Salim S. Virani

Implications of the 2013 ACC/AHA Cholesterol Guidelines for Adults in Contemporary Cardiovascular Practice: Insights From the NCDR PINNACLE Registry

BACKGROUNDnIn a significant update, the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines recommend fixed-dose statin therapy for those at risk and do not recommend nonstatin therapies or treatment to target low-density lipoprotein cholesterol (LDL-C) levels, limiting the need for repeated LDL-C testing.nnnOBJECTIVESnThe goal of this study was to examine the impact of the 2013 ACC/AHA cholesterol guidelines on current U.S. cardiovascular practice.nnnMETHODSnUsing the NCDR PINNACLE (National Cardiovascular Data Registry Practice Innovation and Clinical Excellence) registry data from 2008 to 2012, we assessed current practice patterns as a function of the 2013 cholesterol guidelines. Lipid-lowering therapies and LDL-C testing patterns by patient risk group (atherosclerotic cardiovascular disease [ASCVD], diabetes, LDL-Cxa0≥190 mg/dl, or an estimated 10-year ASCVD riskxa0≥7.5%) were described.nnnRESULTSnAmong a cohort of 1,174,545 patients, 1,129,205 (96.1%) were statin-eligible (91.2% ASCVD, 6.6% diabetes, 0.3% off-treatment LDL-Cxa0≥190 mg/dl, 1.9% estimated 10-year ASCVD riskxa0≥7.5%). There were 377,311 patients (32.4%) not receiving statin therapy and 259,143 (22.6%) receiving nonstatin therapies. During the study period, 20.8% of patients had 2 or more LDL-C assessments, and 7.0% had more thanxa04.nnnCONCLUSIONSnIn U.S. cardiovascular practices, 32.4% of statin-eligible patients, as defined by the 2013 ACC/AHA cholesterol guidelines, were not currently receiving statins. In addition, 22.6% were receiving nonstatin lipid-lowering therapies and 20.8% had repeated LDL-C testing. Achieving concordance with the new cholesterol guidelines in patients treated in U.S. cardiovascular practices would result in significant increases in statin use, as well as significant reductions in nonstatin therapies and laboratory testing.

Is 2015 the Primetime Year for Prehypertension? Prehypertension: A Cardiovascular Risk Factor or Simply a Risk Marker?

The Comparative Risk Assessment module of the World Health Organizations Global Burden of Disease 2000 study[1][1] conducted a systematic assessment of changes in population health resulting from modifying exposure to 26 risk factors. These included atherosclerotic risk factors such as high blood

Acute Coronary Syndromes: Unstable Angina and Non–ST Elevation Myocardial Infarction

Non-ST elevation acute coronary syndromes (NSTE-ACS) encompass the clinical entities of unstable angina and non-ST elevation myocardial infarction. Several advances have occurred over the past decade, including the emergence of new antiplatelet and antithrombotic therapies and novel treatment strategies, leading to marked improvements in mortality. However, there has also been an increased incidence in NSTE-ACS as a result of the use of high-sensitivity troponins and the increase in cardiovascular risk factors. This article provides a focused update on contemporary management strategies pertaining to antiplatelet, antithrombotic, and anti-ischemic therapies and to revascularization strategies in patients with ACS.

Persistent socioeconomic disparities in cardiovascular risk factors and health in the United States: Medical Expenditure Panel Survey 2002-2013

BACKGROUND AND AIMSnSocioeconomic status (SES) has been linked to worse cardiovascular risk factor (CRF) profiles and higher rates of cardiovascular disease (CVD), with an especially high burden of disease for low-income groups. We aimed to describe the trends in prevalence of CRFs among US adults by SES from 2002 to 2013.nnnMETHODSnData from the Medical Expenditure Panel Survey was analyzed. CRFs (obesity, diabetes, hypertension, physical inactivity, smoking and hypercholesterolemia), were ascertained by ICD-9-CM and/or self-report.nnnRESULTSnThe proportion of individuals with obesity, diabetes and hypertension increased overall, with low-income groups representing a higher prevalence for each CRF. Of note, physical inactivity had the highest prevalence increase, with the lowest-income group observing a relative percent increase of 71.1%.nnnCONCLUSIONSnDisparities in CRF burden continue to increase, across SES groups. Strategies to potentially eliminate the persistent health disparities gap may include a shift to greater coverage for prevention, and efforts to engage in healthy lifestyle behaviors.

ST Elevation: Telling Pathology from the Benign Patterns

Benefits of early reperfusion in patients presenting with acute ST elevation myocardial infarction (STEMI) are well known. The American College of Cardiology / American Heart Association guidelines recommend triage decisions are made within 10 minutes of performing initial electrocardiogram (ECG). Since many patients presenting with ischemic symptoms may have ST elevation (STE) at baseline, not all STE signify transmural ischemia. Benign patterns can be easy to find in some cases. However, patients with benign STE at baseline (left ventricular hypertrophy, early repolarization pattern) may have ongoing ischemia and present with Non-ST elevation myocardial infarction (NSTEMI) or even STEMI superimposed on the benign pattern. The ability of clinicians to distinguish between ischemic and non ischemic STE varies widely and is affected by prevalence of such changes in patient population. More studies need to be done to delineate the criteria to clearly distinguish between ischemic and non ischemic ST elevation.

Antihypertensive adherence and outcomes among community-dwelling Medicare beneficiaries: the Atherosclerosis Risk in Communities Study.

RATIONALE, AIMS, AND OBJECTIVESnDespite proven benefits for reducing incidence of major cardiac events, antihypertensive drug therapy remains underutilized in the United States. This analysis assesses antihypertensive drug adherence, utilization predictors, and associations between adherence and outcomes (a composite of cardiovascular events, Medicare inpatient payments, and inpatient days).nnnMETHODSnThe sample consisted of Atherosclerosis Risk in Communities Study cohort participants reporting hypertension without prevalent cardiovascular disease during 2006 to 2007 annual follow-up calls. Atherosclerosis Risk in Communities records were linked to Medicare claims through 2012. Antihypertensive medication adherence was measured as more than 80% proportion days covered by using Medicare Part D claims. Standard and hierarchical regression models were used to evaluate adjusted associations between person characteristics and adherence and between adherence and outcomes.nnnRESULTSnAmong 1826 hypertensive participants with Part D coverage, 31.5% had no antihypertensive class with more than 80% proportion days covered in the 3xa0months preceding the report of hypertension in 2006 to 2007. After adjustment for confounders, positive predictors of use included female gender and diabetes; negative predictors were African-American race and current smoking. Adjusted association between receiving no therapy and a composite endpoint of cardiovascular outcomes through 2012 was not statistically significant (hazard ratio: 0.93; 95% confidence interval: 0.72, 1.22) nor was the adjusted association with Medicare inpatient days or payments (incremental difference at 48xa0months in payments:

Implications of the LEGACY trial on US Atrial Fibrillation Patients: An NCDR Research to Practice (R2P) Project

1217; 95% CI: -

Factors associated with rhythm control treatment decisions in patients with atrial fibrillation—Insights from the NCDR PINNACLE registry

2030,

Frequency of Attainment of Low-Density Lipoprotein Cholesterol and Non–High-Density Lipoprotein Cholesterol Goals in Cardiovascular Clinical Practice (from the National Cardiovascular Data Registry PINNACLE Registry)

4463).nnnCONCLUSIONSnDespite having medical and prescription coverage, nearly a third of hypertensive participants were not adherent to antihypertensive drug therapy. Differences in clinical outcomes associated with nonadherence, though not statistically significant, were consistent with results from randomized trials. The approach provides a model framework for rigorous assessment of detailed data that are increasingly available through emerging sources.

TROPONIN T IDENTIFIES INDIVIDUALS AT HIGHER RISK FOR HEART FAILURE AMONG ALL BLOOD PRESSURE CATEGORIES IN THE ATHEROSCLEROSIS RISK IN COMMUNITIES (ARIC) STUDY

The Long-term Effect of Goal Directed Weight Management in an Atrial Fibrillation Cohort: A Long-term Follow-up Study (LEGACY) demonstrated that weight reduction in a cohort of Australian patients with atrial fibrillation (AF) resulted in a reduction in AF burden and improvement in AF symptom severity. The applicability of LEGACY in US cardiovascular practice is not known. A cohort of patients with AF from the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence (PINNACLE) registry of US cardiovascular ambulatory care practices was created. The proportion of PINNACLE AF patients meeting enrollment criteria for LEGACY was assessed. Differences between these patients and LEGACY trial patients were qualitatively compared. Treatment for AF among LEGACY eligible and noneligible patients was compared. Among 349,999 US patients with AF from 179 cardiovascular practices in the PINNACLE registry, 197,255 (56.4%) met enrollment criteria for LEGACY. LEGACY-eligible PINNACLE AF had significantly lower rates of tobacco and alcohol abuse than the LEGACY trial population. There were significant differences in drug therapy comparing LEGACY eligible and LEGACY noneligible PINNACLE AF patients. In this cohort of patients in ambulatory practice in the United States with AF, over 1/2 were potential candidates for a weight management program. Differences between patients in practice and those enrolled in the trial could influence the success and impact of the LEGACY weight management intervention. Our study identifies a potential opportunity to improve AF morbidity and costs to the health care system in the United States by implementing a structured weight reduction program, such as that described in LEGACY.