S. Noaman

Prescribing statins for cardiovascular disease prevention in the old: an absence of evidence and an absence of guidelines.

Australias oldest old are potentially being harmed by the under- and over- use of statins. Variations in prescription of statins are in part due to the vacuum of clinical research trial evidence and paucity of contemporary guidelines that are needed to address the use of lipid lowering therapy in the oldest old. There are a few randomised placebo-controlled trials that recruited an older population. Therefore evidence of statins efficacy in the oldest old is based on an extrapolation of results from those studies. The extensive exclusion criteria of those studies, the relative youth of the study participants, the low levels of comorbidity and functional impairment limit the external validity and the generalisability of the findings. Current guidelines are silent or generally non-specific about statin therapy for the oldest old deferring decisions to individual medical practitioners. Life expectancy, time to benefit, functional status and medication related adverse events, polypharmacy, adherence to treatment are factors that need to be considered when forming appropriate guidelines for statin prescription in the very old. Well-designed clinical trials that account for the heterogeneity of this population are needed. While waiting for this research evidence better clinical guidelines are needed to address this issue.

Australian Trends in Procedural Characteristics and Outcomes in Patients Undergoing Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Over the last decade, systems of care for ST-elevation myocardial infarction (STEMI) have evolved to try to improve outcomes and timely access to percutaneous coronary intervention (PCI). There have also been advances in PCI techniques and adjunctive pharmacotherapies. In this study, we sought to determine temporal changes in practices and clinical outcomes of PCI in patients with STEMI. We prospectively collected data on 8,412 consecutive patients undergoing PCI for STEMI between 2005 and 2016 in the multicenter Melbourne Interventional Group registry. Data were divided by procedure year for trends analysis. The primary end point was 30-day mortality. Patient demographics and comorbidities including smoking and diabetes have remained stable. The volume of primary PCI performed within 12 hours of symptom onset has significantly risen (65.7% to 80.1%, p < 0.01). The proportion of patients achieving the recommended door-to-balloon time ≤90 minutes has also risen (37.6% to 59.0%, p < 0.01). Patient complexity has also increased with more patients after out-of-hospital cardiac arrest with STEMI now being treated with PCI (2.6% to 9.1%, p < 0.01). A shift from mainly femoral to radial access and from bare-metal to drug-eluting stent use was seen. Glycoprotein IIb/IIIa inhibitors are being used less frequently with increasing use of newer antiplatelet agents. Thirty-day mortality has remained low throughout the study period at 6.5% overall. In conclusion, although timely access to primary PCI has improved, mortality rates have remained unchanged, but remain low and compare favorably with international data. Australian PCI practice has overall evolved in response to evidence and emergence of new adjunctive device and pharmacotherapies.

Changes in Statin Prescription Patterns in Patients Admitted to an Australian Geriatric Subacute Unit

BACKGROUND Assessment of demographic and clinical factors influencing the decision of statin discontinuation in the elderly population admitted to subacute geriatric unit. The aim of this study is to assess the clinical factors impacting the decision-making process of statin discontinuation in the elderly. METHODS We retrospectively assessed changes in statin discontinuation and prescription among patients (≥60 years old) discharged from a geriatric evaluation and management unit by reviewing hospital digital medical records at Western Health - The Williamstown Hospital over a 12-month period from 4 February 2012 until 4 February 2013 inclusive. The main outcome of the study was to determine the independent predictors of statin discontinuation using logistic regression analysis. RESULTS Of the studied population, 46% were already prescribed statins prior to their admission. Statins were discontinued in 17.5% of patients at discharge. Predictors of statin de-prescription included octogenarian status, primary prevention indication, poor functional recovery, residential care facility discharge destination and lower cognitive function. The presence of previous cardiovascular disease history and the burden of comorbidities were not predictors of statin discontinuation. CONCLUSIONS We observed that factors that conveyed poor prognosis such as advanced age, poor functional recovery, worse cognitive function, being discharged to a residential care facility as well as primary prevention indication for statin prescription are predictors of statin discontinuation in the geriatric unit.