1
|
Rowe IA, Villanueva C, Shearer JE, Torres F, Albillos A, Genescà J, Garcia-Pagan JC, Tripathi D, Hayes PC, Bosch J, Abraldes JG. Quantifying the benefit of nonselective beta-blockers in the prevention of hepatic decompensation: A Bayesian reanalysis of the PREDESCI trial. Hepatology 2023; 78:530-539. [PMID: 36897269 DOI: 10.1097/hep.0000000000000342] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/09/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND AIMS Beta-blockers have been studied for the prevention of variceal bleeding and, more recently, for the prevention of all-cause decompensation. Some uncertainties regarding the benefit of beta-blockers for the prevention of decompensation remain. Bayesian analyses enhance the interpretation of trials. The purpose of this study was to provide clinically meaningful estimates of both the probability and magnitude of the benefit of beta-blocker treatment across a range of patient types. APPROACH AND RESULTS We undertook a Bayesian reanalysis of PREDESCI incorporating 3 priors (moderate neutral, moderate optimistic, and weak pessimistic). The probability of clinical benefit was assessed considering the prevention of all-cause decompensation. Microsimulation analyses were done to determine the magnitude of the benefit. In the Bayesian analysis, the probability that beta-blockers reduce all-cause decompensation was >0.93 for all priors. The Bayesian posterior hazard ratios (HR) for decompensation ranged from 0.50 (optimistic prior, 95% credible interval 0.27-0.93) to 0.70 (neutral prior, 95% credible interval 0.44-1.12). Exploring the benefit of treatment using microsimulation highlights substantial treatment benefits. For the neutral prior derived posterior HR and a 5% annual incidence of decompensation, at 10 years, an average of 497 decompensation-free years per 1000 patients were gained with treatment. In contrast, at 10 years 1639 years per 1000 patients were gained from the optimistic prior derived posterior HR and a 10% incidence of decompensation. CONCLUSIONS Beta-blocker treatment is associated with a high probability of clinical benefit. This likely translates to a substantial gain in decompensation-free life years at the population level.
Collapse
Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
| | - Jessica E Shearer
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ferran Torres
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). Madrid, Spain
| | - Joan Genescà
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
- Liver Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Joan C Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Dhiraj Tripathi
- University Hospitals Birmingham NHS Foundation Trust. Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham. UK
- Department of Hepatology. Royal Infirmary of Edinburgh. Edinburgh, UK
| | - Peter C Hayes
- Department of Hepatology. Royal Infirmary of Edinburgh. Edinburgh, UK
| | - Jaume Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
2
|
Hunter RW, Dhaun N, Bailey MA. The impact of excessive salt intake on human health. Nat Rev Nephrol 2022; 18:321-335. [DOI: 10.1038/s41581-021-00533-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 12/19/2022]
|
3
|
Taylor-Robinson D, Kee F. Precision public health-the Emperor's new clothes. Int J Epidemiol 2020; 48:1-6. [PMID: 30212875 PMCID: PMC6380317 DOI: 10.1093/ije/dyy184] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2018] [Indexed: 01/08/2023] Open
Affiliation(s)
- David Taylor-Robinson
- Institute of Psychology, Health and Society, The Farr Institute@HeRC, University of Liverpool, Liverpool, UK
| | - Frank Kee
- UKCRC Centre of Excellence for Public Health Research, Centre for Public Health, Queens University of Belfast, Belfast, UK
| |
Collapse
|
4
|
Conner SC, Sullivan LM, Benjamin EJ, LaValley MP, Galea S, Trinquart L. Adjusted restricted mean survival times in observational studies. Stat Med 2019; 38:3832-3860. [PMID: 31119770 PMCID: PMC7534830 DOI: 10.1002/sim.8206] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/05/2019] [Accepted: 04/26/2019] [Indexed: 12/24/2022]
Abstract
In observational studies with censored data, exposure-outcome associations are commonly measured with adjusted hazard ratios from multivariable Cox proportional hazards models. The difference in restricted mean survival times (RMSTs) up to a pre-specified time point is an alternative measure that offers a clinically meaningful interpretation. Several regression-based methods exist to estimate an adjusted difference in RMSTs, but they digress from the model-free method of taking the area under the survival function. We derive the adjusted RMST by integrating an adjusted Kaplan-Meier estimator with inverse probability weighting (IPW). The adjusted difference in RMSTs is the area between the two IPW-adjusted survival functions. In a Monte Carlo-type simulation study, we demonstrate that the proposed estimator performs as well as two regression-based approaches: the ANCOVA-type method of Tian et al and the pseudo-observation method of Andersen et al. We illustrate the methods by reexamining the association between total cholesterol and the 10-year risk of coronary heart disease in the Framingham Heart Study.
Collapse
Affiliation(s)
- Sarah C. Conner
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- National Heart, Lung, and Blood Institute’s and Boston University’s Framingham Heart Study, Framingham, MA
| | - Lisa M. Sullivan
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Emelia J. Benjamin
- National Heart, Lung, and Blood Institute’s and Boston University’s Framingham Heart Study, Framingham, MA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Section of Cardiovascular Medicine, Evans Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Michael P. LaValley
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Sandro Galea
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ludovic Trinquart
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- National Heart, Lung, and Blood Institute’s and Boston University’s Framingham Heart Study, Framingham, MA
| |
Collapse
|
5
|
Masi S, Taddei S, Virdis A. Statin guidelines: Friend or foes? Eur J Prev Cardiol 2018; 25:867-869. [DOI: 10.1177/2047487318768941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| |
Collapse
|
6
|
Wieringa S, Engebretsen E, Heggen K, Greenhalgh T. How Knowledge Is Constructed and Exchanged in Virtual Communities of Physicians: Qualitative Study of Mindlines Online. J Med Internet Res 2018; 20:e34. [PMID: 29396385 PMCID: PMC5882224 DOI: 10.2196/jmir.8325] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/13/2017] [Accepted: 10/11/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND As a response to the criticisms evidence-based practice currently faces, groups of health care researchers and guideline makers have started to call for the appraisal and inclusion of different kinds of knowledge in guideline production (other than randomized controlled trials [RCTs]) to better link with the informal knowledge used in clinical practice. In an ethnographic study, Gabbay and Le May showed that clinicians in everyday practice situations do not explicitly or consciously use guidelines. Instead, they use mindlines: collectively shared, mostly tacit knowledge that is shaped by many sources, including accumulated personal experiences, education (formal and informal), guidance, and the narratives about patients that are shared among colleagues. In this study on informal knowledge, we consider virtual networks of clinicians as representative of the mindlines in the wider medical community, as holders of knowledge, as well as catalysts of knowing. OBJECTIVE The aim of this study was to explore how informal knowledge and its creation in communities of clinicians can be characterized as opposed to the more structured knowledge produced in guideline development. METHODS This study included a qualitative study of postings on three large virtual networks for physicians in the United Kingdom, the Netherlands, and Norway, taking the topic of statins as a case study and covering more than 1400 posts. Data were analyzed thematically with reference to theories of collaborative knowledge construction and communities of practice. RESULTS The dataset showed very few postings referring to, or seeking to adhere to, explicit guidance and recommendations. Participants presented many instances of individual case narratives that highlighted quantitative test results and clinical examination findings. There was an emphasis on outliers and the material, regulatory, and practical constraints on knowledge use by clinicians. Participants conveyed not-so-explicit knowledge as tacit and practical knowledge and used a prevailing style of pragmatic reasoning focusing on what was likely to work in a particular case. Throughout the discussions, a collective conceptualization of statins was generated and reinforced in many contexts through stories, jokes, and imagery. CONCLUSIONS Informal knowledge and knowing in clinical communities entail an inherently collective dynamic practice that includes explicit and nonexplicit components. It can be characterized as knowledge-in-context in practice, with a strong focus on casuistry. Validity of knowledge appears not to be based on criteria of consensus, coherence, or correspondence but on a more polyphonic understanding of truth. We contend that our findings give enough ground for further research on how exploring mindlines of clinicians online could help improve guideline development processes.
Collapse
Affiliation(s)
- Sietse Wieringa
- Evidence-Based Health Care Program, Department of Continuing Education, University of Oxford, Oxford, United Kingdom.,Department of Health Sciences, University of Oslo, Oslo, Norway
| | | | - Kristin Heggen
- Department of Health Sciences, University of Oslo, Oslo, Norway
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
7
|
Kones R, Rumana U. Cultural primer for cardiometabolic health: health disparities, structural factors, community, pathways to improvement, and clinical applications. Postgrad Med 2018; 130:200-221. [PMID: 29291669 DOI: 10.1080/00325481.2018.1421395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The quest to optimize cardiometabolic health has created great interest in nonmedical health variables in the population, community-based research and coordination, and addressing social, ethnic, and cultural barriers. All of these may be of equal or even greater importance than classical health care delivery in achieving individual well-being. One dominant issue is health disparity - causes, methods of reduction, and community versus other levels of solutions. This communication summarizes some major views regarding social structures, followed by amplification and synthesis of central ideas in the literature. The role of community involvement, tools, and partnerships is also presented in this Primer. Recent views of how these approaches could be incorporated into cardiometabolic initiatives and strategies follow, with implications for research. Two examples comparing selected aspects of community leverage and interventions in relation to individual approaches to health care equity are examined in depth: overall performance in reducing cardiovascular risk and mortality, and the recent National Diabetes Prevention Program, both touching upon healthy diets and adherence. Finally, the potential that precision medicine offers, and possible effects on disparities are also discussed.
Collapse
Affiliation(s)
- Richard Kones
- a The Cardiometabolic Research Institute , Houston , TX , USA
| | - Umme Rumana
- a The Cardiometabolic Research Institute , Houston , TX , USA.,b University of Texas Health Science Center , Houston , TX , USA
| |
Collapse
|
8
|
do Nascimento RCRM, Álvares J, Guerra AA, Gomes IC, Silveira MR, Costa EA, Leite SN, Costa KS, Soeiro OM, Guibu IA, Karnikowski MGDO, Acurcio FDA. Polypharmacy: a challenge for the primary health care of the Brazilian Unified Health System. Rev Saude Publica 2017; 51:19s. [PMID: 29160460 PMCID: PMC5676396 DOI: 10.11606/s1518-8787.2017051007136] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 02/07/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To characterize the polypharmacy in primary health care patients and to identify its associated factors. METHODS This is a cross-sectional, exploratory, and evaluative study, part of the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos - Serviços, 2015 (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines - Services, 2015). The variable of interest was polypharmacy, defined as the use of five or more medicines. We sought to identify the association of sociodemographic variables and indicators of health conditions to polypharmacy. For group comparison, the Pearson's Chi-square test was used. The association between polypharmacy and explanatory variables was evaluated by logistic regression model (p < 0.05). The quality of the adjustment was verified by Hosmer-Lemeshow test. RESULTS The prevalence of polypharmacy among medicine users was 9.4% (95%CI 7.8-12.0) in the general population and 18.1% (95%CI 13.6-22.8) in older adults above 65 years old. We found statistically significant association between polypharmacy and age above 45 years, lower self-perception of health, presence of chronic diseases, having health insurance, care in emergency services, and region of the Country. South users presented the highest chances to polypharmacy. The most used medicines were those of the cardiovascular system, being compatible with the national epidemiological profile. CONCLUSIONS Polypharmacy is a reality in the population met within the primary care of Brazilian Unified Health System and may be related to excessive or inappropriate use of medicines. The main challenge to qualify health care is to ensure that prescription of multiple medicines be appropriate and safe.
Collapse
Affiliation(s)
| | - Juliana Álvares
- Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| | - Augusto Afonso Guerra
- Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| | | | - Micheline Rosa Silveira
- Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| | - Ediná Alves Costa
- Instituto de Saúde Coletiva. Universidade Federal da Bahia. Salvador, BA, Brasil
| | - Silvana Nair Leite
- Departamento de Ciências Farmacêuticas. Universidade Federal de Santa Catarina. Florianópolis, SC, Brasil
| | - Karen Sarmento Costa
- Núcleo de Estudos de Políticas Públicas. Universidade Estadual de Campinas. Campinas, SP, Brasil
- Programa de Pós-Graduação em Saúde Coletiva. Departamento de Saúde Coletiva. Faculdade de Ciências Médicas. Universidade Estadual de Campinas. Campinas, SP, Brasil
- Programa de Pós-Graduação em Epidemiologia. Faculdade de Medicina. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil
| | - Orlando Mario Soeiro
- Faculdade de Ciências Farmacêuticas. Pontifícia Universidade Católica de Campinas. Campinas, SP, Brasil
| | - Ione Aquemi Guibu
- Departamento de Saúde Coletiva. Faculdade de Ciências Médicas. Santa Casa de São Paulo. São Paulo, SP, Brasil
| | | | - Francisco de Assis Acurcio
- Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| |
Collapse
|
9
|
Ennezat PV, Cosgrove S, Bouvaist H, Maréchaux S, Guerbaai RA, Le Jemtel T, Andréjak M, Vital-Durand D. From evidence-based medicine to personalized medicine, with particular emphasis on drug-safety monitoring. Arch Cardiovasc Dis 2017; 110:413-419. [PMID: 28552224 DOI: 10.1016/j.acvd.2017.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/09/2017] [Accepted: 01/12/2017] [Indexed: 01/09/2023]
Abstract
Nowadays, guidelines are derived from the findings of randomized controlled therapeutic trials. However, an overall significant P value does not exclude that some patients may be harmed by or will not respond to the therapeutic agent being studied. Trials in patients with a low risk of events and/or a limited chance of providing significant differences in therapeutic effects require a large patient population to demonstrate a beneficial effect. Composite efficacy endpoints are often employed to obviate the need for a large patient population when low rates of events or limited therapeutic efficacy are anticipated. Results of randomized controlled therapeutic trials are commonly expressed in terms of relative risk reduction, whereas absolute risk reduction allows the calculation of the "number needed to treat" to prevent an adverse outcome. The number needed to treat is a far more clinically relevant variable than relative risk reduction. The clinician's mission is to match treatment to patient with the goal of achieving optimal therapeutic response. Drug-safety monitoring is also of major importance to avoid exposing patients to irreversible adverse effects. Unfortunately, drug-safety monitoring is often overlooked in routine clinical practice. Finally, the lack of long-term therapeutic data (>5-10 years) is an unsolved dilemma, as most trials are limited to a duration of a few months or years.
Collapse
Affiliation(s)
| | - Shona Cosgrove
- Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Hélène Bouvaist
- Service de Cardiologie, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France
| | - Sylvestre Maréchaux
- Department of Cardiology, Groupement des Hôpitaux de l'Institut Catholique de Lille, Faculté Libre de Médecine, Université Catholique de Lille, 59000 Lille, France; INSERM U1088, Université de Picardie, Amiens, France
| | | | - Thierry Le Jemtel
- Tulane University Heart and Vascular Institute, Tulane School of Medicine, New Orleans, LA, USA
| | - Michel Andréjak
- Department of Clinical Pharmacology, CHU d'Amiens, 80054 Amiens cedex 1, France
| | - Denis Vital-Durand
- Department of Internal Medicine, CHU Lyon Sud, 69310 Pierre-Bénite, France
| |
Collapse
|
10
|
Albarqouni L, Doust J, Glasziou P. Patient preferences for cardiovascular preventive medication: a systematic review. Heart 2017; 103:1578-1586. [PMID: 28501795 DOI: 10.1136/heartjnl-2017-311244] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/11/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To systematically review current evidence regarding the minimum acceptable risk reduction of a cardiovascular event that patients feel would justify daily intake of a preventive medication. METHODS We used the Web of Science to track the forward and backward citations of a set of five key articles until 15 November 2016. Studies were eligible if they quantitatively assessed the minimum acceptable benefit-in absolute values-of a cardiovascular disease preventive medication among a sample of the general population and required participants to choose if they would consider taking the medication. RESULTS Of 341 studies screened, we included 22, involving a total of 17 751 participants: 6 studied prolongation of life (POL), 12 studied absolute risk reduction (ARR) and 14 studied number needed to treat (NNT) as measures of risk reduction communicated to the patients. In studies framed using POL, 39%-54% (average: 48%) of participants would consider taking a medication if it prolonged life by <8 months and 56%-73% (average: 64%) if it prolonged life by ≥8 months. In studies framed using ARR, 42%-72% (average: 54%) of participants would consider taking a medication that reduces their 5-year cardiovascular disease (CVD) risk by <3% and 50%-89% (average: 77%) would consider taking a medication that reduces their 5-year CVD risk by ≥3%. In studies framed using 5-year NNT, 31%-81% (average: 60%) of participants would consider taking a medication with an NNT of >30 and 46%-87% (average: 71%) with an NNT of ≤30. CONCLUSIONS Many patients require a substantial risk reduction before they consider taking a daily medication worthwhile, even when the medication is described as being side effect free and costless.
Collapse
Affiliation(s)
- Loai Albarqouni
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
| | - Jenny Doust
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Australia
| |
Collapse
|
11
|
Balder JW, de Vries JK, Mulder DJ, Kamphuisen PW. Time to improve statin prescription guidelines in low-risk patients? Eur J Prev Cardiol 2017; 24:1064-1070. [PMID: 28429651 PMCID: PMC5476184 DOI: 10.1177/2047487317698585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The challenge of the primary prevention of cardiovascular disease (CVD) is to identify patients who would benefit from treatment with statins. Statins are currently prescribed to many patients, even those at a low 10-year risk of CVD. These latter patients may not be eligible for statins according to current guidelines. Design This study investigated the prescription of guideline-consistent (according to guidelines) and guideline-inconsistent (not according to guidelines) lipid-lowering treatment in primary prevention in a large contemporary Dutch cohort study (Lifelines). Methods Lifelines is a large cohort study from the Netherlands. Participants were recruited between 2006 and 2013. They completed questionnaires and underwent a physical examination. Participants with previous CVD were excluded. Statins and ezetimibe were grouped as statin treatment. The Dutch guideline on cardiovascular management was used to assess eligibility for statins. Results Of 147,785 participants, 7092 (4.8%) reported statin treatment. In 4667 (66%) participants, statin treatment was inconsistent with the Dutch guideline. A total of 78% of these participants had a low 10-year predicted CVD risk. Multivariable logistic regression analysis showed that female sex and smoking were strongly associated with guideline-inconsistent treatment. Interestingly, 65% of the these participants had low-density lipoprotein cholesterol levels above the 95th percentile, adjusted for age and sex, two or more major risk factors of CVD or a positive family history of premature CVD. Therefore treatment might be reasonable. Conclusions There is a large inconsistency between guideline recommendations and the prescription of statins in clinical practice in the Netherlands. This is especially true for patients with low CVD risk. Many of these patients probably had risk-increasing circumstances justifying treatment.
Collapse
Affiliation(s)
- Jan W Balder
- 1 Section of Molecular Genetics, Department of Pediatrics, University of Groningen, University Medical Center Groningen, the Netherlands.,2 Department of Vascular Medicine, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Jeroen K de Vries
- 2 Department of Vascular Medicine, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Douwe J Mulder
- 2 Department of Vascular Medicine, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Pieter W Kamphuisen
- 2 Department of Vascular Medicine, University of Groningen, University Medical Center Groningen, the Netherlands.,3 Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands
| |
Collapse
|