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STATINS
Many Elders Don't Receive Primary Preventive Treatment for Cardiovascular Disease
Statins were unlikely to be prescribed for patients 75 or older.
Previous
research has shown that patients with known cardiovascular disease
(CVD) are less likely to receive these drugs as they get older, and
women are less likely than men to get these drugs. Whether the same is
true for primary prevention of CVD is unclear. In this cross-sectional
U.K. study, investigators assessed the effects of age and sex on primary
prevention of CVD in 37,000 patients (age,  40).
The proportion of patients who received antihypertensive drugs
increased with age from 5% among the youngest patients (age range,
40–44) to 57% among the oldest patients (age, 85).
In fact, the likelihood of receiving an antihypertensive drug
prescription increased significantly with each 5-year increment up to
age 84 but not for age 85.
The proportion of patients who received statins increased with age from
3% among the youngest patients (age range, 40–44) to 29% among patients
who were 70 to 74. The likelihood of receiving a statin drug
prescription increased significantly with each 5-year increment up to
age 74 but decreased significantly with each 5-year increment
thereafter. Treatment of women and men did not differ.
Comment: Increasing age increases risk for CVD, and many elders have high 10-year risk for CVD ( 20%). For some elders (age, 75),
primary prevention with antihypertensive and statin drugs can lower
this risk. However, fewer randomized trial data exist for this age group
(and especially for age 85)
than for age <75 75.="75." and="and" be="be" call="call" clarification="clarification" clinical="clinical" considered="considered" drugs="drugs" effects="effects" elders="elders" especially="especially" expectancy="expectancy" for="for" guidelines="guidelines" in="in" life="life" of="of" older="older" overall="overall" p="p" polypharmacy="polypharmacy" populations.="populations." researchers="researchers" should="should" than="than" the="the" these="these" those="those" trials="trials" using="using">
— Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine August 14, 2012
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statins primary prevention
Free
Full-Text Article
Summary
and Comment
Many Elders Don't Receive Primary Preventive Treatment for Cardiovascular
Disease
Statins were unlikely to be prescribed for patients 75 or
older.
Previous research has shown that patients with known
cardiovascular disease (CVD) are less likely to receive these drugs as they
get older, and women are less likely than men to get these drugs. Whether
the same is true for primary prevention of CVD is unclear. In this
cross-sectional U.K. study, investigators assessed the effects of age and
sex on primary prevention of CVD in 37,000 patients (age,
40).
The proportion of patients who received antihypertensive drugs increased
with age from 5% among the youngest patients (age range, 40–44) to
57% among the oldest patients (age,
85). In fact, the likelihood of receiving an antihypertensive
drug prescription increased significantly with each 5-year increment up to
age 84 but not for age
85.
The proportion of patients who received statins increased with age from 3%
among the youngest patients (age range, 40–44) to 29% among patients
who were 70 to 74. The likelihood of receiving a statin drug prescription
increased significantly with each 5-year increment up to age 74 but
decreased significantly with each 5-year increment thereafter. Treatment of
women and men did not differ.
Comment: Increasing age increases risk for CVD, and many elders
have high 10-year risk for CVD (
20%). For some elders (age,
75), primary prevention with antihypertensive and statin drugs
can lower this risk. However, fewer randomized trial data exist for this
age group (and especially for age
85) than for age <75 75.="75." and="and" be="be" call="call" clarification="clarification" clinical="clinical" considered="considered" drugs="drugs" effects="effects" elders="elders" especially="especially" expectancy="expectancy" for="for" guidelines="guidelines" in="in" life="life" of="of" older="older" overall="overall" p="p" polypharmacy="polypharmacy" populations.="populations." researchers="researchers" should="should" than="than" the="the" these="these" those="those" trials="trials" using="using">
— Paul
S. Mueller, MD, MPH, FACP
Published in Journal
Watch General Medicine August 14, 2012
Citation(s):
Sheppard
JP et al. Impact of age and sex on primary preventive treatment for
cardiovascular disease in the West Midlands, UK: Cross sectional study.
BMJ
2012 Jul 12; 345:e4535. (
http://dx.doi.org/10.1136/bmj.e4535)
statins
Impact of age and sex on primary preventive treatment for cardiovascular disease in the West Midlands, UK: cross sectional study
BMJ
2012;
345
doi: 10.1136/bmj.e4535
(Published 12 July 2012)
Cite this as:
BMJ
2012;345:e4535
More topics
- J P Sheppard, research fellow1,
- S Singh, clinical research fellow1,
- K Fletcher, research fellow1,
- R J McManus, professor2,
- J Mant, professor3
- Correspondence to: R J McManus richard.mcmanus@phc.ox.ac.uk
Abstract
Objectives
To establish the impact of age and sex on primary preventive treatment
for cardiovascular disease in a typical primary care population.
Design Cross sectional study of anonymised patient records.
Participants
All 41 250 records of patients aged ≥40 registered at 19 general
practices in the West Midlands, United Kingdom, were extracted and
analysed.
Main outcome measures
Patients’ demographics, risk factors for cardiovascular disease (blood
pressure, total cholesterol concentration), and prescriptions for
primary preventive drugs were extracted from patients’ records. Patients
were subdivided into five year age bands up to 85 (patients aged ≥85
were analysed as one group) and prescribing trends across the population
were assessed by estimating the proportion of patients prescribed with
antihypertensive drug or statin drug, or both, in each group.
Results
Of the 41 250 records screened in this study, 36 679 (89%) patients did
not have a history of cardiovascular disease and therefore could be
considered for primary preventive treatment. The proportion receiving
antihypertensive drugs increased with age (from 5% (378/6978) aged 40-44
to 57% (621/1092) aged ≥85) as did the proportion taking statins up to
the age of 74 (from 3% (201/6978) aged 40-44 to 29% (675/2367) aged
70-74). In those aged 75 and above, the odds of a receiving prescription
for a statin (relative to the 40-44 age group) decreased with every
five year increment in age (odds ratio 12.9 (95% confidence interval
10.8 to 15.3) at age 75-79 to 5.7 (4.6 to 7.2) at age ≥85; P<0 .001=".001" by="by" consistent="consistent" differences="differences" in="in" no="no" p="p" prescribing="prescribing" sex.="sex." there="there" trends="trends" were="were">
Conclusions
Previously described undertreatment of women in secondary prevention of
cardiovascular disease was not observed for primary prevention. Low use
of statins in older people highlights the need for a stronger evidence
base and clearer guidelines for people aged over 75.
dabigatran
SUMMARY
AND COMMENT
Within 12
weeks of marketing approval, dabigatran was found to be responsible for
more adverse events than nearly all other medications.
Reviewing:
Radecki RP. Ann Intern Med 2012 Jul 3; 157:66
ACE-inhibitor
Free
Full-Text Article
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Summary
and Comment
ACE Inhibitor Use Lowers Risks for Pneumonia
A meta-analysis showed that
angiotensin-converting–enzyme inhibitors, but not
angiotensin-receptor blockers, lowered risk.
Many
patients (as many as one third) who take
angiotensin-converting–enzyme (ACE) inhibitors develop coughs.
However, an enhanced cough reflex might lower risk for pneumonia. In this
meta-analysis of 37 studies (18 randomized trials, 11 cohort studies, and 8
case-control studies), investigators evaluated the association between use
of ACE inhibitors or angiotensin-receptor blockers (ARBs) and risk for
pneumonia.
Overall, use of ACE inhibitors was associated with a significant 34%
lower risk for pneumonia compared with no use of ACE inhibitors and a
significant 30% lower risk for pneumonia compared with ARB use. Subgroup
analyses of patients with stroke or heart failure yielded similar results.
Finally, use of ACE inhibitors compared with no use was associated with a
significant 27% lower risk for pneumonia-related death.
Comment: In this study, ACE inhibitor use was associated with
attenuation of risks for pneumonia and pneumonia-related death. The authors
suggest that "patients taking ACE inhibitors who develop cough should,
providing that cough is tolerable, persist with treatment." Although this
suggestion is reasonable (especially because ACE inhibitors confer
considerable cardiovascular benefit), many patients with ACE
inhibitor–related cough find this side effect too annoying or
disruptive to continue taking the drug.
— Paul
S. Mueller, MD, MPH, FACP
Published in Journal
Watch General Medicine August 2, 2012
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atrium fibrilleren AF
rate controle = hartfrequentie
Rhythm controle = ritme
Detail van boezemfibrilleren met een snelle ventrikel-respons
Boezemfibrilleren is een ritmestoornis waarbij er sprake is van een
chaotische depolarisatie van de atria. De sinusknoop wordt hierdoor als
het ware overschreeuwd. De electrische acitiviteit in de boezems kan tot
600 / min oplopen. Boezemfibrilleren ontstaat vaak rond eilandjes van
cellen rond de inmonding van de longvenen in het linker atrium.
Boezemfibrilleren is een van de meest voorkomende ritmestoornissen. Ongeveer 10% van de 70 jarige heeft boezemfibrilleren
[1].
De kans op boezemfibrilleren is verhoogd bij gedilateerde atria,
atriale ischemie, hyperthyreoidie en alcoholgebruik. Er bestaan ook
zeldzame erfelijke vormen van boezemfibrilleren.
De AV knoop is te traag om elk signaal uit de boezems door te
geven. Willekeurig wordt er wel een signaal doorgegeven dat leidt tot
kamercontractie. Door deze willekeur zijn de ventriculaire slagen
onregelmatig en dat is meteen ook een van de belangrijkste ECG-kenmerken van boezemfibrilleren.
Soms is er sprake van grofslagig boezemfibrilleren dat zich uit
in een onregelmatige basislijn, soms is de basislijn volledig vlak.
Boezemfibrilleren wordt als volgt ingedeeld:
- Eerste geregistreerde episode: indien boezemfibrilleren voor het eerst geregistreerd wordt.
- Recidiverend boezemfibrilleren: na twee of meer episodes.
- Paroxysmaal boezemfibrilleren: als recidiverend boezemfibrilleren telkens spontaan over gaat in sinusritme.
- Persisterend boezemfibrilleren: indien een episode van boezemfibrilleren langer dan 7 dagen aanhoudt.
- Permanent boezemfibrilleren: indien boezemfibrilleren aanhoudt ondanks een poging tot medicamenteuze of electrische cardioversie
Lone AF is boezemfibrilleren in patienten jonger dan 60 jaar
zonder klinische of electrocardiografische aanwijzingen voor hart- en of
longziekte. Deze patiënten hebben een gunstigere prognose ten aanzien
van trombo-embolische events.
Non-valvulair boezemfibrilleren is boezemfibrilleren
zonder aanwijzingen voor rheumatische hartklepziekte of bij patienten
zonder mechanische hartklep of hartklep reparatie.
[2]
De behandeling van boezemfibrilleren kan door middel van
ritme-controle (rhythm-control) of frequentie-controle (rate-control).
Er is veel onderzoek gedaan naar de beste strategie. De verschillen op
de lange termijn tussen beide strategieën verschillen in grote groepen
patiënten weinig.
[3]
- Bij rhythm-control wordt er gestreefd naar sinusritme door met medicatie of electrische cardioversie het boezemfibrilleren te beëindigen.
- Bij rate-conrol wordt het boezemfibrilleren
geaccepteerd. Hierbij is de behandelig gericht op het voorkomen van hoge
hartfrequenties door de AV knoop te onderdrukken met medicijnen. De
streeffrequentie is onder de 100 slagen / min in rust en liefst nog iets
lager.
atrial fibrillation AF
Rhythm vs. Rate Control in Older Atrial Fibrillation Patients
Rhythm control might be superior in the long term.
In a major trial published in 2002 (AFFIRM;
JW Gen Med Dec 13 2002),
investigators found no difference in outcome between rhythm and rate
control during 5 years of follow-up in patients with atrial fibrillation
(AF). However, many clinicians still favor rhythm control. In this
retrospective cohort study, researchers used a Canadian database to
identify 26,000 hospitalized patients (median age, 77) with incident AF
who were treated with rhythm or rate control. Patient follow-up was
available for as long as 9 years (median, 3.1 years); during that time,
half of the patients died.
Analyses were adjusted for many demographic and clinical confounders.
Compared with rate control, rhythm control was associated with 7%
higher mortality at 6 months, equal mortality through 4 years, and 11%
and 23% lower mortality at years 5 and 8, respectively.
Comment: Results from this population-based older cohort are
similar to those of AFFIRM — no difference between rhythm and rate
control for AF during short-term and intermediate-term follow-up. In the
current analysis, however, rhythm control was superior during longer
follow-up. Because potential unidentified confounders can't be ruled out
in a retrospective study, a long-term randomized trial would be
justified to confirm these findings.
— Thomas L. Schwenk, MD
Published in Journal Watch General Medicine July 26, 2012
Citation(s):
PPI C. difficile
Summary
and Comment
Proton-Pump Inhibitors Raise Risk for C. difficile Infections
In two
meta-analyses, PPI use was associated with a 1.7-fold higher risk for
Clostridium difficile infection.
In February 2012, the FDA
issued a
safety
alert regarding an association between proton-pump inhibitors (PPIs)
and
Clostridium difficile infection. In new meta-analyses, two
groups of researchers used slightly different criteria to select studies in
which this association could be evaluated; all included studies (23 and 42,
respectively) were observational (cohort or case-control). Each
meta-analysis involved roughly 300,000 patients.
In both meta-analyses, risk for
C. difficile infection was
significantly higher in PPI users than in nonusers (risk ratio, about 1.7).
Although results across individual studies were heterogeneous, nearly all
trended toward higher risk. Most of the included studies were adjusted for
confounding variables, including antibiotic use. Concomitant use of both
PPIs and antibiotics — examined in one meta-analysis — was
associated with greater risk for
C. difficile infection than was use
of PPIs alone or antibiotics alone. Risk for
C. difficile infection
was higher with histamine (H)
2-receptor antagonists than with no
acid-suppressive therapy, but lower with H
2-receptor antagonists
than with PPIs.
Comment: The opportunity for residual confounding in these
studies is substantial, because sicker patients are more likely both to
receive PPIs and to be vulnerable to
C. difficile infection. Still,
these worrisome findings should remind clinicians to initiate PPIs only for
valid indications and to stop PPIs in patients who take them for unclear
reasons.
— Allan
S. Brett, MD
Published in Journal
Watch General Medicine July 31, 2012
statines
SUMMARY
AND COMMENT
An
observational study suggests that statin use before and during
hospitalization for stroke improves short-term outcomes.
Reviewing:
Flint AC et al. Neurology 2012 May 22; 78:1678
