Twenty-Year Nationwide Trends in Statin Utilization and Expenditure in Denmark

Temporal trends in patient demographics and kidney outcomes in cardiac surgery: a regional Danish follow-up study

OBJECTIVES

Chronic kidney disease can develop as a long-term complication after cardiac surgery-a condition associated with increased risk of new cardiovascular events, readmissions and mortality. Diagnosis is often delayed, as the condition is asymptomatic in early stages and post-discharge kidney follow-up is not routinely performed. We aimed to evaluate the occurrence and timing of chronic kidney disease after cardiac surgery in patients with normal preoperative kidney function and describe associated temporal trends in risk factors and mortality.

METHODS

Patients undergoing cardiac surgery at Odense University Hospital, Denmark, between January 2000 and May 2022 were identified from the Western Denmark Heart Registry. Clinical data were extracted and merged with biochemical data from regional laboratory systems. Only the most recent operation was included in the analysis. Patients with pre-existing kidney disease and endovascular procedures were excluded.

RESULTS

A total of 13 299 patients were included. Median follow-up time was 88 months (42-141 months). Competing risk analysis revealed that 13.8% developed chronic kidney disease within 3 years after surgery and 18.8% within 5 years. Overall 90-day mortality was 3.6%, and 1-year mortality was 5.1%, with variations over time. During the observation period, patients became older and more comorbid, while preoperative kidney function improved. Postoperative acute kidney injury occurred in 25-30% of patients, with increasing severity over time.

CONCLUSIONS

Chronic kidney disease is a common and serious complication following cardiac surgery. Identification of patients in high risk of chronic kidney disease is important to develop post-discharge follow-up programs and improve patient outcomes.

Statin use and risk of breast cancer among women with benign breast disease: a Danish nationwide cohort study

BACKGROUND

Statins have been suggested to protect against breast cancer risk, but the observational evidence is inconclusive. We examined the association between statin use and breast cancer incidence among women at higher risk of breast cancer due to a history of benign breast disease (BBD).

METHODS

Using Danish registries, we identified cancer-free women aged ≥50 years during 1996-2018 with a history of BBD and no prior statin prescriptions. Using Cox regression, we estimated multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for invasive breast cancer through 2020 with time-varying statin use defined according to continuity, duration, and intensity (estimated average daily dose), derived from prescription data.

RESULTS

Among 111,550 women, 7629 were diagnosed with breast cancer during median follow-up of 12.2 years. Overall statin use was not associated with breast cancer incidence (adjusted HR = 0.99; 95% CI, 0.93-1.06), with similar associations observed according to continuity and duration of use. However, long-term (≥10 years), high-intensity statin use was associated with a reduced HR of 0.75 (95% CI, 0.60-0.96).

CONCLUSIONS

Our findings did not indicate an association for overall statin use with breast cancer incidence among women with BBD. The inverse association with long-term, high-dose statin use requires further evaluation.

Statin effects on the lipidome: Predicting statin usage and implications for cardiovascular risk prediction

Statin therapy is a highly successful and cost-effective strategy for the prevention and treatment of cardiovascular diseases (CVD). Adjusting for statin usage is crucial when exploring the association of the lipidome with CVD to avoid erroneous conclusions. However, practical challenges arise in real-world scenarios due to the frequent absence of statin usage information. To address this limitation, we demonstrate that statin usage can be accurately predicted using lipidomic data. Using three large population datasets and a longitudinal clinical study, we show that lipidomic-based statin prediction models exhibit high prediction accuracy in external validation. Furthermore, we introduce a re-weighted model, designed to overcome a ubiquitous limitation of prediction models, namely the need for predictor alignment between training and target data. We demonstrated that the re-weighted models achieved comparable prediction accuracy to ad hoc models which use the aligned predictor between training and target data. This innovation holds promise for significantly enhancing the transferability of statin prediction and other 'omics prediction models, especially in situations where predictor alignment is incomplete. Our statin prediction model now allows for the inclusion of statin usage in lipidomic analyses of cohorts even where statin use is not available, improving the interpretability of the resulting analyses.

Global, regional, and national temporal trends in metabolism-related ischemic stroke mortality and disability from 1990 to 2021

BACKGROUND

Stroke ranks as the second leading cause of mortality and the third leading cause of disability worldwide. Nonetheless, the evolving burden of ischemic stroke attributable to various metabolic risk factors remains inadequately elucidated. A thorough grasp of these trends is crucial for a nuanced comprehension of stroke epidemiology and the formulation of effective preventive and interventional measures.

METHOD

Based on the Global Burden of Disease, Injury, and Risk Factors Study 2021 (GBD), we analyzed national temporal trends in the burden of metabolism-associated ischemic stroke in 204 countries and territories globally from 1990-2021, as measured by the average annual percentage change (AAPC), using join-point regression models. The burden of disease was assessed using age-standardized (ASR) mortality rates and disability-adjusted life years (DALY) per 100 000 population. Cross-country inequalities in ischemic stroke burden were quantified using standard health equity methods and changes in ischemic stroke burden were projected to 2045.

RESULTS

Globally, the ASR for ischemic stroke mortality linked to overall dietary metabolic risk declined by an average of 1.6% annually, while the ASR for disability-adjusted life years saw an average annual decrease of 1.3%. High systolic blood pressure remained a primary contributor to metabolism-related ischemic stroke, accounting for 57.9% of deaths and 58.0% of disability in 2021. Disparities associated with the sociodemographic index (SDI) diminished, with the gap in DALYs between countries with the highest and lowest SDIs narrowing from 592.2 (95% CI: 440.2-744.4) to 480.4 (95% CI: 309.7-651.2) in 2021. Projections indicate a continued decline in overall metabolism-related ischemic stroke deaths, mortality rates, and ASRs through 2045, although an increase in DALYs and ASRs is anticipated within the male population.

CONCLUSION

The global burden of metabolic risk-associated ischemic stroke has generally been decreasing from 2019 to 2021. This study highlights significant challenges in controlling and managing metabolic risk-associated ischemic stroke, including an increase in the number of cases in certain countries and regions, as well as an uneven distribution worldwide. These findings may provide valuable insights for the development of improved public health policies and the rational allocation of healthcare resources.

Low-density lipoprotein cholesterol response to statins according to comorbidities and co-medications: A population-based study

BACKGROUND

The response of low-density lipoprotein cholesterol (LDL-C) to statin therapy is variable, and may be affected by the presence of co-morbid conditions or the use of concomitant medications. Systematic variation in the response to statins based on these factors could affect the selection of the statin treatment regimen in population subgroups. We investigated whether common comorbidities and co-medications had clinically important effects on statin responses in individual patients.

METHODS

This register-based cohort study included 89,006 simvastatin or atorvastatin initiators with measurements of pre-statin and on-statin LDL-C levels, in Denmark, 2008-2018. We defined statin response as the percentage reduction in LDL-C, and used linear regression to estimate percentage reduction differences (PRD) according to 175 chronic comorbidities and 99 co-medications. We evaluated both the statistical significance (P-values corrected for multiple testing) and the clinical importance (PRD of 5 percentage points or more) of the observed associations.

RESULTS

Concomitant use of oral blood-glucose lowering drugs, which included metformin in 96% of treated individuals, was associated with a greater response to statin therapy that was both statistically significant and clinically important, with a PRD of 5.18 (95% confidence interval: 4.79 to 5.57). No other comorbidity or co-medication reached the prespecified thresholds for a significant, clinically important effect on statin response. Overall, comorbidities and co-medications had little effect on statin response, and altogether explained only 1.7% of the total observed population variance.

CONCLUSION

Most of the studied comorbidities and co-medications did not have a clinically important effect on statin response, suggesting no need to modify treatment regimens. However, use of metformin was associated with a significantly enhanced LDL-C response to statins, suggesting that lower statin doses may be effective in patients taking metformin.

Trends in the Use of Medications for Secondary Ischemic Stroke Prevention in Denmark, 2005-2021

BACKGROUND AND OBJECTIVES

Understanding trends in the use of medications for secondary stroke prevention is crucial for identifying areas for improvement in stroke care. We examined the use of lipid-lowering, antihypertensive, glucose-lowering, oral anticoagulant, and antiplatelet medications after ischemic stroke hospitalization, from 2005 to 2021.

METHODS

Using nationwide registries in Denmark, we identified a cohort of patients discharged from hospital with a first-time or recurrent ischemic stroke (N = 150,744). Stratified by calendar year, we ascertained the 180-day probability of filling a prescription for the abovementioned medications after discharge. We further assessed factors associated with medication use.

RESULTS

From 2005 to 2021, lipid-lowering medication use increased from 58.3% to 82.0%; atorvastatin use rose from 2.1% to 64.8% and simvastatin use decreased from 55.7% to 8.6%. Antihypertensive medication use remained stable, at approximately 89%, and various antihypertensive classes were used comparably. Glucose-lowering medication use increased from 71.5% in 2005 to 84.1% in 2021, driven primarily by an increase in metformin use (from 28.0% to 59.5%). Use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors continually increased (from 1.7% to 17.5% and from 0.5% to 17.3%, respectively) between 2015 and 2021. Anticoagulant medication use rose from 45.9% in 2005 to 87.0% in 2021, primarily because of increased use of direct oral anticoagulant medications starting around 2010 and a decline in warfarin use. Antiplatelet use remained consistently high, at approximately 95%. Trends were consistent across subgroups of interest; however, overall medication use was lower in older patients (65 years and older), patients with severe stroke, and patients with neurologic and psychiatric comorbidities.

DISCUSSION

Despite increasing trends in the use of 3 of 5 medication classes, the overall use of lipid-lowering, glucose-lowering, and oral anticoagulant medications was somewhat lower than expected according to clinical guidelines, particularly among older patients with more severe stroke and other comorbidities. The relatively low use in these subgroups may signify appropriate clinical decision making in consideration of frequent contraindications and reduced life expectancy or highlight potential areas of improvement for the care of patients with recent ischemic stroke.

Global, regional and national burden of ischemic stroke attributed to high low-density lipoprotein cholesterol, 1990-2019：A decomposition analysis and age-period-cohort analysis

High levels of low-density lipoprotein cholesterol (LDL-C) have been associated with an augmented mortality of ischemic stroke. The yearly deaths and mortality data of IS-hLDL-C were derived from the global burden of disease 2019 dataset. The joinpoint, age-period-cohort and decomposition analysis were utilized to evaluate the long-term patterns in the disease burden of IS-hLDL-C, and the effects of population growth and aging. Globally, in 2019, 0.61 million ischemic stroke-related deaths were attributable to high LDL-C, with the highest death burden in the high-middle socio-demographic index (SDI) region. From 1990 to 2019, the age-standardized death rate (ASDR) for IS-hLDL-C exhibited a downward trend, with an average annual percentage change of -1.69 [95% confidence interval: -1.90, -1.48)]. The fastest decreasing trends in ASDR were experienced in the high SDI region. In 119 (58.33%) countries, aging increased the disease burden of hLDL-IS, and population growth increased the disease burden of IS-hLDL-C in 163 (79.90%) countries. The trend in disease burden of IS-hLDL-C exhibited variation across countries and regions, particularly in territories with high to middle high SDI. Aging in upper to middle-income countries and population growth in low to middle-income countries further offset endeavors to reduce the burden of ischemic stroke deaths.

Eleven-Year Trends in Lipid-Modifying Medicines Utilisation and Expenditure in a Low-Income Country: A Study from the Republic of Srpska, Bosnia and Herzegovina

Background

In last two decades, there have been substantial changes in the pattern of lipid-modifying medicines utilisation following the new treatment guidelines based on clinical trials. The main purpose of this study was to analyse the overall utilisation and expenditure of lipid-modifying medicines in the Republic of Srpska, Bosnia and Herzegovina during an 11-year follow-up period and to express its share in relation to the total cardiovascular medicines (C group) utilisation.

Methods

In this retrospective, observational study, medicines utilisation data were analysed between 2010 and 2020 period using the ATC/DDD methodology and expressed as the number of DDD/1000 inhabitants/day (DDD/TID). The medicines expenditure analysis was used to estimate the annual expenditure of medicines in Euro based on DDD.

Results

During the analysed period, the use of lipid-modifying medicines increased almost 3-times (12.82 DDD/TID in 2010 vs 34.32 DDD/TID in 2020), with a rise in expenditure from 1.24 million Euro to 2.15 million Euro in the same period. This was mainly driven by an increased use of statins with 163.07%, and among these, rosuvastatin increased more than 1500-fold, and atorvastatin with 106.95% increase. With the appearance of generics, simvastatin showed a constant decline, while the other lipid-modifying medicines in relation to the total utilisation had a neglecting increase.

Conclusion

The use of lipid-modifying medicines in the Republic of Srpska has constantly increased and strongly corresponded to the adopted treatment guidelines and the positive medicines list of health insurance fund. The results and trends are comparable with other countries, but still the utilisation of lipid-lowering medicines represents the smallest share of total medicines use for the treatment of cardiovascular diseases, compared to high-income countries.

The long-term effect of generic price competition on the Hungarian statin market

BACKGROUND

Generic competition is a vital health policy tool used in regulating the pharmaceutical market. Drug group HMG-CoA reductase (3-hydroxy-3-methyl-glutaryl-coenzyme-A reductase) inhibitors, widely known as "statins," was the first drug group in Hungary in which generic prescriptions became mandatory. Our aim is to analyze the changes in the retail and wholesale margins through the generic competition regarding "statins".

METHODS

Data was derived from the nationwide pharmaceutical database of the Hungarian National Health Insurance Fund Administration, the only health care financing agency in Hungary. We observed the turnover data regarding the HMG-CoA-reductase inhibitor "statins" from 2010 through 2019. As the drugs under review have a fixed price point in Hungary, we effectively calculated the margins.

RESULTS

In 2010, the consumer expenditure of statins was 30.7 billion HUF ($148 million), which decreased by 59%, to 12.5 billion HUF ($42.9 million) in 2019. In 2010, the annual health insurance reimbursement of statins was 23.7 billion HUF ($114 million), which underwent a 63% decrease to 8.6 billion HUF ($29.7 million) in 2019. In 2010, the DOT turnover was 287 million days, and it increased to above 346 million days for 2019, which reflects a 20% increase over the past nine years. The monthly retail margins decreased from 334 million HUF ($1.6 million), (January, 2010) to 176 million HUF ($0.61 million), (December, 2019). The monthly wholesale margins decreased from 96.3 million HUF ($0.46 million), (January, 2010) to 41.4 million HUF ($0.14 million), (December, 2019). The most significant downturn in margins was due to the introduction of the first two blind bids. The combined DOT turnover in reference to the examined 43 products consistently increased.

CONCLUSIONS

The decline in retail and wholesale margin and in health insurance expenditures was largely due to a reduction in the consumer price of generic medicines. DOT turnover of statins also increased significantly.

Inclisiran-Safety and Effectiveness of Small Interfering RNA in Inhibition of PCSK-9

Dyslipidemia is listed among important cardiovascular disease risk factors. Treating lipid disorders is difficult, and achieving desirable levels of LDL-cholesterol (LDL-C) is essential in both the secondary and primary prevention of cardiovascular disease. For many years, statins became the basis of lipid-lowering therapy. Nevertheless, these drugs are often insufficient due to their side effects and restrictive criteria for achieving the recommended LDL-C values. Even the addition of other drugs, i.e., ezetimibe, does not help one achieve the target LDL-C. The discovery of proprotein convertase subtilisin/kexin type 9 (PCSK9) discovery has triggered intensive research on a new class of protein-based drugs. The protein PCSK9 is located mainly in hepatocytes and is involved in the metabolism of LDL-C. In the beginning, antibodies against the PCSK9 protein, such as evolocumab, were invented. The next step was inclisiran. Inclisiran is a small interfering RNA (siRNA) that inhibits the expression of PCSK9 by binding specifically to the mRNA precursor of PCSK9 protein and causing its degradation. It has been noticed in recent years that siRNA is a powerful tool for biomedical research and drug discovery. The purpose of this work is to summarize the molecular mechanisms, pharmacokinetics, pharmacodynamics of inclisiran and to review the latest research.

Ten-Year Evolution of Statin Eligibility and Use in a Population-Based Cohort

Studies showing that the management of dyslipidemia is suboptimal are hampered by their cross-sectional design or short follow-up. Using recent data from a population-based cohort with a 10-year follow-up, we assessed the use of statins, including their intensity. We used data from the CoLaus|PsyColaus study, involving 4,655 participants at baseline (2003 to 2006) and 3,587 at 10-year follow-up (2014 to 2017). We assessed the cardiovascular risk of participants according to established guidelines from the European Society of Cardiology (ESC) and from the American Heart Association/American College of Cardiology and estimated 10-year cardiovascular risk using corresponding risk scores, Systemic Coronary Risk Evaluation risk prediction model and Pooled Cohort Equations. We first determined eligibility for statins and adherence to recommendations at 2 time periods. Additionally, we assessed the prevalence of statin users from 2014 to 2017 in persons without atherosclerotic cardiovascular disease at baseline and who developed it during the follow-up (secondary prevention). A total of 219 participants developed a first atherosclerotic cardiovascular disease during follow-up. Statin use in eligible subjects was 25.9% and 24.0% from 2003 to 2006 and 35.9% and 26.3% from 2014 to 2017, according to ESC and American Heart Association/American College of Cardiology guidelines, respectively. Per ESC guidelines, only 28.2% of treated persons achieved low-density lipoproteins cholesterol target levels from 2014 to 2017 (15.8% from 2003 to 2006), and women less frequently attained goals. Only 18% of subjects used high-intensity statins from 2014 to 2017, with women less often receiving them (14% vs 22%). In secondary prevention, only 74% of eligible subjects were using statins. In conclusion, based on contemporaneous data, management of dyslipidemia is suboptimal, including in secondary prevention, especially in women who are less frequently treated and, if treated, less frequently receive high-intensity treatment.

Twenty-Three-Year Trends in the Use of Potentially Nephrotoxic Drugs in Denmark

Background

The occurrence of acute and chronic kidney diseases has been rising in the last decades. Although drug use is a common risk factor for impaired kidney function, changes in utilization of potential nephrotoxic drugs have received little attention.

Purpose

To describe temporal trends in the utilization of potentially nephrotoxic drugs in Denmark between 1999 and 2021.

Methods

Specific drugs known or suspected to be nephrotoxic were identified in the literature. Data on the sold defined daily doses (DDDs) of potentially nephrotoxic drugs between 1999 and 2021 were retrieved using the Danish Register of Medical Product Statistics. Trends in sales of DDDs per 1000 inhabitants per day were tabulated and illustrated graphically.

Results

From 1999 to 2021, the total sale of all selected drugs increased from 286 to 457 DDDs per 1000 inhabitants per day. The overall sale reached a preliminary peak in 2012 with 449 DDDs per 1000 inhabitants per day and remained relatively stable thereafter until reaching an all-time high in 2021 with 457 DDDs per 1000 inhabitants per day. Contributing with the majority in volume, sales of drugs inhibiting the renin-angiotensin-aldosterone system (RAAS) increased dramatically throughout the period. The same was observed for acetaminophen, methotrexate, tacrolimus, and iodinated contrast dye. In contrast, the sales of diuretics, acetylsalicylic acid, and ciclosporin decreased during the last decade of the study period.

Conclusion

From 1999-2021 considerable changes in sales of potentially nephrotoxic drugs were observed. In general, the sales increased, in volume predominated by RAAS inhibiting drugs. This increase in sales of potential nephrotoxins could contribute to an increasing occurrence of kidney diseases.

National Trends in Statin Use in Lithuania from 2010 to 2021

Objective: In Lithuania, no comprehensive national research on statin utilization and trends has yet been undertaken. Nonetheless, this knowledge is critical for the healthcare system to identify key areas for development. We aimed to analyze trends in statin utilization in Lithuania from the past 12 years considering changes in reimbursement policies and the publication of updated international CVD prevention guidelines. Methods: We performed a retrospective, descriptive study of statin utilization in Lithuania from 2010 to 2021. The data were obtained from PharmaZOOM LT, an independent software supplier with nationwide coverage on pharmaceutical market data. The data coverage was 95%. We used anatomical therapeutic chemical (ATC) classification for data extraction and calculated defined daily doses (DDDs) according to the ATC/DDD Toolkit of World Health Organization according to statin dose in a pill. Results: Statin use increased overall from 8.28 DDD/TID in 2010 to 96.06 DDD/TID in 2021. The annual growth rate in sales of statin DDD/TID was 22.28%. The increase was mostly due to the increase in moderate- and high-intensity statins. The increases coincided with changes in reimbursement policy or the publication of international guidelines. Polypill use in Lithuania began steadily increasing after 2016 and reached 19.37% of the total DDD/TID of statins in 2021. Conclusions: The use of statins has increased dramatically in Lithuania over the last decade. Changes in statin reimbursement regulations in the country, as well as worldwide cardiovascular preventive recommendations aiming at lower LDL-C objectives, fueled the progress.

Dyslipidemia and the preventive potential in the Greenlandic population

Background

Low-density lipoprotein cholesterol (LDL-C) is a well-established risk factor for development of cardiovascular diseases. Based on available clinical data, we aimed to investigate the plasma lipid profile in the Greenlandic population, the proportion on cholesterol-lowering treatment and the adherence to local indications for cholesterol-lowering therapy.

Methods

This is an observational cross-sectional study of the adult (≥21 years) Greenlandic population with focus on clinically determined lipid levels from 2017 to early 2022. We investigated levels of dyslipidemia and assessed cholesterol-lowering medication usage in individuals with an indication according to current Greenlandic guidelines, which include a) LDL-C >5 mmol/l, b) diabetes, c) diagnosed atherosclerotic disease and 4) a SCORE2 >7.5%.

Results

In the adult Greenlandic population of 40,565 individuals a lipid profile was available in 13,895 with a mean LDL-C of 3.0 mmol/L and 976 (7%) had a LDL-C >5 mmol/l. One or more indications for cholesterol-lowering medication was present in 3988 individuals and a total of 5464 adult Greenlanders either fulfilled local criteria for statin therapy or received a statin (some without current indication) and among these, 2232 (41%) individuals received no statin.

Conclusion

These findings indicate that clinically significant dyslipidemia is common in the adult Greenlandic population and that the cardiovascular preventive potential of cholesterol-lowering therapy is currently underutilized.

Global Trends in the Epidemiology and Management of Dyslipidemia

Dyslipidemia, especially a circulating non-optimal level of cholesterol, is one of the most important risk factors for atherosclerotic cardiovascular disease (ASCVD), which accounts for the most deaths worldwide. Maintaining a healthy level of blood cholesterol is an important prevention strategy for ASCVD, through lifestyle intervention or cholesterol-lowering therapy. Over the past three decades, the epidemiology and management of dyslipidemia has changed greatly in many countries. Therefore, it is necessary to understand the current epidemiologic features of dyslipidemia and challenges from a global perspective.

Thirteen-year trends in cardiovascular risk in men and women with chronic coronary syndrome

AIMS

To examine combined and sex-specific temporal changes in risks of adverse cardiovascular events and coronary revascularization in patients with chronic coronary syndrome undergoing coronary angiography.

METHODS AND RESULTS

We included all patients with stable angina pectoris and coronary artery disease examined by coronary angiography in Western Denmark from 2004 to 2016. Patients were stratified by examination year interval: 2004-2006, 2007-2009, 2010-2012, and 2013-2016. Outcomes were 2-year risk of myocardial infarction, ischaemic stroke, cardiac death, and all-cause death estimated by adjusted incidence rate ratios using patients examined in 2004-2006 as reference. A total of 29 471 patients were included, of whom 70% were men. The 2-year risk of myocardial infarction [2.8% vs. 1.9%, adjusted incidence rate ratio 0.65, 95% confidence interval (CI) 0.53-0.81], ischaemic stroke (1.8% vs. 1.1%, adjusted incidence rate ratio 0.48, 95% CI 0.37-0.64), cardiac death (2.1% vs. 0.9%, adjusted incidence rate ratio 0.38, 95% CI 0.29-0.51), and all-cause death (5.0% vs. 3.6%, adjusted incidence rate ratio 0.65, 95% CI 0.55-0.76) decreased from the first examination interval (2004-2006) to the last examination interval (2013-2016). Coronary revascularizations also decreased (percutaneous coronary intervention: 51.6% vs. 42.5%; coronary artery bypass grafting: 24.6% vs. 17.5%). Risk reductions were observed in both men and women, however, women had a lower absolute risk.

CONCLUSION

The risk for adverse cardiovascular events decreased substantially in both men and women with chronic coronary syndrome from 2004 to 2016. These results most likely reflect the cumulative effect of improvements in the management of chronic coronary artery disease.

Global epidemiology of dyslipidaemias

Dyslipidaemias are alterations to the plasma lipid profile that are often associated with clinical conditions. Dyslipidaemias, particularly elevated plasma LDL-cholesterol levels, are major risk factors for cardiovascular disease, but some forms, such as hypertriglyceridaemia, are associated with severe diseases in other organ systems, including non-alcoholic fatty liver disease and acute pancreatitis. Dyslipidaemias can be genetically determined (primary or familial dyslipidaemias) or secondary to other conditions (such as diabetes mellitus, obesity or an unhealthy lifestyle), the latter being more common. Hypercholesterolaemia is the most common form of dyslipidaemia and is associated with an increased risk of cardiovascular disease, with elevated plasma LDL-cholesterol levels being the 15th leading risk factor for death in 1990, rising to 11th in 2007 and 8th in 2019. The global burden of dyslipidaemias has increased over the past 30 years. Furthermore, the combination of high triglyceride levels and low HDL-cholesterol levels (together with the presence of small, dense LDL particles), referred to as atherogenic dyslipidaemia, is highly prevalent in patients with diabetes or metabolic syndrome and increases their risk of cardiovascular disease. Given the increasing prevalence of diabetes worldwide, treating lipid abnormalities in these patients might reduce their risk of cardiovascular disease.

Statin Initiation and Risk of Amyotrophic Lateral Sclerosis: A Danish Population-based Cohort Study

BACKGROUND

The evidence of an association between statins and amyotrophic lateral sclerosis (ALS) is heterogeneous and inconclusive.

METHODS

We performed a population-based cohort study consisting of 974,304 statin initiators ≥40 years of age and 1,948,606 matched general population comparators identified from Danish, nationwide registries (1996-2016). We computed incidence rates and hazard ratios (HRs) of a first-time hospital-based diagnosis of ALS. HRs were controlled for sex, birth year, calendar year, medically diagnosed comorbidities, and concomitant medications.

RESULTS

During a median follow-up of 7.7 years, 852 ALS events occurred among statin initiators (11.3 [95% confidence interval (CI) = 10.6, 12.1] events per 100,000 person-years) and 1,679 among noninitiators (11.4 [95% CI = 10.9, 12.0] events per 100,000 person years). The overall adjusted HR indicated a slight association between statin initiation and ALS (1.11 [95% CI = 1.00, 1.23]. In the first year after initiation, the HR was 1.40 (95% CI = 1.09, 1.79) for both sexes combined, 1.00 (95% CI = 0.70, 1.42) for men, and 1.92 (95% CI = 1.30, 2.82) for women. The associations diminished to approximately null after the first year of follow-up for both sexes combined and for men, but point estimates were above 1 for women until 10 years after initiation.

CONCLUSIONS

Statin initiation was largely unassociated with ALS diagnosis but was associated with an elevated risk of ALS in women, especially in the first year after initiation. The association could be explained by reverse causation, detection bias, early neurotoxic effects of statins that affect women more than men, or a combination thereof.

Opportunity for Genotype-Guided Prescribing Among Adult Patients in 11 US Health Systems

The value of utilizing a multigene pharmacogenetic panel to tailor pharmacotherapy is contingent on the prevalence of prescribed medications with an actionable pharmacogenetic association. The Clinical Pharmacogenetics Implementation Consortium (CPIC) has categorized over 35 gene-drug pairs as "level A," for which there is sufficiently strong evidence to recommend that genetic information be used to guide drug prescribing. The opportunity to use genetic information to tailor pharmacotherapy among adult patients was determined by elucidating the exposure to CPIC level A drugs among 11 Implementing Genomics In Practice Network (IGNITE)-affiliated health systems across the US. Inpatient and/or outpatient electronic-prescribing data were collected between January 1, 2011 and December 31, 2016 for patients ≥ 18 years of age who had at least one medical encounter that was eligible for drug prescribing in a calendar year. A median of ~ 7.2 million adult patients was available for assessment of drug prescribing per year. From 2011 to 2016, the annual estimated prevalence of exposure to at least one CPIC level A drug prescribed to unique patients ranged between 15,719 (95% confidence interval (CI): 15,658-15,781) in 2011 to 17,335 (CI: 17,283-17,386) in 2016 per 100,000 patients. The estimated annual exposure to at least 2 drugs was above 7,200 per 100,000 patients in most years of the study, reaching an apex of 7,660 (CI: 7,632-7,687) per 100,000 patients in 2014. An estimated 4,748 per 100,000 prescribing events were potentially eligible for a genotype-guided intervention. Results from this study show that a significant portion of adults treated at medical institutions across the United States is exposed to medications for which genetic information, if available, should be used to guide prescribing.

A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis

Importance

Management of transient ischemic attack (TIA) has gained significant attention during the past 25 years after several landmark studies indicated the high incidence of a subsequent stroke.

Objective

To calculate the pooled event rate of subsequent ischemic stroke within 2, 7, 30, and 90 days of a TIA and compare this incidence among the population with TIA recruited before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C).

Data Sources

All published studies of TIA outcomes were obtained by searching PubMed from 1996, to the last update on January 31, 2020, irrespective of the study design, document type, or language.

Study Selection

Of 11 516 identified citations, 175 articles were relevant to this review. Both the classic time-based definition of TIA and the new tissue-based definition were accepted. Studies with a combined record of patients with TIA and ischemic stroke, without clinical evaluation for the index TIA, with diagnosis of index TIA event after ischemic stroke occurrence, with low suspicion for TIA, or duplicate reports of the same database were excluded.

Data Extraction and Synthesis

The study was conducted and reported according to the PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality assessment used the Quality in Prognosis Studies tool. Publication bias was visualized by funnel plots and measured by the Begg-Mazumdar rank correlation Kendall τ2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models.

Main Outcomes and Measures

The proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size.

Results

Systematic review yielded 68 unique studies with 223 866 unique patients from 1971 to 2019. The meta-analysis included 206 455 patients (58% women) during a span of 4 decades. The overall subsequent ischemic stroke incidence rates were estimated as 2.4% (95% CI, 1.8%-3.2%) within 2 days, 3.8% (95% CI, 2.5%-5.4%) within 7 days, 4.1% (95% CI, 2.4%-6.3%) within 30 days, and 4.7% (95% CI, 3.3%-6.4%) within 90 days. There was a recurrence risk of 3.4% among group A in comparison with 2.1% in group B or 2.1% in group C within 2 days; 5.5% in group A vs 2.9% in group B or 3.2% in group C within 7 days; 6.3% in group A vs 2.9% in group B or 3.4% in group C within 30 days, and 7.4% in group A vs 3.9% in group B or 3.9% in group C within 90 days.

Conclusions and Relevance

These findings suggest that TIA continues to be associated with a high risk of early stroke; however, the rate of post-TIA stroke might have decreased slightly during the past 2 decades.

Trends in lipid-modifying agent use in 83 countries

BACKGROUND AND AIMS

Lipid-modifying agents (LMAs) are increasingly used to reduce lipid levels and prevent cardiovascular events but the magnitude of their consumption in different world regions is unknown. We aimed to describe recent global trends in LMA consumption and to explore the relationship between country-level LMA consumption and cholesterol concentrations.

METHODS

This cross-sectional and ecological study used monthly pharmaceutical sales data from January 2008 to December 2018 for 83 countries from the IQVIA Multinational Integrated Data Analysis System and total and non-high-density lipoprotein (non-HDL) cholesterol concentrations from the NCD Risk Factor Collaboration. Compound annual growth rate (CAGR) was used to assess changes in LMA consumption over time.

RESULTS

From 2008 to 2018, use of LMAs increased from 7468 to 11,197 standard units per 1000 inhabitants per year (CAGR 4.13%). An estimated 173 million people used LMAs in 2018. Statins were the most used class of LMA and their market share increased in 75% of countries between 2008 and 2018. From 2013 to 2018, consumption of low-density lipoprotein lowering therapies increased (statins 3.99%; ezetimibe 4.01%; proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors 104.47%). Limited evidence supports a clear relationship between country-level changes in LMA consumption and mean total and non-HDL cholesterol concentrations in 2008 versus 2018.

CONCLUSIONS

Since 2008, global access to LMAs, especially statins, has improved. In line with international lipid guideline recommendations, recent trends indicate growth in the use of statins, ezetimibe, and PCSK9 inhibitors. Country-level patterns of LMA use and total and non-HDL cholesterol varied considerably.

Geranylgeranyl pyrophosphate amplifies Treg differentiation via increased IL-2 expression to ameliorate DSS-induced colitis

Blocking the mevalonate pathway for cholesterol reduction by using statin may have adverse effects including statin-induced colitis. Moreover, one of the predisposing factors for colitis is an imbalanced CD4⁺ T cell, which can be observed on the complete deletion of HMG-CoA reductase (HMGCR), a target of statins. In this study, we inquired geranylgeranyl pyrophosphate (GGPP) is responsible for maintaining the T-cell homeostasis. Following dextran sulfate sodium (DSS)-induced colitis, simvastatin increased the severity of disease, while cotreatment with GGPP, but not with cholesterol, reversed the disease magnitude. GGPP ameliorated DSS-induced colitis by increasing T_reg cells. GGPP amplified T_reg differentiation through increased IL-2/STAT 5 signaling. GGPP prenylated Ras protein, a prerequisite for extracellular signal-regulated kinase (ERK) pathway activation, leading to increased IL-2 production. Higher simvastatin dose increased the severity of colitis. GGPP ameliorated simvastatin-increased colitis by increasing T_reg cells. T_reg cells, which have the capacity to suppress inflammatory T cells and were generated through IL-2/STAT5 signaling, increased IL-2 production through prenylation and activation of the Ras/ERK pathway.

Temporal Changes in Secondary Prevention and Cardiovascular Outcomes After Revascularization for Peripheral Arterial Disease in Denmark: A Nationwide Cohort Study

BACKGROUND

Patients with peripheral arterial disease (PAD) are at increased risk of cardiovascular morbidity and mortality. Medical prevention with antithrombotic and statin therapies is a mainstay of treatment to prevent adverse outcomes; nevertheless, patients with PAD are often undertreated. This study describes the temporal changes in medical prevention and adverse outcomes in a national cohort of patients with symptomatic PAD after revascularization.

METHODS

We identified all patients with a first open surgical or endovascular revascularization procedure in the lower extremities or abdomen in Denmark, from 2000 to 2016. We examined temporal changes in the use of aspirin, clopidogrel, and statins and 1-year cause-specific hazard ratios for adverse clinical outcomes, after adjusting for procedure type, treatment indication, age, sex, and cardiovascular risk factors. The analyses were performed overall and within strata of index procedure (endovascular versus surgical), treatment indication, age, sex, and high-risk comorbidities.

RESULTS

Between 2000 and 2016, we identified 32 911 patients who underwent revascularization for symptomatic PAD. The mean age was 69 years and increased over time, as did the burden of comorbidity. The cumulative incidence of medication use increased between 2000 to 2004 and 2013 to 2016, respectively, from 57.3% to 64.3% for aspirin, 3.6% to 24.8% for clopidogrel, and 36.2% to 77.1% for statins. Concurrently, the 1-year outcome rates declined. Compared with 2000 to 2004, the adjusted hazard ratios in 2013 to 2016 were 0.73 (95% CI, 0.62-0.84) for major adverse cardiovascular events, 0.92 (95% CI, 0.85-1.00) for major adverse limb events, 0.60 (95% CI, 0.48-0.74) for myocardial infarction, 0.94 (95% CI, 0.75-1.18) for ischemic stroke, 0.92 (95% CI, 0.75-1.12) for major bleeding, 0.54 (95% CI, 0.39-0.76) for cardiovascular death, and 0.80 (95% CI, 0.72-0.88) for all-cause death. These improvements in prognosis were most prominent from 2000 to 2004 to 2005 to 2008 and occurred in all strata of index procedure, treatment indication, sex, age, and comorbidity. In contrast, the adjusted hazard ratio for major amputations was 1.00 (95% CI, 0.90-1.11) when comparing 2013 to 2016 to 2000 to 2004.

CONCLUSIONS

Medical prevention of adverse events has increased considerably over time in patients who underwent revascularization for symptomatic PAD. This increase was accompanied by reductions in all adverse outcomes, except major amputations.

Danish National Trends in Cardiovascular Disease and Cancer Drug Expenditure in Relation to Trends in Cardiovascular Disease and Cancer Deaths

BACKGROUND

Cancer and cardiovascular disease are the 2 leading causes of death in most developed countries, making up the majority of national health care expenditures. In this study, we investigated nationwide trends of cardiovascular disease and cancer drug expenditure in relation to concomitant trends in cardiovascular disease and cancer death rates.

METHODS

We obtained cardiovascular and cancer drug expenditure data in Denmark through the Danish Register of Medical Product Statistics. Trends in cancer deaths and cardiovascular disease deaths were observed by linkage to the cancer statistics for the Nordic Countries and Danish Heart Foundation databases.

RESULTS

Our data show that introduction and rapid uptake of generic versions of most cardiovascular disease drugs have resulted in a remarkable cost-neutral development in cardiovascular disease drug expenditure from 1995 to 2018 despite increased drug use. This development is contrasted to cancer drug expenditure, which has increased more than 15-fold in the same period. Since 2006, expenditure for cancer drugs has exceeded that for cardiovascular disease drugs and is now more than triple that cost. However, death rates for cancer have dropped a fraction as much as for cardiovascular disease.

CONCLUSION

Our results point to a disproportionate high mortality-adjusted expenditure for cancer drugs compared to cardiovascular disease drugs and demonstrate an enormous potential for national health care savings when cheaper versions like biosimilars of many cancer drugs are introduced.

Temporal trends of acute kidney injury in patients undergoing percutaneous coronary intervention over a span of 12 years

BACKGROUND

AKI is a known complication of PCI and is associated with higher rates of adverse events. We assessed temporal trends in rates of AKI, factors associated with risk of AKI and prognosis.

METHODS

From a prospective registry of patients undergoing PCI at two hospitals of the Rabin Medical Center, 15,153 consecutive patients were assessed at two time periods: 2006-2012 and 2012-2018. AKI was defined as either a relative elevation of ≥25% in serum creatinine or an absolute elevation of ≥0.5 mg/dl in serum creatinine at 48 h post PCI.

RESULTS

Data for 7913 patients from 2006 to 2012 and 7240 during 2012-2018 was available for analysis. Mean age was 65.0 ± 11.9y and 66.0 ± 12.3y (p < 0.001) and baseline creatinine was 1.08 ± 0.87 mg/dl and 1.15 ± 0.97 mg/dl, respectively (p < 0.001). Rates of AKI were 11.1% in the early and 7.3% in the late period (p < 0.001). Following adjustment, risk of AKI was lower in the late period (OR- 0.72; 95% CI 0.61-0.85, p < 0.001). AKI was associated with increased MACE (HR 1.62; 95% CI 1.44-1.82, p < 0.001 for the early period and HR 2.11; 95% CI 1.80-2.46, P < 0.001 for the late period) and death (HR 1.86; 95% CI 1.64-2.11, p < 0.001; HR 2.4; 95% CI 2.02-2.86; p < 0.001) in both time periods.

CONCLUSIONS

Over time, there was an improvement in the rates of post-PCI AKI. Increased adverse outcomes were evident at both periods. Further research is warranted, to further reduce peri-procedural AKI which is associated with impaired prognosis.

Global variation of risk thresholds for initiating statins for primary prevention of cardiovascular disease: a benefit-harm balance modelling study

BACKGROUND

We previously showed that the 10-year cardiovascular disease (CVD) risk threshold to initiate statins for primary prevention depends on the baseline CVD risk, age, sex, and the incidence of statin-related harm outcome and competing risk for non-CVD death. As these factors appear to vary across countries, we aimed in this study to determine country-specific thresholds and provide guidelines a quantitative benefit-harm assessment method for local adaptation.

METHODS

For each of the 186 countries included, we replicated the benefit-harm balance analysis using an exponential model to determine the thresholds to initiate statin use for populations aged 40 to 75 years, with no history of CVD. The analyses took data inputs from a priori studies, including statin effect estimates (network meta-analysis), patient preferences (survey), and baseline incidence of harm outcomes and competing risk for non-CVD (global burden of disease study). We estimated the risk thresholds above which the benefits of statins were more likely to outweigh the harms using a stochastic approach to account for statistical uncertainty of the input parameters.

RESULTS

The 5th and 95th percentiles of the 10-year risk thresholds above which the benefits of statins outweigh the harms across 186 countries ranged between 14 and 20% in men and 19-24% in women, depending on age (i.e., 90% of the country-specific thresholds were in the ranges stated). The median risk thresholds varied from 14 to 18.5% in men and 19 to 22% in women. The between-country variability of the thresholds was slightly attenuated when further adjusted for age resulting, for example, in a 5th and 95th percentiles of 14-16% for ages 40-44 years and 17-21% for ages 70-74 years in men. Some countries, especially the islands of the Western Pacific Region, had higher thresholds to achieve net benefit of statins at 25-36% 10-year CVD risks.

CONCLUSIONS

This extensive benefit-harm analysis modeling shows that a single CVD risk threshold, irrespective of age, sex and country, is not appropriate to initiate statin use globally. Instead, countries need to carefully determine thresholds, considering the national or subnational contexts, to optimize benefits of statins while minimizing related harms and economic burden.

A safety, tolerability, and pharmacokinetic study of a novel simvastatin silica-lipid hybrid formulation in healthy male participants

Simvastatin (SIM) is a commonly used cholesterol-lowering drug that can reduce the risk of major cardiovascular events. However, due to its poor intrinsic water solubility, the drug is poorly absorbed from the gastrointestinal tract and exhibits a low oral bioavailability of approximately 5%. The aim of this study was to fabricate and optimize SIM encapsulated silica-lipid hybrids (SLH) as a solid-state lipid-based formulation to enhance absorption and bioavailability during a human in vivo pharmacokinetic study. SLH formulations were formulated by spray drying a submicron emulsion with either Aerosil® 300 fumed silica nanoparticles (SLH-A) or Syloid® 244 amorphous micronized silica (SLH-B). A cross-over, double-blinded study design was implemented to evaluate the performance of SLH formulations compared with a commercially available formulation in 12 healthy male participants after oral administration under fasting conditions. SLH formulations enhanced the bioavailability of SIM up to 1.6-fold and more importantly the active simvastatin acid (SIMA), 3.5-fold when compared with an equivalent dose of commercial formulation. The results demonstrate that the porous nanostructure of SLH impact systemic SIM and SIMA concentrations and may serve as a novel approach to enhance the bioavailability of specifically the parent or metabolite. No significant difference was observed in exposure when SLH formulations were administered at 10 mg in comparison with 20 mg of the commercial formulation, suggesting the potential for dose reduction. The study indicated that SLH formulations were safe and well-tolerated when administered to healthy males, confirming the commercial potential of SLH to enhance the bioavailability of poorly water-soluble drugs. Graphical abstract.

Systematic review and meta-analysis of studies assessing the relationship between statin use and risk of ovarian cancer

PURPOSE

The link between lipid-stabilizing medications and epithelial ovarian carcinogenesis is incompletely understood. Statins may reduce ovarian cancer risk, but results are inconclusive.

METHODS

We conducted a systematic review and meta-analysis of studies reporting associations between statin use and ovarian cancer risk in PubMed. Summary risk ratios (RRs) and confidence intervals (CIs) were calculated. Subgroup analyses by cancer histotype, statin class (lipo- or hydrophilic) and duration of statin use were conducted. Use of individual statins in populations was assessed to determine population-specific differences in statin types.

RESULTS

Nine studies with 435,237 total women were included (1 randomized controlled trial (RCT); 4 prospective; 4 case-control). Statin use was associated with a reduced risk of ovarian cancer (RR 0.87, 95% CI 0.74-1.03) and risk was significantly reduced in populations with low pravastatin use (RR 0.83, 95% CI 0.70-0.99). Risk estimates varied by statin class (3 studies; lipophilic: RR 0.88, 95% CI 0.69-1.12; hydrophilic: RR 1.06, 95% CI 0.72-1.57) and cancer histotype (3 studies; serous: RR 0.95, 95% CI 0.69-1.30; clear cell: RR 1.17, 95% CI 0.74-1.86). Long-term use was associated with a reduced risk of ovarian cancer (RR 0.77, 95% CI 0.54-1.10) that further reduced when pravastatin use was low (RR 0.68, 95% CI 0.46-1.01). Between-study heterogeneity was high overall and in subgroups (I² > 60%).

CONCLUSION

Statins may be associated with a reduced risk of ovarian cancer, but the effect likely differs by individual statin, duration of use and cancer histotype. Additional well-powered studies are needed to elucidate important subgroup effects.

Statin use and risk of acute diverticulitis: A population-based case-control study

The goal of the study was to examine the association between statin use and the development of acute diverticulitis requiring hospital admission.Acute diverticulitis is a common and costly gastrointestinal disorder. Although the incidence is increasing its pathophysiology and modifiable risk factors are incompletely understood. Statins affect the inflammatory response and represent a potential risk reducing agent.A retrospective, population-based, case-control study was carried out on a cohort of adults, resident in Canterbury, New Zealand. All identified cases were admitted to hospital and had computed tomography confirmed diverticulitis. The positive control group comprised patients on non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs), and the negative control group were patients on selective serotonin reuptake inhibitors (SSRIs). Medicine exposure was obtained from the Pharmaceutical Management Agency of New Zealand. Subgroup analysis was done by age and for complicated and recurrent diverticulitis.During the study period, there were 381,792 adults resident in Canterbury. The annual incidence of diverticulitis requiring hospital presentation was 18.6 per 100,000 per year. Complicated disease was seen in 37.4% (158) of patients, and 14.7% (62) had recurrent disease. Statins were not found to affect the risk of developing acute diverticulitis, nor the risk of complicated or recurrent diverticulitis. Subgroup analysis suggested statin use was associated with a decreased risk of acute diverticulitis in the elderly (age >64 years). NSAIDs were associated with a decreased risk of acute diverticulitis (risk ratio = 0.65, confidence interval: 0.26-0.46, P < .01), as were SSRIs (risk ratio = 0.37, confidence interval: 0.26-0.54, P < .01).This population-based study does not support the hypothesis that statins have a preventative effect on the development of diverticulitis, including complicated disease. We also found a decreased risk of diverticulitis associated with NSAID and SSRI use.

Ischemic heart failure as a complication of incident acute myocardial infarction: Timing and time trends: A national analysis including 78,814 Danish patients during 2000-2009

Aim: Heart failure is a serious complication of acute myocardial infarction leading to poor prognosis. We aimed at exploring time trends of heart failure and their impact on mortality among patients with an incident acute myocardial infarction. Methods: From the National Patient Danish Registry we collected data on all patients hospitalized with an incident of acute myocardial infarction during 2000-2009 and identified cases with in-hospital heart failure (presented on admission or developing heart failure during acute myocardial infarction hospitalization) or post-discharge heart failure (a hospitalization or outpatient visit following acute myocardial infarction discharge), and assessed in-hospital, 30-day and 1-year mortality. Results: Of the 78,814 patients included in the study, 10,248 (13.0%) developed in-hospital heart failure. The odds of in-hospital heart failure declined 0.9% per year (odds ratio=0.991, 95% confidence interval: 0.983-0.999). In-hospital heart failure was associated with 13% (odds ratio=1.13, 95% confidence interval: 1.06-1.20) and 14% (odds ratio=1.14, 95% confidence interval: 1.07-1.20) higher in-hospital and 30-day mortality, respectively. Of the 61,637 patients discharged alive without in-hospital heart failure, 5978 (9.7%) experienced post-discharge heart failure, 4116 (6.7%) were hospitalized and 1862 (3.0%) were diagnosed at outpatient clinics. The risk of heart failure requiring hospitalization declined 5.5% per year (hazard ratio=0.945, 95% confidence interval: 0.934-0.955) whereas the risk of heart failure diagnosed at outpatient clinics increased 13.4% per year (hazard ratio=1.134, 95% confidence interval: 1.115-1.153). Post-discharge heart failure was associated with 239% (hazard ratio=3.39, 95% confidence interval: 3.18-3.63) higher 1-year mortality. Conclusions: In-hospital and post-discharge heart failure requiring hospitalization decreased whereas post-discharge heart failure diagnosed at outpatient clinics increased among incident acute myocardial infarction patients during 2000-2009. The development of heart failure, especially after acute myocardial infarction discharge, indicates a poor prognosis.

Statin treatment, oxidative stress and inflammation in a Danish population

Background

While statins may have anti-inflammatory effects, anti-oxidative effects are controversial. We investigated if statin treatment is associated with differences in oxidatively generated nucleotide damage and chronic inflammation, and the relationship between nucleotide damage and chronic inflammation.

Methods

We included 19,795 participants from the Danish General Suburban Population Study. In 3420 participants, we measured urinary 8-oxodG and 8-oxoGuo by liquid chromatography-tandem mass spectrometry as markers of oxidatively generated damage to DNA and RNA, respectively. We used a composite score for chronic inflammation (INFLA score) of hsCRP, WBC, platelet count, and neutrophil granulocyte to lymphocyte ratio. Associations were assessed using multivariate linear regression models.

Results

Compared with non-users, statin users had 4.3–6.0% lower 8-oxodG in three separate models (p < 0.05); there were no differences in 8-oxoGuo. Among participants aged > 60 y, statin users had 11.4% lower 8-oxodG (95%CI: 6.7–15.9%, p_interaction<0.001) and 3.9% lower 8-oxoGuo (95%CI: 0.1–7.5%, p_interaction = 0.002), compared with non-users. Compared with non-users, statin users had 11.1% (95%CI: 5.4–16.5%, p_interaction<0.001) lower 8-oxodG in participants treated for hypertension, and 18.6% (95%CI: 6.8–28.9%, p_interaction<0.001) lower 8-oxodG in participants with decreased renal function. Compared with non-users, statin users had significantly lower INFLA score (p < 0.001). 8-oxodG and 8-oxoGuo associated positively with markers of chronic inflammation.

Conclusions

Oxidatively generated DNA damage and inflammatory burden are lower in statin users compared with non-users. Together, anti-oxidative and anti-inflammatory effects may contribute to the beneficial effects of statins.

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Statin users have lower oxidatively generated DNA damage than non-users.

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The protective effect of statins is more pronounced in high-risk groups.

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Statin users have lower levels of chronic inflammation than non-users.