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Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox
Dennis T Ko1, Muhammad Mamdani, David A Alter
1Division of Cardiology, Schulich Heart Centre, and Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario.
Insights
Physicians prescribed statins less often to high-risk patients, despite evidence showing statin benefits for secondary cardiovascular prevention. Optimal statin use requires prioritizing high-risk individuals to maximize cardiovascular health outcomes.
Area of Science:
- Cardiology
- Health Services Research
- Public Health
Background:
- Cardiovascular therapies, including statins, are crucial for secondary prevention.
- Optimal utilization of these therapies should align with patient cardiovascular risk.
- Current practices may not fully leverage statins in high-risk populations.
Purpose of the Study:
- To investigate the relationship between physician treatment intensity and patient baseline cardiovascular risk.
- To determine if statin prescription patterns correlate with predicted cardiovascular risk.
Main Methods:
- Retrospective cohort study using linked healthcare administrative databases in Ontario.
- Included 396,077 patients aged 66+ with cardiovascular disease or diabetes.
- Baseline risk modeled using a 3-year mortality prediction index.
Main Results:
- Only 19.1% of the secondary prevention cohort received statins.
- Statin prescription rates decreased as baseline cardiovascular risk and predicted mortality increased.
- Age and baseline risk interacted, with older patients and higher risk showing lower statin use.
Conclusions:
- Statin prescription was inversely associated with cardiovascular risk and predicted mortality.
- Maximum benefits of statins may be unrealized due to underutilization in highest-risk patients.
- Implementation of statin therapy needs to prioritize individuals with the greatest cardiovascular risk.
Context:
The benefits of cardiovascular therapies such as statins for secondary prevention have been well documented, although they may not be optimally used in patients most likely to benefit. Ideally, aggressiveness in the use of these beneficial therapies should correlate with baseline cardiovascular risk.
Objective:
To examine the association between physicians' treatment aggressiveness and baseline cardiovascular risk.
Design, Setting, And Patients:
Retrospective cohort study incorporating the use of multiple linked health care administrative databases covering more than 1.4 million elderly residents of Ontario. We included 396,077 patients aged 66 years or older who had a history of cardiovascular disease or diabetes while undergoing medical treatment and who were alive on April 1, 1998. Baseline cardiovascular risk was derived using a risk-adjustment index in which we modeled probability of death after 3 years of follow-up.
Main Outcome Measure:
Likelihood of statin use, stratified by baseline cardiovascular risk, after adjusting for age, sex, socioeconomic status, and rural or urban residence.
Results:
Only 75,617 patients (19.1%) in this secondary prevention cohort were prescribed statins. In patients 66 to 74 years old, the adjusted probabilities of statin prescription were 37.7%, 26.7%, and 23.4% in the categories of low, intermediate, and high baseline risk, respectively. The likelihood of statin prescription was 6.4% lower (adjusted odds ratio, 0.94; 95% confidence interval, 0.93-0.95) for each year of increase in age and each 1% increase in predicted 3-year mortality risk. The influence of age also interacted synergistically with baseline risk on the prescription of statins (P<.001).
Conclusions:
We found that prescription of statins diminished progressively as baseline cardiovascular risk and future probability of death increased. Since the benefits of a therapy are dependent on the baseline risk, the maximum benefits of statins may not be fully realized until implementation of therapy includes patients at highest risk.
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