screening for statin eligibility differed across race and ethnicity over this guideline change. We examine racial/ethnic/language differences in screening measure prevalence for period-specific statin consideration using a retrospective cohort design and linked electronic health records from 635 community health centers in 24 U.S. states. Adults 50+ years, without known ASCVD, and ≥ 1 visit in 2009-2013 and/or 2014-2018 were included, grouped as: Asian, Latino, Black, or White further distinguished by language preference. Outcomes included screening measure prevalence for statin consideration, 2009-2013: low-density lipoprotein (LDL), 2014-2018: pooled cohort equation (PCE) components age, sex, race, systolic blood pressure, total cholesterol, high-density lipoprotein, smoking status. Among patients seen both periods, change in period-specific measure prevalence was assessed. Adjusting for sociodemographic and clinical factors, compared to English-preferring White patients, all other groups were more likely to have LDL documented (2009-2013, n = 195,061) and all PCE components documented (2014-2018, n = 344,504). Among patients seen in both periods (n = 128,621), all groups had lower odds of PCE components versus LDL documented in the measures' respective period; English-preferring Black adults experienced a greater decline compared to English-preferring White adults (OR 0.81; 95% CI: 0.72-0.91). Racial/ethnic/language disparities in documented screening measures that guide statin therapy for ASCVD prevention were unaffected by a major guideline change advising this practice. It is important to understand whether the newer guidelines have altered disparate prescribing and morbidity/mortality for this disease.

Health Disparities Across the Continuum of ASCVD Risk

PURPOSE OF THE REVIEW

Despite marked progress in cardiovascular disease management in the last several decades, there remain significant, persistent disparities in cardiovascular health in historically marginalized racial and ethnic groups. Here, we outline current state of health disparities in cardiovascular disease, discuss the interplay between social determinants of health, structural racism, and cardiovascular outcomes, and highlight strategies to address these issues.

RECENT FINDINGS

Across the continuum of atherosclerotic cardiovascular disease (ASCVD) prevention, there remain significant disparities in outcomes including morbidity and mortality by race, ethnicity, and socioeconomic status (SES). These disparities begin early in childhood (primordial prevention) and continue with a higher prevalence of cardiovascular risk factors (primary prevention), and in the uptake of evidence-based therapies (secondary prevention). These disparities are driven by social determinants of health and structural racism that disproportionately disadvantage historically marginalized populations. Structural racism and social determinants of health contribute to significant disparities in cardiovascular morbidity and mortality.

Race/ethnic and sex differences in the initiation of non-statin lipid-lowering medication following myocardial infarction

BACKGROUND

Adults with atherosclerotic cardiovascular disease (ASCVD) at very high-risk for recurrent events who have low-density lipoprotein cholesterol ≥ 70 mg/dL despite maximally-tolerated statin therapy are recommended to initiate ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor.

OBJECTIVE

Compare the initiation of ezetimibe and a PCSK9 inhibitor after a myocardial infarction (MI) among very high-risk ASCVD patients by race/ethnicity and sex.

METHODS

We analyzed data from 374,786 adults ≥ 66 years of age with Medicare fee-for-service coverage who had an MI between July 1, 2015 and December 31, 2018, were not taking ezetimibe or a PCSK9 inhibitor, and had very high-risk ASCVD defined by the 2018 American Heart Association/American College of Cardiology multi-society cholesterol guideline. Pharmacy claims through December 31, 2018 were used to determine ezetimibe and PCSK9 inhibitor initiation.

RESULTS

Overall, 6980 (1.9%) beneficiaries initiated ezetimibe, and 1433 (0.4%) initiated a PCSK9 inhibitor. Adjusted hazard ratios (aHR) for ezetimibe initiation among non-Hispanic Black, Hispanic, and Asian versus non-Hispanic White beneficiaries were 0.77 (95% confidence interval [95%CI]: 0.70-0.86), 0.92 (95%CI: 0.76-1.11) and 0.73 (95%CI: 0.59-0.89), respectively. Compared to non-Hispanic White beneficiaries, the aHRs for PCSK9 inhibitor initiation were 0.63 (95%CI: 0.48-0.81) among non-Hispanic Black, 0.70 (95%CI: 0.43-1.13) among Hispanic, and 0.93 (95%CI: 0.62-1.39) among Asian beneficiaries. The aHRs for ezetimibe and PCSK9 inhibitor initiation comparing women to men were 1.11 (95%CI: 1.06-1.17) and 1.13 (95%CI: 1.01-1.25), respectively.

CONCLUSION

There are race/ethnic and sex disparities in the initiation of ezetimibe and a PCSK9 inhibitor following MI among very high-risk ASCVD patients.

How the National Ambulatory Medical Care Survey has been used to identify health disparities in the care of patients in the United States

BACKGROUND

Healthcare disparities negatively impact patient health outcomes; addressing disparities could improve quality of life and decrease overall healthcare cost. The National Ambulatory Medical Care Survey (NAMCS) is an objective and reliable source for collecting information on United States (U.S.) ambulatory medical care service visits and may be a useful tool for identifying potential disparities in care.

OBJECTIVE

The purpose of this literature review is to describe studies utilizing NAMCS to capture U.S. healthcare disparities.

METHODS

PubMed was searched for scientific articles that utilized NAMCS to determine health disparities in the U.S. The keywords queried included "NAMCS" or "National Ambulatory Medical Care Survey" and "disparity" or "disparities" as a pair or additionally paired with one of the following: "race", "ethnicity", "age", "gender", "geography", or "insurance".

RESULTS

66 studies were found that incorporated NAMCS data from 1980-2016 into their methods to measure outcomes relating to health disparities. Disparities were found in the following categories: race/ethnicity, geographic location, age, insurance type, gender, specialist care versus primary care, body habitus, and preexisting conditions affecting patient outcomes. Disparities were identified in pain management, neurology, dermatology, psychiatry, patient communication access, and non-specialty specific or primary care visits related to disease conditions, screening, and treatment plans.

LIMITATIONS

Only PubMed was utilized as a search engine and may not encompass all studies on NAMCS and health disparities. NAMCS is a cross-sectional database and does not allow for longitudinal analyses.

CONCLUSIONS

NAMCS may be an underused tool given the limited number of articles that identify health disparities using it. Research studies utilizing NAMCS may identify potential disparities ultimately leading to better healthcare outcomes.

Is race or ethnicity associated with under-utilization of statins among women in the United States: The study of women's health across the nation

Background

Rates of statin use among minority women are unclear.

Hypothesis

We hypothesized that statin use would vary by race/ethnicity with lower rates among minority women compared with Whites.

Methods

Data from the study of women's health across the nation, a multiethnic cohort of women collected between 2009 to 2011 were used to examine reported statin use by race/ethnicity and risk profile. Multivariable logistic modeling was performed to estimate the odds ratio (OR) of statin treatment.

Results

Of the 2399 women included, 234 had a diagnosis of atherosclerotic disease (ASCVD), 254 were diabetic (without ASCVD), 163 had an LDL ≥190 mg/dL, and 151 had a 10 year ASCVD pooled risk score ≥7.5%. Statins were used by 49.6% of women with CVD; 59.8% of women with diabetes without known ASCVD; 42.3% of women with an LDL ≥190 mg/dL; and 19.9% of women with an ASCVD risk ≥7.5%. Rates of statin use were 43.8% for women with ≥ two prior ASCVD events and 69.4% for women with ≥ one prior ASCVD event plus multiple high‐risk conditions. Among women eligible for statins, Black women had a significantly reduced adjusted odds of being on a statin (OR 0.53, 95% confidence interval [CI] 0.36‐0.78) compared with White women.

Conclusions

In this cohort of multiethnic women, rates of statin use among women who would benefit were low, with Black women having lower odds of statin use than White women.

Statin Prescription Rates, Adherence, and Associated Clinical Outcomes Among Women with PAD and ICVD

PURPOSE

This study sought to investigate gender-based disparities in statin prescription rates and adherence among patients with peripheral arterial disease (PAD) and ischemic cerebrovascular disease (ICVD).

METHODS

We identified patients with PAD or ICVD seeking primary care between 2013 and 2014 in the VA healthcare system. We assessed any statin use, high-intensity statin (HIS) use, and statin adherence among women with PAD or ICVD compared with men. We also compared proportion of days covered (PDC) as a measure of statin adherence; PDC ≥ 0.8 deemed a patient statin adherent. Association between statin use (or adherence) and odds of death or myocardial infarction (MI) at 12-month follow-up was also ascertained.

RESULTS

Our analyses included 192,219 males and 3188 females with PAD and 331,352 males and 10,490 females with ICVD. Women with PAD had lower prescription rates of any statin (68.5% vs. 78.7%, OR 0.68, 95% confidence interval (CI) 0.62-0.75), HIS (21.1% vs. 23.7%, OR 0.88, 95% CI 0.79-0.97), and lower statin adherence (PDC ≥ 0.8: 34.6% vs. 45.5%, OR 0.75, 95% CI 0.69-0.82) compared with men. Similar disparities were seen in ICVD patients. Among female patients with PAD or ICVD, statin adherence was associated with lower odds of MI (OR 0.76, 95% CI 0.59-0.98), while use of any statin (OR 0.71, 95% CI 0.56-0.91) and HIS (OR 0.68, 95% CI 0.48-0.97) was associated with lower odds of death at 12 months.

CONCLUSIONS

Women with PAD or ICVD had lower odds of receiving any statins, HIS, or being statin adherent. Targeted clinician- and patient-level interventions are needed to study and address these disparities among patients with PAD and ICVD.