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Sex-Based Utilization of Guideline Recommended Statin Therapy and Cardiovascular Disease Outcomes: A Primary
Insights
High-risk women were less likely to receive guideline-directed statin intensity (GDSI) for primary prevention, despite statins improving survival in both sexes. Further strategies are needed to ensure equitable statin use among women.
Area of Science:
- Cardiovascular Medicine
- Preventive Cardiology
- Health Services Research
Background:
- Cardiovascular death rates are similar for men and women in the US.
- Sex differences in statin use for primary prevention and associated atherosclerotic cardiovascular disease (ASCVD) outcomes require further investigation.
Approach:
- Electronic health records from 2013-2019 were analyzed for patients without prior ASCVD.
- Statin intensity and ASCVD outcomes were compared between sexes across risk groups.
- Cox regression models assessed the association between statin use and outcomes, with interaction terms for sex.
Key Points:
- High-risk women were less likely than high-risk men to be on guideline-directed statin intensity (GDSI) at follow-up visits (2-year: 27.7% vs 32.0%; 5-year: 47.2% vs 55.2%).
- No statin use was linked to increased risk of myocardial infarction (MI) and ischemic stroke/transient ischemic attack (TIA) in both sexes.
- High-risk women on GDSI had a lower mortality risk compared to similar-risk men (HR=1.39 [1.22-1.59] vs HR=1.67 [1.50-1.86]).
Conclusions:
- Statin underutilization for primary prevention was observed in both sexes within a large healthcare system.
- Initiation of GDSI was less frequent in high-risk women compared to high-risk men.
- GDSI significantly improved survival for both sexes, highlighting the need for strategies to improve statin use in women.
Background:
In the US, women have similar cardiovascular death rates than men. Less is known about sex differences in statin use for primary prevention and associated atherosclerotic cardiovascular disease (ASCVD) outcomes.
Methods:
Statin prescriptions using electronic health records were examined in patients without ASCVD (myocardial infarction (MI), revascularization or ischemic stroke) between 2013-2019. Guideline-directed statin intensity (GDSI) at index and follow-up visits were compared among sexes across ASCVD risk groups, defined by pooled-cohort equation. Cox regression hazard ratios (HR) [95% CI] were calculated for statin use and outcomes (myocardial infarction, stroke/transient ischemic attack (TIA), and all-cause mortality) stratified by sex. Interaction terms (statin and sex) were applied.
Results:
Among 282,298 patients, (mean age ∼ 50 years) 17.1% women and 19.5% men were prescribed any statin at index visit. Time to GDSI was similar between sexes, but the proportion of high-risk women on GDSI at follow-ups was lower compared to high-risk men (2-years: 27.7 vs 32.0%, and 5-years: 47.2 vs 55.2%, p<0.05). When compared to GDSI, no statin use was associated with higher risk of MI and ischemic stroke/TIA amongst both sexes. High-risk women on GDSI had a lower risk of mortality (HR=1.39 [1.22-1.59]) versus men (HR=1.67 [1.50-1.86]) of similar risk (p value interaction=0.004).
Conclusion:
In a large contemporary healthcare system, there was underutilization of statins across both sexes in primary prevention. High-risk women were less likely to be initiated on GDSI compared with high-risk men. GDSI significantly improved the survival in both sexes regardless of ASCVD risk group. Future strategies to ensure continued use of GDSI, specifically among women, should be explored.
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