The Danish-Norwegian randomized trial on beta-blocker therapy after myocardial infarction: Design, rationale, and baseline characteristics

BACKGROUND AND AIMS

The evidence for beta-blocker therapy after myocardial infarction (MI) is randomized trials conducted more than 30 years ago, and the continued efficacy has been questioned.

DESIGN AND METHODS

The ongoing Danish (DANBLOCK) and Norwegian (BETAMI) randomized beta-blocker trials are joined to evaluate the effectiveness and risks of long-term beta-blocker therapy after MI. Patients with normal or mildly reduced left ventricular ejection fraction (LVEF ≥ 40%) will be randomized to open-label treatment with beta-blockers or no such therapy. The event-driven trial will randomize ∼5700 patients and continue until 950 primary endpoints have occurred. As of July 2023, 5228 patients have been randomized. Of the first 4000 patients randomized, median age was 62 years, 79% were men, 48% had a ST-segment elevation myocardial infarction (STEMI), and 84% had a normal LVEF. The primary endpoint is a composite of adjudicated recurrent MI, incident heart failure (HF), coronary revascularization, ischaemic stroke, all-cause mortality, malignant ventricular arrhythmia, or resuscitated cardiac arrest. The primary safety endpoint includes a composite of recurrent MI, HF, all-cause mortality, malignant ventricular arrhythmia, or resuscitated cardiac arrest 30 days after randomization. Secondary endpoints include each of the components of the primary endpoint, patient-reported outcomes, and other clinical outcomes linked to beta-blocker therapy. The primary analysis will be conducted according to the intention-to-treat principle using a Cox proportional hazards regression model. End of follow-up is expected in December 2024.

CONCLUSION

The combined BETAMI-DANBLOCK trial will have the potential to affect current clinical practice for beta-blocker therapy in patients with normal or mildly reduced LVEF after MI.

Treatment patterns and adherence to lipid-lowering drugs during eight-year follow-up after a coronary heart disease event

BACKGROUND AND AIMS

Proper prescription and high adherence to intensive lipid lowering drugs (LLD) in patients with coronary heart disease (CHD) are crucial and strongly recommended. The aim of this study is to investigate long-term treatment patterns and adherence to LLD following hospitalization for a CHD event.

METHODS

Patients admitted to two Norwegian hospitals with a CHD event from 2011 to 2014 (N = 1094) attended clinical examination and completed a questionnaire, median 16 months later. Clinical data were linked to pharmacy dispensing data from 2010 to 2020. The proportions using high-intensity statin therapy (atorvastatin 40/80 mg or rosuvastatin 20/40 mg) and non-statin LLD after the CHD event were assessed. Adherence was evaluated by proportion of days covered (PDC) and gaps in treatment.

RESULTS

Median age at hospitalization was 63 (IQR 12) years, 21 % were female. Altogether, 1054 patients (96 %) were discharged with a statin prescription, while treatment was dispensed in 85 % within the following 90 days. During median 8 (SD 2.5) years follow-up, the proportion using high-intensity statin therapy ranged 62-68 %, whereas the use of ezetimibe increased from 4 to 26 %. PDC <0.8 was found in 22 % of statin users and 26 % of ezetimibe users. The proportions with a treatment gap exceeding 180 days were 22 % for statins and 28 % for ezetimibe. Smoking at hospitalization and negative affectivity were significantly associated with reduced statin adherence, regardless of adherence measure.

CONCLUSIONS

In this long-term follow-up of patients with CHD, less than 70 % used high-intensity statin therapy with only small changes over time, and only 25 % used additional treatment with ezetimibe. We identified factors associated with reduced statin adherence that may be target for interventions.

The atorvastatin metabolite pattern in muscle tissue and blood plasma is associated with statin muscle side effects in patients with coronary heart disease; An exploratory case-control study

Background and aims

Statin-associated muscle symptoms (SAMS) is a prevalent cause of statin discontinuation. It is challenging and time-consuming for clinicians to assess whether symptoms are caused by the statin or not, and diagnostic biomarkers are requested. Atorvastatin metabolites have been associated with SAMS. We aimed to compare atorvastatin pharmacokinetics between coronary heart disease (CHD) patients with and without clinically statin intolerance and statin-dependent histopathological alterations in muscle tissue. Secondarily we aimed to assess genetic variants relevant for the observed pharmacokinetic variables.

Methods

Twenty-eight patients with CHD and subjective SAMS were included in the exploratory MUSE biomarker study in 2020. Participants received atorvastatin 40 mg/day for seven weeks followed by no statins for eight weeks. Muscle biopsies and blood were collected at the end of each period. Four patients were categorized as clinically intolerant to ≥3 statins prior to study start whereas four patients had signs of muscle cell damage during treatment.

Results

We found significantly lower levels of atorvastatin acids, and higher lactone/acid ratios in the statin intolerant, both in muscle and plasma. With optimal cut-off, the combination of 2-OH-atorvastatin acid and the 2-OH-atorvastatin lactone/acid ratio provided sensitivity, specificity, and predictive values of 100 %. Patients with variants in UGT1A1 and UGT1A3 had higher lactone metabolite levels than those with wild type, both in muscle and plasma.

Conclusion

Atorvastatin metabolites appear promising as biomarkers for the identification of clinical statin intolerance in patients with self-perceived SAMS, but the findings have to be confirmed in larger studies.

A multi-component intervention increased access to smoking cessation treatment after hospitalization for atherosclerotic cardiovascular disease: a randomized trial

Aims

To evaluate the effects of a multi-component intervention for smokers hospitalized for atherosclerotic cardiovascular disease (ASCVD) on the participation rate in community-based cessation programmes and the use of cessation drugs. Additionally, to explore the impact on the cessation rates at 6 months.

Methods and results

A randomized parallel-group study was conducted at a Norwegian secondary care hospital in 2021. The intervention group was: (i) counselled using motivational interviewing techniques during hospitalization; (ii) given an information leaflet, detailing the cessation programme; and (iii) referred to the community-based smoking cessation treatment including a post-discharge pro-active telephone invitation. The control group received usual care and the same information leaflet containing clear contact details for initiating participation. Data were collected at baseline, 1, 3, and 6 months. Among 99 smokers hospitalized with ASCVD, 40 were excluded. Of 59 randomized patients, 4 were lost to follow-up and 55 completed the study. The mean age was 65.1 (standard deviation 9.3) years, 35% were female, and 88% had smoked >20 years. Co-morbidity was prevalent (mean Charlson score 4.8). The intervention group was more likely to participate in the smoking cessation treatment {48 vs. 7%, difference: 41% [95% confidence interval (CI): 14%, 63%]} and used cessation drugs more frequently [59 vs. 21%, difference: 38% (95% CI: 17%, 59%)]. At the 6 months point prevalence, we observed notable between-group differences in self-reported cessation rate (48 vs. 25%).

Conclusion

The intervention significantly increased the participation rate at community-based smoking cessation programmes and the use of cessation drugs among multi-morbid smokers hospitalized for ASCVD.

Frailty, health literacy and self-care in patients admitted with acute heart failure

BACKGROUND

There is limited knowledge from Norway on clinical characteristics, self-care and health literacy in patients admitted to hospital with acute heart failure. Our aim was to identify these factors in this group.

MATERIAL AND METHOD

We included patients admitted with acute heart failure over a period of six months (2022/2023) at Drammen Hospital and Vestfold Hospital Trust. Cardiac nurses collected information from the patients, including self-assessed knowledge on an ordinal scale from 0 (little knowledge) to 10 (good knowledge). Clinical frailty scores were calculated and data from the hospital records were recorded.

RESULTS

Of 136 patients with acute heart failure, 81 were included. Median age was 79 (range 35-95) years, 35 (43 %) were women. A total of 35 (43 %) had been admitted with heart failure exacerbation in the past year. The patients had a median of 5 (1-10) diagnoses, and the median score on the clinical frailty scale was 4 (1-7), corresponding to 'vulnerable'. A total of 63 (78 %) had been diagnosed with heart failure before admission to hospital. Of these, 13 (21 %) were unaware of the diagnosis, and their self-assessed knowledge was median 3 (25th and 75th percentile, 0-5) for management of heart failure, 2 (25th and 75th percentile, 0-5) for lifestyle interventions and 0 (25th and 75th percentile, 0-2) for heart medications. Altogether 42 out of 63 (67 %) weighed themselves weekly, 13 (21 %) measured their blood pressure, while 3 (5 %) had a self-care plan. Of 50 patients with left ventricle ejection fraction ≤ 40 %, 32 (64 %) were discharged with betablockers and angiotensin II receptor blockers or a combination drug with a neprilysin inhibitor, whereas 11 (22 %) were also prescribed SGLT2 inhibitors and mineralocorticoid receptor antagonists.

INTERPRETATION

The included patients were multimorbid and had a low level of self-care and health literacy. There is potential to optimise well-documented medicinal treatment.

Attention training technique delivered in groups as treatment for anxiety and depression in patients with coronary heart disease: study protocol for a waiting-list randomized controlled trial

Introduction

Clinically significant symptoms of depression and anxiety in coronary heart disease (CHD) patients are common and associated with adverse outcomes. Psychological treatments have shown limited effectiveness and more effective treatments have been requested. Attention training technique (ATT), a component of metacognitive therapy, can potentially be effective as a stand-alone treatment for anxiety and depression. In an open study, ATT delivered face-to-face in a group format was feasible and potentially effective for improving depression and anxiety symptoms in CHD patients. The next progressive step is to test the effectiveness of ATT in a randomized controlled trial. This paper describes the methodology of this trial.

Methods

ATT-CHD is a randomized wait-list (WL) controlled study. Eligible CHD patients from two hospitals with Hospital Anxiety and Depression Scale (HADS)-Anxiety and/or HADS-Depression subscales scores ≥8 will be randomized into ATT (n = 32) or WL control (n = 32). After 6-8 weeks, WL patients will be allocated to ATT. Participants will be evaluated pre-, mid- and post-treatment, and at 6-months follow-up using changes in HADS as primary outcome. Secondary outcomes will be changes in psychiatric disorders, rumination, worry, type D-personality, metacognitions, insomnia, quality of life, and C-Reactive protein (CRP).

Discussion

To our knowledge, this will be the first WL-controlled randomized study testing the effectiveness of group-based ATT as treatment of symptoms of anxiety and depression in CHD patients. It will also explore correlations between changes in psychological distress and CRP. A qualitative analysis will reveal patients' experience with ATT including processes that may facilitate or serve as barriers to effectiveness. Recruitment into the study commenced in December 2022.

Ethics and dissemination

The Regional Committees for Medical and Health Research Ethics (REK), Norway has granted approval for the study (ID 52002). The trial results will be published in peer-reviewed journals. According to Norwegian legislation, the Norwegian Data Protection Authority, and the Committee of Ethics, we are not allowed to share original study data publicly.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05621408 pre-inclusion. There were no significant changes of methods or outcomes after study start.

Psychiatric disorders, rumination, and metacognitions in patients with type D personality and coronary heart disease

BACKGROUND

Little is known regarding the prevalence of psychiatric disorders in patients with both coronary heart disease (CHD) and type D personality, and whether these patients may benefit from psychotherapy that modifies metacognitive beliefs implicated in disorder maintenance. This study explored prevalence rates among these patients and associations between type D characteristics, rumination and metacognitions.

METHODS

Forty-seven consecutive patients with CHD who scored positive for type D personality were included in this pre-planned study. Participants underwent structured clinical interviews for mental and personality disorders and completed questionnaires assessing rumination and metacognitions.

RESULTS

Mean age was 53.8 (SD 8.1) years and 21.3% were female. At least one mood disorder or anxiety disorder was found in 70.2% and 61.7% of the patients. The most common disorders were major depressive disorder (59.6%), social phobia (40.4%), and generalized anxiety disorder (29.8%). At least one personality disorder was detected in 42.6%. Only 21% reported ongoing treatment with psychotropic medication whereas none had psychotherapy. Metacognitions and rumination were significantly associated with negative affectivity (0.53-0.72, p < .001) but not social inhibition.

CONCLUSION

Mood and anxiety disorders were highly prevalent and relatively untreated among these patients. Future studies should test the metacognitive model for type D personality.

Predictors of health-related quality of life in outpatients with coronary heart disease

Introduction

Health-related quality of life (HRQoL) is an important treatment target in patients with coronary heart disease (CHD) and is associated with poor outcomes. Therefore, it is of clinical importance to identify the key determinants of HRQoL among these patients. There is, however, limited knowledge of how a comprehensive set of psychosocial factors influence HRQoL. We aimed to determine the relative associations of clinical and psychosocial factors with mental and physical components of HRQoL in a sample of CHD outpatients.

Methods

This cross-sectional study included 1,042 patients 2-36 (mean 16) months after a CHD event recruited from two general Norwegian hospitals with a combined catchment area making up 7% of the Norwegian population, representative with regards to demographic and clinical factors. We collected data on HRQoL, demographics, comorbidities, coronary risk factors, and psychosocial factors. HRQoL was assessed using the Short Form 12 (SF12), which comprises a Mental Component Scale (MCS), and the Physical Component Scale (PCS). Crude and multi-adjusted linear regression analyses were used to investigate the association between covariates and MCS and PCS.

Results

Mean age was 61 [standard deviation (SD) 10] years, 20% were females, 18% had type D personality, 20% significant depression symptoms, 14% significant symptoms of anxiety whereas 45% reported insomnia. The presence of type D personality (β: -0.19), significant symptoms of depression (β: -0.15), and the presence of insomnia (β: -0.13) were negatively associated with MCS, but not PCS in multi-adjusted analyses. The presence of chronic kidney disease (β: -0.11) was associated with reduced MCS, whereas the presence of chronic obstructive pulmonary disease (β: -0.08) and low physical activity (β: -0.14) were negatively associated with PCS. Younger age was associated with lower MCS, whereas older age was associated with lower PCS.

Discussion

We conclude that Type D personality, depressive symptoms, insomnia, and chronic kidney disease were the strongest determinants of the mental component of HRQoL. Assessing and managing these psychological factors among CHD outpatients may improve their mental HRQoL.

Plasma concentration of atorvastatin metabolites correlates with low-density lipoprotein cholesterol reduction in patients with coronary heart disease

In this exploratory study from a randomized double-blinded crossover trial including 70 patients with coronary heart disease and self-perceived muscular side effects of statins, we aimed to determine the relationship between low-density lipoprotein cholesterol (LDL-C) reduction and atorvastatin metabolite plasma concentrations. All patients underwent a 7 weeks treatment period with atorvastatin 40 mg/day and a 7 weeks placebo period in random order. Nonlinear regression with a three-parameter equation explored the relationship between percentage LDL-C reduction (statin vs. placebo) and the pharmacokinetic variables. Mean LDL-C reduction was 49% (range 12% to 71%). The sum of 4-OH-atorvastatin acid and lactone correlated moderately with the LDL-C response (Spearman ρ 0.27, 95% confidence interval [CI]: 0.03 to 0.48). Accordingly, nonlinear regression showed R² of 0.14 (95% CI: 0.03 to 0.37, R² adjusted equaled 0.11). Even a perfect underlying correlation of 1.0 showed R²  = 0.32 by simulation, using historical intra-individual LDL-C variation (8.5%). The 90% inhibitory concentration was 2.1 nmol/L, and the 4-OH-metabolite sum exceeded this threshold in 34% of the patients. In conclusion, trough plasma concentrations of 4-OH-atorvastatin metabolites correlated moderately to the LDL-C reduction. A plateau LDL-C response was observed above a pharmacokinetic threshold, below which the response was highly variable. The usefulness of monitoring concentrations of atorvastatin metabolites to optimize the individual dosage have limitations, but its supportive potential may be pursued in relevant patient subsets to achieve adequate efficacy at the lowest possible dose. The results add knowledge to the overall understanding of the variable LDL-C response mediated by atorvastatin.

Atorvastatin Metabolite Pattern in Skeletal Muscle and Blood from Patients with Coronary Heart Disease and Statin-Associated Muscle Symptoms

Self-perceived statin-associated muscle symptoms (SAMS) are prevalent, but only a minority is drug-dependent. Diagnostic biomarkers are not yet identified. The local statin exposure in skeletal muscle tissue may correlate to the adverse effects. We aimed to determine whether atorvastatin metabolites in blood reflect the corresponding metabolite levels in skeletal muscle, and whether genetic variants of statin transporters modulate this relationship. We also addressed atorvastatin metabolites as potential objective biomarkers of SAMS. Muscle symptoms were examined in patients with coronary disease and self-perceived SAMS during 7 weeks of double-blinded treatment with atorvastatin 40 mg/day and placebo in randomized order. A subset of 12 patients individually identified with more muscle symptoms on atorvastatin than placebo (confirmed SAMS) and 15 patients with no difference in muscle symptom intensity (non-SAMS) attended the present follow-up study. All received 7 weeks of treatment with atorvastatin 40 mg/day followed by 8 weeks without statins. Biopsies from the quadriceps muscle and blood plasma were collected after each treatment period. Strong correlations (rho > 0.7) between muscle and blood plasma concentrations were found for most atorvastatin metabolites. The impact of the SLCO1B1 c.521T>C (rs4149056) gene variant on atorvastatin's systemic pharmacokinetics was translated into muscle tissue. The SLCO2B1 c.395G>A (rs12422149) variant did not modulate the accumulation of atorvastatin metabolites in muscle tissue. Atorvastatin pharmacokinetics in patients with confirmed SAMS were not different from patients with non-SAMS. In conclusion, atorvastatin metabolite levels in skeletal muscle and plasma are strongly correlated, implying that plasma measurements are suitable proxies of atorvastatin exposure in muscle tissue. The relationship between atorvastatin metabolites in plasma and SAMS deserves further investigation.

Risk of recurrent cardiovascular events in coronary artery disease patients with Type D personality

Introduction

Data on the association between Type D personality, its traits negative affectivity (NA) and social inhibition (SI), and risk of major adverse cardiac events (MACE) in coronary outpatients is sparse. Furthermore, the associations between Type D subgroups and cardiovascular risk factors are largely unknown.

Methods

We investigated i) Type D personality, NA and SI and risk of recurrent MACE, and ii) the relationship between Type D subgroups and risk factors in a coronary population. This prospective cohort study included 1083 patients` median 16 months after a myocardial infarction and/or a revascularization procedure who were followed-up for 4.2 (SD 0.4) years. Type D personality was assessed by DS14. Anxiety and depression, statin adherence, and risk factors were assessed by patients’ self-report and a clinical examination with blood samples. MACE, defined as cardiovascular death, myocardial infarction, revascularization, stroke or heart failure, were obtained from hospital records from index event to end of study lasting 5.7 years. Data were analyzed by Cox proportional hazard regression.

Results

In all, 352 MACE occurred in 230 patients after average 4.2 years follow-up. Higher NA score was associated with MACE after adjustment for age, risk factors and comorbidity (HR 1.02 per unit increase, 95% CI 1.00-1.05), whereas we found a weaker, not statistically significant estimated effect of higher SI score. After additional adjustment for symptoms of anxiety and depression, we found a weaker, not statistically significant association between NA and MACE (HR 1.01 per unit increase, 95% CI 0.98-1.05). Low statin adherence and smoking were more prevalent in the Type D and high NA group.

Discussion

Our results indicate that the NA trait is related to worse prognosis in outpatients with coronary artery disease.

Barriers and facilitators for smoking cessation in chronic smokers with atherosclerotic cardiovascular disease enrolled in a randomized intervention trial: A qualitative study

Objectives

Smoking is common in patients with cardiovascular disease. Despite strong recommendations for cessation and the existence of efficacious pharmacological and behavioral interventions, cessation rates remain low. Therefore, in this study, we explore perceived facilitators and barriers to smoking cessation in patients with atherosclerotic cardiovascular disease who have participated in a cessation intervention study.

Methods

Participants (N = 10) from the intervention arm of a randomized controlled study with access to free cessation support and pharmacological aids completed a semi-structured, in-depth telephone interview after a 6-monthfollow-up between October 2021 and July 2022. The interviews were audio recorded, transcribed, and analyzed according to principles of thematic analysis.

Results

The mean age was 65.7 (range: 55-79) years, and three of the 10 participants were women. Among the participants, five had quit smoking, three had relapsed, and two were persistent smokers. The themes identified encompassed barriers and facilitators to cessation, both including individual and contextual factors. Barriers included the upsides of smoking, difficult life situations, addiction to smoking, smoking in social circles, perceived lack of support and understanding from health professionals. Facilitators included intrinsic motivation, concerns about the health condition, financial implications, specific behavioral strategies, positive influence from the social environment, and helpful components of the cessation intervention.

Conclusion

Smokers with cardiovascular disease who have attended a cessation intervention study report several facilitators weighted against barriers, interacting with the intention to cease smoking. The most important potentially modifiable factors of significance for cessation identified may be addressed through motivational interviews and focus groups with other smokers.

Gaps and discontinuation of statin treatment in Norway: potential for optimizing management of lipid lowering drugs

AIMS

In clinical practice, many patients do not reach the recommended treatment targets for LDL-cholesterol levels. We aimed to examine treatment patterns and adherence for patients on lipid lowering drugs in Norway to inform future strategies to improve therapies.

METHODS AND RESULTS

We obtained information on all dispensed statins, ezetimibe, and proprotein convertase subtilisin/-kexin 9 (PCSK9) inhibitors 2010-2019 from the Norwegian Prescription Database. Treatment gaps were assessed assuming patients take one tablet per day and were defined to occur if a patient did not refill a prescription when the previous one should have been depleted. Treatment was defined as discontinued when the preceding prescription would have been used and no new subsequent prescription was filled. The mean proportion of days covered (PDC) was calculated by aggregating the total number of tablets dispensed during each calendar year and dividing by 365. Patients 80 years were excluded. A considerable proportion of statin users in Norway had long treatment gaps or discontinuation in treatment. The 19.6% of the patients had treatment gaps of 180 days or more, and 10.8% had gaps or greater than 365 days. Similar results were found for patients on antidiabetics and hypertensives. PDC ranged from 84.9% for simvastatin to 72.2% for ezetimibe (2019). The most common lipid lowering drugs in 2019 were atorvastatin, simvastatin, and ezetimibe.

CONCLUSION

There is a great potential for improving drug adherence and optimizing lipid lowering therapy by switching to more effective statins in greater doses, and more often add ezetimibe and PCSK9 inhibitors to treatment.

Cost-effectiveness of a rule-out algorithm of acute myocardial infarction in low-risk patients: emergency primary care versus hospital setting

Aims

Hospital admissions of patients with chest pain considered as low risk for acute coronary syndrome contribute to increased costs and crowding in the emergency departments. This study aims to estimate the cost-effectiveness of assessing these patients in a primary care emergency setting, using the European Society of Cardiology (ESC) 0/1-h algorithm for high-sensitivity cardiac troponin T, compared to routine hospital management.

Methods

A cost-effectiveness analysis was conducted. For the primary care estimates, costs and health care expenditure from the observational OUT-ACS (One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome) study were compared with anonymous extracted administrative data on low-risk patients at a large general hospital in Norway. Patients discharged home after the hs-cTnT assessment were defined as low risk in the primary care cohort. In the hospital setting, the low-risk group comprised patients discharged with a non-specific chest pain diagnosis (ICD-10 codes R07.4 and Z03.5). Loss of health related to a potential increase in acute myocardial infarctions the following 30-days was estimated. The primary outcome measure was the costs per quality-adjusted life year (QALY) of applying the ESC 0/1-h algorithm in primary care. The secondary outcomes were health care costs and length of stay in the two settings.

Results

Differences in costs comprise personnel and laboratory costs of applying the algorithm at primary care level (€192) and expenses related to ambulance transports and complete hospital costs for low-risk patients admitted to hospital (€1986). Additional diagnostic procedures were performed in 31.9% (181/567) of the low-risk hospital cohort. The estimated reduction in health care cost when using the 0/1-h algorithm outside of hospital was €1794 per low-risk patient, with a mean decrease in length of stay of 18.9 h. These numbers result in an average per-person QALY gain of 0.0005. Increased QALY and decreased costs indicate that the primary care approach is clearly cost-effective.

Conclusion

Using the ESC 0/1-h algorithm in low-risk patients in emergency primary care appears to be cost-effective compared to standard hospital management, with an extensive reduction in costs and length of stay per patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08697-6.

Effect of in-hospital nurse-led smoking cessation intervention for patients with atherosclerotic cardiovascular disease: a randomised pilot study

Background

Smoking remains prevalent after cardiovascular disease (CVD) events and knowledge on how to facilitate effective cessation in clinical practice is needed.

Purpose

To test the effect of an in-hospital nurse-led intervention on the participation rate at municipal Healthy Life Centres (HLC) and the use of smoking cessation drugs. Secondary, to determine long-term effects on cessation rates.

Methods

A prospective, randomized, open-label, parallel-group intervention pilot-study was conducted at a Norwegian secondary care hospital in 2021. Patients with atherosclerotic CVD who smoked at least one cigarette daily when admitted with an acute CVD event were consecutively included. The nurse-led intervention included cessation counselling utilizing motivational interview technique, information and guidance in proper use of cessation drugs and direct referral to a 12-weeks digital (video ± phone) HLC program where patients received free cessation drugs. The low-threshold intervention included written information about the offer in the HLC with free cessation drugs. The primary endpoints were between-group differences in attendance rates at the HLC program and the use of cessation drugs.

Results

Of 99 potential participants, 24 did not meet the entry criteria whereas 17 declined to participate. Of 58 randomised patients, three died during follow-up and 55 completed the study. Mean age was 65.7 (SD 9.2) years, 35% were female, 88% had low education, 88% had smoked &gt;20 years, and motivation for quitting smoking was high (mean 8.5 on a 0 [no motivation] to 10 [high motivation] Likert scale). Comorbidity was common (mean Charlson score 5.1) and 40% had symptoms of anxiety and/or depression. The nurse-led intervention resulted in significantly higher participation rate at the HLC (48% vs. 4%, difference: 44% [95% CI: 24%, 65%], P&lt;0.0001) and more frequent use of cessation drugs (48% vs. 11%, difference: 37% [95% CI: 15%, 60%], P=0.002) compared to the low-threshold intervention (Figure A). All participants in the intervention group who attended the HLC program were offered follow-up within 21 days following randomisation. In the intervention group 15% used varenicline and 33% used a combination of short and long-acting nicotine replacements. Clinically significant differences in cessation rates after six months were observed between the groups (Figure B). Concomitant carbon monoxide measurements were obtained of 5 participants in the intervention group and 4 in the control group who reported cessation and all confirmed non-smoking.

Conclusion

Among multi-morbid patients hospitalised for a CVD event, a nurse-led intervention resulted in substantially higher participation rate at a municipal HLC program and higher use of smoking cessation drugs compared to written information. We also found clinically significant long-term effects on cessation rates which needs to be confirmed in a large-scale study.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Dam Foundation

Relationships between depression, anxiety, type D personality, and worry and rumination in patients with coronary heart disease

Psychological distress, including depression and anxiety, and Type-D personality are prevalent in patients with coronary heart disease (CHD) and associated with poor cardiovascular outcomes. Worry and rumination may be among the core features responsible for driving psychological distress in these patients. However, the nature of associations between these constructs remains to be delineated, yet they may have implications for the assessment and treatment of CHD patients. This study aimed to (1) explore the factorial structure and potential overlap between measures of depression, anxiety and the Type-D personality factors known as negative affectivity and social inhibition, and (2) examine how these constructs relate to worry and rumination in a sample of 1,042 CHD outpatients who participated in the in the cross-sectional NORwegian CORonary Prevention study. We conducted confirmatory factor analyses (n = 1,042) and regression analyses (n = 904) within a structural equation modeling framework. Results showed all constructs to have acceptable factor structure and indicated an overlap between the constructs of depression and negative affectivity. Worry was most strongly associated with anxiety, whereas rumination was most strongly associated with depression and negative affectivity. The results suggest conceptual similarities across the measures of depression and negative affectivity. They further suggest that intervention efforts could benefit from targeting worry and/or rumination in the treatment of CHD outpatients presenting with symptoms of psychological distress.

Monitoring Simvastatin Adherence in Patients With Coronary Heart Disease: A Proof-of-Concept Study Based on Pharmacokinetic Measurements in Blood Plasma

BACKGROUND

Poor statin adherence remains a public health concern associated with adverse outcomes. We evaluated the use of pharmacokinetic measurements to monitor adherence to simvastatin in patients with coronary heart disease (CHD).

METHODS

Eighteen patients with CHD taking an evening dose of simvastatin 20 mg (n = 7), 40 mg (n = 5), or 80 mg (n = 6) were examined at steady-state pharmacokinetics. Ten patients were instructed to interrupt simvastatin dosing and return for blood sampling for the subsequent 3 days. Dose-normalized plasma concentrations of simvastatin lactone and simvastatin acid and the sum of the 2 were evaluated to discriminate between adherent dosing and dose omission. Bioanalytical quantification was performed using liquid chromatography-tandem mass spectrometry.

RESULTS

A simvastatin acid cutoff of 1.0 × 10 -2 nmol -1 ·L -1 ·mg -1 identified 100% of those omitting 2 doses and 60% of those omitting a single dose. Simvastatin acid showed superior ability to discriminate dose omission, as well as the best agreement between samples handled at ambient and cool temperatures (median deviation 3.5%; interquartile range -2.5% to 13%). The cutoff for a morning dose schedule, with a similar ability to discriminate, was estimated at 2.0 × 10 -3 nmol -1 ·L -1 ·mg -1 .

CONCLUSIONS

The present method discriminated between adherence and reduced adherence to simvastatin therapy in patients with CHD. Sample handling is feasible for routine practice, and the assessment of adherence can be performed by direct measurement of simvastatin acid in a blood sample, according to defined cutoff values. Further studies validating the cutoff value and utility for clinical application are encouraged.

The Attention Training Technique Reduces Anxiety and Depression in Patients With Coronary Heart Disease: A Pilot Feasibility Study

Background and Objectives

Depression and anxiety symptoms are highly prevalent in coronary heart disease (CHD) patients and associated with poor outcome. Most psychological treatments have shown limited effectiveness on anxiety and depression in these patients. This study evaluates the feasibility of the attention training technique (ATT) in CHD patients with symptoms of anxiety and/or depression.

Methods

Five consecutive CHD patients with significant depression and anxiety symptoms with Hospital Anxiety and Depression rating scale (HADS) -anxiety or -depression subscale score > 8 received 6 weekly group-sessions of ATT in an open trial. Outcomes included feasibility and symptoms measured by HADS, at baseline, post-treatment and at 6 months follow-up. We also assessed psychiatric diagnoses, type D personality, insomnia, worry, and rumination.

Results

The sample comprised five men with a mean age of 59.9 (SD 4.4) years. Four of the patients attended all six sessions, and one patient attended all but one session. Mean HADS-A scores at baseline, post-treatment, and follow-up were 9.4 (SD 3.0), 4.2 (SD 3.0), and 4.0 (SD 2.5), and for HADS-D 8.6 (SD 3.3), 3.0 (SD 3.7), and 1.6 (SD 1.5), respectively. The results showed clinically significant changes in anxiety, depression, psychiatric disorders, insomnia, worry, and rumination. Statistically significant changes were found from pre- to post-treatment scores for HADS-A and worry, which were maintained at follow-up, and HADS-D scores significantly decreased from pre-treatment to 6-months follow-up.

Conclusions

ATT in a group format appears to be a feasible stand-alone metacognitive treatment for CHD patients. An adequately powered randomized controlled trial is warranted.

Shared genetic loci between depression and cardiometabolic traits

Epidemiological and clinical studies have found associations between depression and cardiovascular disease risk factors, and coronary artery disease patients with depression have worse prognosis. The genetic relationship between depression and these cardiovascular phenotypes is not known. We here investigated overlap at the genome-wide level and in individual loci between depression, coronary artery disease and cardiovascular risk factors. We used the bivariate causal mixture model (MiXeR) to quantify genome-wide polygenic overlap and the conditional/conjunctional false discovery rate (pleioFDR) method to identify shared loci, based on genome-wide association study summary statistics on depression (n = 450,619), coronary artery disease (n = 502,713) and nine cardiovascular risk factors (n = 204,402–776,078). Genetic loci were functionally annotated using FUnctional Mapping and Annotation (FUMA). Of 13.9K variants influencing depression, 9.5K (SD 1.0K) were shared with body-mass index. Of 4.4K variants influencing systolic blood pressure, 2K were shared with depression. ConjFDR identified 79 unique loci associated with depression and coronary artery disease or cardiovascular risk factors. Six genomic loci were associated jointly with depression and coronary artery disease, 69 with blood pressure, 49 with lipids, 9 with type 2 diabetes and 8 with c-reactive protein at conjFDR < 0.05. Loci associated with increased risk for depression were also associated with increased risk of coronary artery disease and higher total cholesterol, low-density lipoprotein and c-reactive protein levels, while there was a mixed pattern of effect direction for the other risk factors. Functional analyses of the shared loci implicated metabolism of alpha-linolenic acid pathway for type 2 diabetes. Our results showed polygenic overlap between depression, coronary artery disease and several cardiovascular risk factors and suggest molecular mechanisms underlying the association between depression and increased cardiovascular disease risk.

Low-density lipoprotein cholesterol increased significantly after short-term discontinuation of atorvastatin, but did not correlate with plasma drug concentrations

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Dam foundation

Introduction

Statin non-adherence remains a prevalent challenge in cardiovascular disease prevention and robust methods to monitor adherence are needed. Large variations in low-density-lipoprotein cholesterol (LDL-C) response to a given type and dose of statin have been reported. The LDL-C response to short-term discontinuation of statins is not well defined. Moreover, the relationship between the blood concentrations of statin metabolites and LDL-C, and how clinical factors interact, are unknown.

Purpose

To determine changes in LDL-C at an individual and group level during four-day discontinuation of atorvastatin, and to investigate whether clinical factors and atorvastatin metabolites concentration correlate with changes in LDL-C.

Methods

This clinical pharmacokinetic adherence study conducted in 2021, included 60 adult participants treated with atorvastatin 20 mg (n=20), 40 mg (n=20) or 80 mg (n=20). The participants were instructed to take atorvastatin daily between 07 and 10 am the week before study start, to ensure steady state drug concentrations. The last dose of atorvastatin was taken 24 hours prior to the first blood sampling (day zero). Atorvastatin doses were omitted until after blood sampling on the fourth day. The concentrations of atorvastatin metabolites (acid and lactone forms, including 2-OH- and 4-OH metabolite) were measured by a liquid chromatography–tandem mass spectrometry assay. Paired-samples T-tests, Spearman rank correlations and linear regression analyses were performed with SPSS.

Results

Mean age was 65 (SD 11) years, 18 (30%) were female, 45 (75%) had cardiovascular disease and 11 (18%) had diabetes mellitus. Mean LDL-C at steady state on day zero was 1.9 (SD 0.6) mmol/L. LDL-C increased on average by 0.5 (SD 0.3) mmol/L (30%) from day zero to day four, during the period with atorvastatin discontinuation. The increase of LDL-C was significant already after the first omitted dose (day one) (Figure 1). LDL-C increased from day zero to day four in 78 out of the 80 patients (97.5%). Higher Body Mass Index was significantly associated with lager increase in LDL-C during the four-day discontinuation (B 0.02, 95% CI 0.01 to 0.04, p=0.028), whereas age, sex, kidney function, cardiovascular disease and diabetes were not. Changes in atorvastatin plus metabolites concentration from day zero to day four were not associated with changes in LDL-C during discontinuation (Figure 2). This also applied if we assessed the individual atorvastatin metabolites.

Conclusion

Atorvastatin discontinuation for only four days resulted in a statistically significant 30% increase of LDL-C. Atorvastatin pharmacokinetics did not correlate with change in LDL-C during the discontinuation. Even short-term non-adherence may have unfavourable consequences, and deserves further attention.

Insomnia was associated with increased risk of recurrent cardiovascular events in coronary heart disease patients

Funding Acknowledgements

Type of funding sources: None.

Background

Insomnia is highly prevalent in coronary heart disease (CHD) patients. However, the potential effect of insomnia on the risk of recurrent major adverse cardiovascular events (MACE) remains uncertain.

Purpose

To estimate the prospective association of insomnia and the risk of recurrent MACE in a CHD population from routine clinical practice.

Methods

This prospective cohort study included 1082 consecutive patients 2-36 (mean 16) months after a myocardial infarction and/or a coronary revascularization procedure. Data on insomnia, coronary risk factors and comorbidity were collected at baseline. Insomnia was assessed by Bergen insomnia scale (BIS), based on sleep symptoms per week during the past three months. BIS is constructed from the clinical diagnostic criteria for primary insomnia in DSM-IV TR. The primary composite endpoint of MACE defined as cardiovascular death, hospitalization due to myocardial infarction, revascularization, stroke or heart failure was obtained from the hospital records on average 4.2 (SD 0.3) years after the baseline study. Data were analysed using Cox proportional hazard regression on a multiple imputated dataset stratified by prior coronary events.

Results

At baseline, mean age was 62 (range 31-80) years, 21% were females, 90% were revascularized, 47% had participated in cardiac rehabilitation and the prescription rate of antiplatelets (97%) and statins (93%) were high. A total of 364 MACE (21%, 95% CI 19%-24%) occurred in 225 patients, including 39 CV deaths. Almost half of the patients (45%) suffered from insomnia at baseline and 24% used sleep medication the past week. For insomnia, the relative risk (RR) of recurrent MACE was 1.62 (95% confidence interval (CI) 1.24-2.11, p-value&lt;0.001) in age and gender adjusted analysis, 1.49 (95% CI 1.14, 1.97, p-value=0.004) in analysis also adjusted for coronary risk factors and 1.48 (95% CI 1.12, 1.96, p-value=0.006) in a multi-adjusted analysis including age, gender, coronary risk factors and cardiovascular comorbidity. When also adjusted for symptoms of anxiety and depression the RR of insomnia on recurrent MACE remained significant at 1.41 (95% CI 1.05, 1.89, p-value=0.023). Insomnia accounted for 16% of the MACE in attributable risk fraction analyses, being third in importance after smoking (27%) and low physical activity (21%). Obstructive sleep apnea (Berlin Questionnaire) was not associated with recurrent MACE.

Conclusions

Insomnia was associated with increased risk of recurrent MACE in this prospective cohort following CHD patients from routine clinical practice. The association remained significant even after adjustments for the major coronary risk factors, comorbidity and symptoms of anxiety and depression, indicating that the effects of insomnia is not mediated through poor risk factor control and other psychosocial factors alone. These results emphasize the importance of identifying patients with insomnia as part of coronary rehabilitation.

A feasibility study of the Attention Training Technique in a group format for anxiety and depression in outpatients with coronary heart disease

Funding Acknowledgements

Type of funding sources: None.

Background

Significant symptoms of anxiety and depression are prevalent (30-40%) in coronary heart disease (CHD) patients and these are associated with a greater risk of death, recurrent cardiovascular events, poorer quality of life, and more frequent use of healthcare services compared to those without this heart condition. To date, only a few psychological treatments have shown limited effectiveness on symptoms of anxiety and depression in CHD patients. Therefore, it is essential to develop and evaluate more effective treatments for depression and anxiety in CHD patients.

Metacognitive therapy (MCT) is effective in reducing significant symptoms of anxiety and depression. A key component of MCT is the attention training technique (ATT), which is based on the self-regulatory executive function model. According to the MCT treatment manual, ATT is brief and does not require extensive training to be delivered by health care personnel in routine care. A review of the empirical evidence shows that ATT can be as effective as full MCT in alleviating anxiety and depressive symptoms. However, ATT has not yet been used as a stand-alone intervention in treating symptoms of anxiety and depression in CHD patients.

Purpose

To evaluate the feasibility of implementing group ATT in CHD patients with significant symptoms of anxiety and depression and describe changes in these symptoms.

Methods

Five consecutively referred CHD patients with significant anxiety and depressive symptoms, as assessed by the Hospital Anxiety and Depression Scale (HADS)-Anxiety or Depression subscale score &gt; 8, were included in the study. They received six weekly group sessions of ATT in an open trial. Outcomes included symptoms measured by HADS at baseline, post-treatment and at six months follow-up. We also assessed psychiatric diagnoses and specific psychological factors (type D personality, insomnia, worry and rumination) as secondary measures.

Results

The sample comprised of five men between 52 and 65 years of age, with a mean age of 59.9 years. Four of the patients attended all six sessions, and one patient attended all but one session. The mean HADS-A scores at baseline, post-treatment, and follow up were 9.4 (SD 3.0), 4.2 (SD 3.0) and 4.0 (SD 2.5), and for HADS-D 8.6 (SD 3.3), 3.0 (3.7) and 1.6 (SD 1.5), respectively. The results showed clinically significant changes in anxiety, depression, psychiatric disorders, insomnia, worry, and rumination. Wilcoxon Signed Rank Tests revealed a significant change in outcome from pre- to post-treatment for HADS-A and worry, which was maintained at 6-months follow-up, and HADS-D significantly decreased from pre-treatment to 6-months follow up.

Conclusions

ATT in a group format appears to be a feasible stand-alone metacognitive treatment for CHD patients with significant symptoms of anxiety or depression. Based on these preliminary results, we believe that an adequately powered randomised controlled trial is now warranted.

Type D personality, cardiovascular risk factors and risk of recurrent major adverse cardiac events in outpatients with coronary heart disease

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Kristin S. Torgersen received founding from the University of Oslo, Research Council of Norway.

Introduction

The mechanisms linking type D personality to cardiac prognosis in terms of major adverse cardiac events (MACE) and the association between Type D and MACE after controlling for symptoms of anxiety and depression is largely unknown.

Propose

To investigate the relationship between Type D personality and the Type D characteristics of negative affectivity (NA) and social inhibition (SI) and i) cardiovascular risk factors and ii) risk of recurrent MACE in CHD outpatients.

Methods

This prospective multicenter cohort study included 1083 patients 2-36 (mean 16) months after a myocardial infarction and/or a revascularization procedure. At baseline, patients underwent a clinical examination and answered a questionnaire including assessment of Type D personality (DS14), anxiety and depression (Hospital Anxiety and Depression Scale (HADS), medication adherence and risk factors (hypertension, smoking, diabetes, low physical activity, waist circumference, low-density lipoprotein cholesterol and C-reactive Protein). The primary composite endpoint of MACE defined as cardiovascular death, hospitalization for myocardial infarction, revascularization, stroke/transitory ischemic attacks or heart failure were obtained from hospital records on average 4.2 (SD 0.4) years after baseline. Data were analyzed by Cox proportional hazard regression stratified for prior coronary events.

Results

The prevalence of Type D was 18% at baseline. Type D patients were younger at the index event (59.3 vs 62.1 years, p= 0.001), more likely to be female (26.4 vs 19.8 %, p=0.038), scored higher on HADS anxiety (8.4 vs 3.9, p &lt; 0.001), HADS depression (3.2 vs 7.0, p &lt;0.001), reported lower medication adherence (14.2 vs 9.2 %, p=0.042), and were more likely to report smoking (29.0 vs 18.9%, p=0.002) compared to those without type D personality. There were no significant differences in other risk factors between the Type D and non-Type D group. A total of 352 MACE occurred in 230 patients (21%, 95% CI 19% to 24%) during follow-up. Higher NA score was associated with MACE in analyses adjusted for age, cardiovascular risk factors and somatic comorbidity (RR 1.02 per unit increase, 95% CI 1.00-1.05, p=0.037), but not after additional adjustment for symptoms of anxiety and depression (RR 1.01 per unit increase, 95% CI 0.98-1.05, p=0.53). Type D personality was not significantly associated with increased risk for MACE, neither was higher SI score.

Conclusions

Type D personality was only associated with low medication adherence and smoking which may represent potential mechanisms linking type D to cardiovascular prognosis. In our study, only negative affectivity was associated with MACE, suggesting that this is the most important type D characteristic for prognosis. However, NA was no longer associated with MACE after adjusting for anxiety and depression raising the question whether NA, depression and anxiety may have common underlying factors or are overlapping constructs.

Insomnia as a predictor of recurrent cardiovascular events in patients with coronary heart disease

Study Objectives

Insomnia is highly prevalent in patients with coronary heart disease (CHD). However, the potential effect of insomnia on the risk of recurrent major adverse cardiovascular events (MACE) remains uncertain.

Methods

This prospective cohort study included 1082 consecutive patients 2-36 (mean 16) months after myocardial infarction and/or coronary revascularization. Data on clinical insomnia, coronary risk factors, and comorbidity were collected at baseline. Clinical insomnia was assessed using the Bergen Insomnia Scale (BIS). The primary composite endpoint of MACE (cardiovascular death, hospitalization due to myocardial infarction, revascularization, stroke, or heart failure) was assessed with an average follow-up of 4.2 (SD 0.3) years after baseline. Data were analyzed using Cox proportional hazard regression models stratified by prior coronary events before the index event.

Results

At baseline, mean age was 62 years, 21% were females, and 45% reported clinical insomnia. A total of 346 MACE occurred in 225 patients during the follow-up period. For clinical insomnia, the relative risk of recurrent MACE was 1.62 (95% confidence interval [CI]: 1.24-2.11, p < .001) adjusted for age, gender, and previous coronary events. In a multi-adjusted analysis, including coronary risk factors, cardiovascular comorbidity, symptoms of anxiety, and depression, the relative risk was 1.41 (95% CI: 1.05-1.89, p = .023). Clinical insomnia accounted for 16% of the MACE in attributable risk fraction analyses, being third in importance after smoking (27%) and low physical activity (21%).

Conclusions

Clinical insomnia was associated with increased risk of recurrent MACE. These results emphasize the importance of identifying and managing insomnia in CHD outpatients.

Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up

STUDY OBJECTIVES

Insomnia is highly prevalent and associated with anxiety and depression in patients with coronary heart disease patients. The development of effective psychological interventions is needed. Worry and rumination are potential risk factors for the maintenance of insomnia, anxiety, and depression that may be modified by psychological treatment grounded in the Self-Regulatory Executive Function model. However, the relationships between worry, rumination, anxiety and depression, and insomnia are not known. Therefore, we investigated these relationships both cross-sectionally and longitudinally among patients with coronary heart disease.

METHODS

A cross-sectional study consecutively included 1,082 patients in 2014-2015, and 686 were followed up after mean of 4.7 years. Data were gathered from hospital records and self-report questionnaires comprising assessment of worry (Penn State Worry Questionnaire), rumination (Ruminative Responses Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and insomnia (Bergen Insomnia Scale).

RESULTS

Insomnia correlated moderately with all other psychological variables (R 0.18-0.50, all P values < .001). After adjustments for anxiety and depression, odds ratios for insomnia at baseline were 1.27 (95% confidence interval 1.08-1.50) and 1.60 (95% confidence interval 1.31-1.94) per 10 points increase of worry and rumination, respectively. Corresponding odds ratios for insomnia at follow-up were 1.28 (95% confidence interval 1.05-1.55) and 1.38 (95% confidence interval 1.09-1.75). Depression was no longer significantly associated with insomnia after adjustments for worry and rumination, but anxiety remained significant.

CONCLUSIONS

Worry and rumination predicted insomnia both cross-sectionally and prospectively, even after controlling for anxiety and depression, although anxiety remained significant. Future studies may test psychological interventions targeting these factors in patients with coronary heart disease and insomnia.

CITATION

Frøjd LA, Papageorgiou C, Munkhaugen J, et al. Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up. J Clin Sleep Med. 2022;18(3):779-787.

Clinical and psychological factors in coronary heart disease patients with statin associated muscle side-effects

Background

To compare clinical and psychological factors among patients with self-perceived statin-associated muscle symptoms (SAMS), confirmed SAMS, and refuted SAMS in coronary heart disease patients (CHD).

Methods

Data were obtained from a cross-sectional study of 1100 CHD outpatients and a study of 71 CHD outpatients attending a randomized, double-blinded, placebo-controlled, crossover study to test effects of atorvastatin 40 mg/day on muscle symptom intensity. Clinical and psychosocial factors were compared between patients with and without SAMS in the cross-sectional study, and between patients with confirmed SAMS and refuted SAMS in the randomized study.

Results

Bilateral, symmetric muscle symptoms in the lower extremities during statin treatment were more prevalent in patients with confirmed SAMS compared to patients with refuted SAMS (75% vs. 41%, p = 0.01) in the randomized study. No significant differences in psychological factors (anxiety, depression, worry, insomnia, type D personality characteristics) were detected between patients with and without self-perceived SAMS in the cross-sectional study, or between patients with confirmed SAMS and refuted SAMS, in the randomized study.

Conclusions

Patients with confirmed SAMS more often present with bilateral lower muscle symptoms compared to those with refuted SAMS. Psychological factors were not associated with self-perceived SAMS or confirmed SAMS. A careful pain history and a search for alternative causes of muscle symptoms are likely to promote communication in patients with SAMS, and may reduce the risk for statin discontinuation.

Post-myocardial infarction rehabilitation and secondary prevention in hospitals

BACKGROUND

Norwegian studies have documented poor cardiovascular risk factor control and a high incidence of new cardiovascular events in myocardial infarction patients. There is little knowledge about the scope of secondary prevention treatment and cardiac rehabilitation in Norwegian hospitals. Therefore, we wanted to conduct a survey of discharge routines and outpatient follow-up after myocardial infarction.

MATERIAL AND METHOD

In October 2018, the heads of cardiology departments and nurse managers/physiotherapists at cardiology outpatient clinics at all Norwegian hospitals (N = 51) were contacted and asked to take part in a telephone interview.

RESULTS

A total of 40 doctors (78 %) and 51 nurses/physiotherapists (100 %) conducted the telephone interview. Eleven hospitals used standardised discharge summary templates with treatment targets and expected follow-up. Ten hospitals offered routine outpatient follow-up. A total of 47 hospitals (92 %) offered multidisciplinary cardiac rehabilitation, 'heart school' classes or cardiac exercise training, and of these 9 (18 %) offered multidisciplinary comprehensive cardiac rehabilitation in line with international recommendations.

INTERPRETATION

The survey revealed considerable differences in reported discharge routines and the provision of cardiac rehabilitation and outpatient follow-up at Norwegian hospitals.

Effect of atorvastatin on muscle symptoms in coronary heart disease patients with self-perceived statin muscle side effects: a randomized, double-blinded crossover trial

AIMS

To estimate the effect of atorvastatin on muscle symptom intensity in coronary heart disease (CHD) patients with self-perceived statin-associated muscle symptoms (SAMS) and to determine the relationship to blood levels of atorvastatin and/or metabolites.

METHODS AND RESULTS

A randomized multi-centre trial consecutively identified 982 patients with previous or ongoing atorvastatin treatment after a CHD event. Of these, 97 (9.9%) reported SAMS and 77 were randomized to 7-week double-blinded treatment with atorvastatin 40 mg/day and placebo in a crossover design. The primary outcome was the individual mean difference in muscle symptom intensity between the treatment periods, measured by visual-analogue scale (VAS) scores. Atorvastatin did not affect the intensity of muscle symptoms among 71 patients who completed the trial. Mean VAS difference (statin-placebo) was 0.31 (95% CI: -0.24 to 0.86). The proportion with more muscle symptoms during placebo than atorvastatin was 17% (n = 12), 55% (n = 39) had the same muscle symptom intensity during both treatment periods whereas 28% (n = 20) had more symptoms during atorvastatin than placebo (confirmed SAMS). There were no differences in clinical or pharmacogenetic characteristics between these groups. The levels of atorvastatin and/or metabolites did not correlate to muscle symptom intensity among patients with confirmed SAMS (Spearman's rho ≤0.40, for all variables).

CONCLUSION

Re-challenge with high-intensity atorvastatin did not affect the intensity of muscle symptoms in CHD patients with self-perceived SAMS during previous atorvastatin therapy. There was no relationship between muscle symptoms and the systemic exposure to atorvastatin and/or its metabolites. The findings encourage an informed discussion to elucidate other causes of muscle complaints and continued statin use.

The relationship between directly measured statin adherence, self-reported adherence measures and cholesterol levels in patients with coronary heart disease

BACKGROUND AND AIMS

We aimed to determine the relationship between statin adherence measured directly, and by self-report measures and serum cholesterol levels.

METHODS

Patients prescribed atorvastatin (N = 373) participated in a cross-sectional study 2-36 months after a coronary event. Self-reported adherence included statin adherence the past week, the 8-item Morisky medication adherence scale (MMAS-8), and the Gehi et al. adherence question. Atorvastatin was measured directly in spot blood plasma by a novel liquid chromatography tandem mass-spectrometry method discriminating adherence (0-1 doses omitted) and reduced adherence (≥2 doses omitted). Participants were unaware of the atorvastatin analyses at study participation.

RESULTS

Mean age was 63 (SD 9) years and 8% had reduced atorvastatin adherence according to the direct method. In patients classified with reduced adherence by the direct method, 40% reported reduced statin adherence, 32% reported reduced adherence with the MMAS-8 and 22% with the Gehi question. In those adherent by the direct method, 96% also reported high statin adherence, 95% reported high adherence on the MMAS-8 whereas 94% reported high adherence on the Gehi question. Cohen's kappa agreement score with the direct method was 0.4 for self-reported statin adherence, 0.3 for the Gehi question and 0.2 for the MMAS-8. Adherence determined by the direct method, self-reported statin adherence last week, and the Gehi question was inversely related to LDL-cholesterol levels with a p-value of <0.001, 0.001 and 0.004, respectively.

CONCLUSIONS

Plasma-statin measurements reveal reduced adherence with higher sensitivity than self-report measures, relate to cholesterol levels, and may prove to be a useful tool to improve lipid management.

Prognostic impact of non-improvement of global longitudinal strain in patients with revascularized acute myocardial infarction

Global longitudinal strain (GLS) is a more sensitive prognostic factor than left ventricular ejection fraction (LVEF) in various cardiac diseases. Little is known about the clinical impact of GLS changes after acute myocardial infarction (AMI). The present study aimed to explore if non-improvement of GLS after 3 months was associated with higher risk of subsequent composite cardiovascular events (CCVE). Patients with AMI were consecutively included at a secondary care center in Norway between April 2016 and July 2018 within 4 days following percutaneous coronary intervention. Echocardiography was performed at baseline and after 3 months. Patients were categorized with non-improvement (0 to − 100%) or improvement (0 to 100%) in GLS relative to the baseline value. Among 214 patients with mean age 65 (± 10) years and mean LVEF 50% (± 8) at baseline, 50 (23%) had non-improvement (GLS: − 16.0% (± 3.7) to − 14.2% (± 3.6)) and 164 (77%) had improvement (GLS: − 14.0% (± 3.0) to − 16.9% (± 3.0%)). During a mean follow-up of 3.3 years (95% CI 3.2 to 3.4) 77 CCVE occurred in 52 patients. In adjusted Cox regression analyses, baseline GLS was associated with all recurrent CCVE (HR 1.1, 95% CI 1.0 to 1.2, p < 0.001) whereas non-improvement versus improvement over 3 months follow-up was not. Baseline GLS was significantly associated with the number of CCVE in revascularized AMI patients whereas non-improvement of GLS after 3 months was not. Further large-scale studies are needed before repeated GLS measurements may be recommended in clinical practice.

Trial registration: Current Research information system in Norway (CRISTIN). Id: 506563

Insomnia in patients with coronary heart disease: prevalence and correlates

STUDY OBJECTIVES

The aim of this study was to determine the prevalence of insomnia and its association with clinical and psychosocial factors in a large sample of outpatients with coronary heart disease.

METHODS

The sample comprised 1,082 patients, mean age 62 years (21% female), who participated in the cross-sectional NORwegian CORonary Prevention Study. Patients who were hospitalized with myocardial infarction and/or a coronary revascularization procedure in 2011-2014 responded to a self-report questionnaire and participated in a clinical examination with blood samples 2-36 (mean, 16) months later. Insomnia was assessed using the Bergen Insomnia Scale, a questionnaire based on the criteria for the clinical diagnosis of insomnia as described in the Diagnostic and Statistical Manual of Mental Disorders, fourth version. We performed bivariate logistic regressions for crude analysis and backward stepwise logistic regressions for multiadjusted odds ratios (OR).

RESULTS

In total, 488 patients (45%) reported insomnia, and 24% of these patients had used sleep medication in the previous week. Anxiety symptoms (OR: 5.61) were the strongest determinants of insomnia, followed by female sex (OR: 1.88), diabetes (OR: 1.83), eating fish fewer than three times a week (OR: 1.69), type D personality (OR: 1.69), and C-reactive protein ≥ 2 mg/L (OR:1.58), in multiadjusted analyses.

CONCLUSIONS

Insomnia was highly prevalent in coronary heart disease outpatients. Psychological factors, lifestyle factors, and subclinical inflammation were associated with insomnia. Our results emphasize the need to identify patients with insomnia and provide appropriate management of insomnia in outpatients with coronary heart disease.

Tailored clinical management after blinded statin challenge improved long-term lipid control in coronary patients with self-perceived muscle side-effects

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helse Sør-Øst, Vestre Viken Trust

Background

Statin discontinuation due to self-perceived muscle side-effects is a major challenge in clinical practice. Strategies are needed to improve lipid control in these patients.

Purpose

We studied if information about the results of a blinded statin challenge experiment, followed by tailored lipid lowering treatment, had long-term effects on lipid control in coronary patients with self-perceived muscle side-effects.

Methods

A post-trial intervention study of patients classified with statin dependent (N = 20) and independent (N = 50) muscle complaints in the MUscle Side-Effects of atorvastatin (MUSE), a randomized, double-blinded, crossover trial. All participants were informed of the MUSE trial results in an individual consultation and provided tailored lipid-lowering treatment according to protocol with 1-2 follow-up calls. Lipids were controlled at the end of follow-up.

Results

Mean age was 64 (SD 9.5) years and 33% (N = 23) were females. During an average follow-up of 13 months (SD 3.3), mean LDL-cholesterol was reduced by 0.3 (SD 0.6) mmol/L (p = 0.005) in patients with statins and by 1.7 (SD 1.0) mmol/L (p = 0.005) in patients without statins at inclusion in the MUSE trial (Table). We found no changes in the overall use of high-intensity statins, but ezetimibe was used by 11 additional patients and 4 patients were prescribed a PCSK9-inhibitor. Participants in the subgroup without statins at inclusion used; atorvastatin (N = 2), rosuvastatin (N = 3) or a PCSK9-inhibitor (N = 2) at follow-up. 90% found their own trial results useful in making decisions about future statin use.

Conclusions

Information about the results of a statin challenge experiment combined with tailored and systematical prescription of lipid-lowering agents had favourable long-term effects on lipid control in coronary patients with self-perceived muscle side-effects.

Characteristics of the study population Using statins at inclusion (n = 62) Not using statins at inclusion (n = 8) Classified with statin-dependent side-effects, n (%) 15 (24) 5 (63) LDL-cholesterol at inclusion, mean (SD) 2.2 (0.8) 4.2 (1.1) LDL-cholesterol at follow-up, mean (SD) 1.9 (0.7) 2.5 (0.8) High intensity statin (ie. ≥40 mg atorvastatin or ≥20 mg rosuvastatin) at inclusion, n (%) 40 (55.6) 0 (0) High intensity statin at follow-up, n (%) 38 (61) 2 (25) Ezetimibe at inclusion, n (%) 13 (21) 3 (38) Ezetimibe at follow-up, n (%) 26 (42) 1 (13) PCSK-9 inhibitor at follow-up, n (%) 2 (3) 2 (25) Usefulness of own trial result in making decisions about future statin use on a 0 to 10 Likert scale, mean (SD) 8.1 (2.0) 9.6 (0.6)

High but not low self-reported statin adherence was confirmed by a novel method based on plasma-statin measurements in coronary outpatients

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helse Sør-Øst

Background

To what extent self-reported adherence measures correspond with directly measured statin adherence is unknown.

Purpose

 To determine the relationship between, self-reported adherence measures, low density lipoprotein-cholesterol (LDL-C) and directly measured statin adherence in coronary outpatients.

Methods

Patients on atorvastatin (N = 373) participated in a cross-sectional study median 16 months after a coronary event. Adherence to statins the past 7 days, general medication adherence assessed by the 8-item Morisky medication adherence scale (MMAS-8), and the Gehi adherence question was obtained by a self-report questionnaire. Atorvastatin was determined in spot blood plasma samples by a novel liquid-chromatography tandem mass-spectrometry method discriminating between adherence (0-1 doses omitted) and reduced (≥2 doses omitted) adherence. Participants were unaware of the atorvastatin analyses at study participation. 

Results

Mean age was 63 (SD 9) years and 19% were females. Mean atorvastatin dose was 64 (SD 21) mg. The number with reduced adherence by the different measurement methods, Cohens kappa agreement score between the self-reported and direct adherence measures, and LDL-C are shown in the Table. Statin adherence was confirmed by the direct method among 96% reporting high statin adherence the past 7 days, among 95% reporting high adherence on the MMAS-8 and among 94% reporting high adherence on the Gehi adherence question. In contrast, among patients classified with reduced statin adherence by the direct method, only 40% reported reduced statin adherence the past week, 32% reported reduced adherence with the MMAS-8 and 22% with the Gehi adherence question.

Conclusions

The direct method confirmed high, but not low, self-reported statin adherence in this selected sample of coronary outpatients. In patients with elevated LDL-cholesterol, plasma-statin measurements emerges as a potential improvement for clinical statin management.

Adherence measures and LDL cholesterol Directly measured atorvastatin adherence Self-reported statin adherence past 7 days Self-reported medication adherence past month (Gehi) 8-item Morisky medication adherence scale Number with reduced adherence, % 7.8 5.5 3.0 8.4 Cohen"s kappa (95% CI) Reference 0.4 (0.2 to 0.6) 0.3 (0.1 to 0.5) 0.2 (0.1 to 0.4) LDL-C, Adherent, mean (95% CI) 1.9 (1.8 to 1.9) 1.9 (1.8 to 2.0) 1.9 (1.8 to 2.0) 1.9 (1.8 to 1.9) LDL-C, Reduced adherence, mean (95% CI) 2.8 (2.4 to 3.2) 2.8 (2.3 to 3.2) 3.2 (2.5 to 3.8) 2.1 (1.9 to 2.4) LDL-C, Adherent versus reduced adherence P &lt;0.001 P = 0.001 P = 0.004 P = 0.07 Agreement between directly measured atorvastatin adherence, self-reported measures of adherence, and mean low density lipoprotein-cholesterol (LDL-C)

A novel direct method to determine adherence to simvastatin therapy in patients with coronary heart disease

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): National Association of Health

OnBehalf

NORCOR

Background

Poor adherence to statin therapy remains a public health concern associated with adverse clinical outcome. Reliable classification and detection of statin adherence is needed in clinical practice and for clinical studies with overall aim to improve the lipid management. Simvastatin is a frequently used statin in cardiovascular disease prevention.

Purpose

To develop a feasible test based on spot blood samples to monitor the adherence to simvastatin therapy in coronary heart disease (CHD) patients.

Methods

Eighteen CHD patients on an evening dose of simvastatin 20 mg (n = 7), 40 mg (n = 5) and 80 mg (n = 6) were studied at steady-state pharmacokinetics. Ten patients were instructed to avoid simvastatin dosing and return for blood sampling the subsequent three days. Dose-normalized plasma concentrations of simvastatin lactone, simvastatin acid and the sum of the two were evaluated as discriminators between adherent dosing and dose avoidance. Bioanalytical quantifications were performed with liquid chromatography tandem mass spectrometry.

Results

The dose-normalized plasma concentrations at steady-state demonstrated 23-fold and 39-fold interindividual variabilities for simvastatin lactone and simvastatin acid. A simvastatin acid cut-off at 1.0·10^-2 nmol/L/mg identified 100% of those omitting 2 doses and 60% of those omitting a single dose (Figure 1). Simvastatin acid showed superior ability to discriminate dose avoidance from adherence, and also the best agreement between samples handled at ambient and cool temperature (median deviation 3.5%, interquartile range -2.5 to 13%). A cut-off for morning dose schedule, with similar ability to discriminate, was estimated at 2.0·10^-3 nmol/L/mg.

Conclusion

A novel method discriminating between good and poor adherence to simvastatin therapy in CHD patients has been developed. The sample handling is feasible for routine practice, and the assessment of adherence can be performed by direct measurements in spot blood samples, according to specific cut-off values.

Abstract Figure 1 Drug levels vs dose avoidance

Challenges in coronary heart disease prevention - experiences from a long-term follow-up study in Norway

Objective. To determine longitudinal changes in lifestyle behaviour and lipid management in a chronic coronary heart disease (CHD) population. Design. A multi-centre cohort study consecutively included 1127 patients at baseline in 2014-2015, on average 16 months after a CHD event. Data were collected from hospital records, a questionnaire and clinical examination. Seven hundred and seven of 1021 eligible patients participated in a questionnaire-based follow-up in 2019. Data were analysed with univariate statistics. Results. After a mean follow-up of 4.7 years (SD 0.4) from baseline, the percentage of current smokers (15% versus 16%), obesity (23% versus 25%) and clinically significant symptoms of anxiety (21% versus 17%) and depression (13% versus 14%) remained unchanged, whereas the proportion with low physical activity increased from 53% to 58% (p < .001). The proportions with reduced physical activity level were similar in patients over and under 70 years of age. Most patients were still taking statins (94% versus 92%) and more patients used high-intensity statin (49% versus 54%, p < .001) and ezetimibe (5% versus 15%, p < .001) at follow-up. 73% reported ≥1 primary-care consultation(s) for CHD during the last year while 27% reported no such follow-up. There were more smokers among participants not attending primary-care consultations compared to those attending (19% versus 14%, p = .026). No differences were found for other risk factors. Conclusions. We found persistent suboptimal risk factor control in coronary outpatients during long-term follow-up. Closer follow-up and intensified risk management including lifestyle and psychological health are needed to improved secondary prevention and outcome of CHD. Trial registration: Registered at ClinicalTrials.gov: NCT02309255.Registered at 5 December 2014, registered retrospectively.

Clinical factors, psychological factors and beliefs about statin use in patients with coronary heart disease and self-perceived muscle side-effects

Background

Statin associated muscle symptoms (SAMS) are commonly reported and constitute the principal reason for statin non-adherence and/or discontinuation. Understanding the determinants of SAMS may enhance the clinical management and form the basis of interventions. The association between psychological distress and the beliefs about statin treatment and SAMS have previously not been investigated under randomized, controlled conditions.

Purpose

To compare clinical and psychological factors among coronary patients with confirmed SAMS and non-SAMS.

Methods

This pre-planned exploratory study included 71 consecutively recruited patients with self-perceived SAMS enrolled in the MUscle Side-Effect of atorvastatin in coronary patients (MUSE) randomized double-blinded crossover trial. Muscle symptom (pain, weakness, tenderness, stiffness and/or cramps) intensity was registered weekly in a patient diary using a 0 (no symptoms) to 10 (worst imaginable) cm visual-analogue scale (VAS). Confirmed SAMS was predefined as a 25% higher individual mean VAS-scores during 7-weeks treatment with atorvastatin 40 mg/day versus 7-weeks treatment with placebo, and ≥1cm absolute difference. Clinical factors (10 variables), psychological factors (5 variables) and beliefs about medicine (3 variables) were obtained from a questionnaire and a clinical examination at study start.

Results

Mean age was 63 (SD 9.5) years, 32% were women, and each participant had tried average 1.3 (SD 0.6, range 1 to 3) statins prior to study start. In all, 28% (n=20) had confirmed SAMS and 72% (n=51) had non-SAMS. There were no differences in mean VAS score at study start between the groups (mean VAS score 4.5 vs. 4.7, p=0.20). More patients with confirmed SAMS than non-SAMS (25% vs. 6%, p&lt;0.001) did not use statin treatment at study start, and mean LDL-cholesterol level was borderline higher (2.8 vs. 2.3 mmol/L, p=0.06). Patients with confirmed SAMS had a weaker belief in their statin use compared to patients with non-SAMS (3.1 vs. 3.6, p&lt;0.001) using a 5-category scale from 1 (weak belief) to 5 (strongest belief). There were no differences in the sociodemographic, clinical (pre-existing muscle skeletal disorders, somatic comorbidity, cardiovascular risk factors) or psychological (symptoms of anxiety or depression, type D personality, worry, insomnia) factors explored between patients with confirmed SAMS or with non-SAMS. There were no associations between these factors and increasing VAS scores in continuous analyses among patients with confirmed SAMS and non-SAMS.

Conclusions

Patients with statin dependent muscle side-effects reported a weaker belief on the necessity to take statins than patients with muscle complaints not caused by the statin. Otherwise, we found no differences in clinical or psychological factors between these populations. The results indicate that these factors do not distinguish patients with and without associated muscle symptoms in clinical practice.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Vestfold Hospital Trust, research grant

Preventable clinical and psychosocial factors predicted two out of three recurrent cardiovascular events in a coronary population

BACKGROUND

The relative importance of lifestyle, medical and psychosocial factors on the risk of recurrent major cardiovascular (CV) events (MACE) in coronary patients' needs to be identified. The main objective of this study is to estimate the association between potentially preventable factors on MACE in an outpatient coronary population from routine clinical practice.

METHODS

This prospective follow-up study of recurrent MACE, determine the predictive impact of risk factors and a wide range of relevant co-factors recorded at baseline. The baseline study included 1127 consecutive patients 2-36 months after myocardial infarction (MI) and/or revascularization procedure. The primary composite endpoint of recurrent MACE defined as CV death, hospitalization due to MI, revascularization, stroke/transitory ischemic attacks or heart failure was obtained from hospital records. Data were analysed using cox proportional hazard regression, stratified by prior coronary events before the index event.

RESULTS

During a mean follow-up of 4.2 years from study inclusion (mean time from index event to end of study 5.7 years), 364 MACE occurred in 240 patients (21, 95% confidence interval: 19 to 24%), of which 39 were CV deaths. In multi-adjusted analyses, the strongest predictor of MACE was not taking statins (Relative risk [RR] 2.13), succeeded by physical inactivity (RR 1.73), peripheral artery disease (RR 1.73), chronic kidney failure (RR 1.52), former smoking (RR 1.46) and higher Hospital Anxiety and Depression Scale-Depression subscale score (RR 1.04 per unit increase). Preventable and potentially modifiable factors addressed accounted for 66% (95% confidence interval: 49 to 77%) of the risk for recurrent events. The major contributions were smoking, low physical activity, not taking statins, not participating in cardiac rehabilitation and diabetes.

CONCLUSIONS

Coronary patients were at high risk of recurrent MACE. Potentially preventable clinical and psychosocial factors predicted two out of three MACE, which is why these factors should be targeted in coronary populations.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov: NCT02309255. Registered at December 5th, 2014, registered retrospectively.