Starting patients on cholesterol-lowering drugs in the hospital instead of an outpatient basis may increase the likelihood that they will continue taking their medications longer, according to an article in the November 24 issue of The Archives of Internal Medicine.

Despite data demonstrating the health benefits of lipid-lowering drugs in patients with heart disease, they remain underused. Because lipid-lowering agents can improve cardiovascular health, strategies to increase their use are needed.

Steven E. Nissen, M.D., of the Cleveland Clinic Foundation, and colleagues examined the relationship between initiation of lipid-lowering therapy (during a hospital stay, or in an outpatient setting) and its long-term use.

The researchers used data from patients at 69 centers from the United States and Canada that participated in the Evaluation in PTCA to Improve Long-term Outcome With Abciximab GP IIb/IIIa Blockade (EPILOG) trial. The EPILOG trial involved patients hospitalized for treatment for heart disease who were randomized to receive placebo or lipid-lowering drugs. The patients were older than 21 years and were not taking lipid-lowering drugs when hospitalized. One hundred and seventy-five patients were discharged taking lipid-lowering therapy and 1,951 were discharged without lipid-lowering therapy.

The researchers found that after six months, 134 patients (77 percent) who started taking lipid-lowering agents before hospital discharge continued taking therapy compared with 494 (25 percent) of those discharged without lipid-lowering therapy, and who had these drugs prescribed by their doctors later (Figure).

 

”We found that initiation of lipid-lowering agents before discharge was the most important independent predictor of their use at follow-up,” the authors write. “In fact, patients in whom lipid-lowering therapy was initiated before discharge were nearly three times as likely to be taking these agents six months later.”

”Our findings suggest that inpatient initiation of lipid-lowering therapy for the secondary prevention of coronary disease is an effective strategy to enhance subsequent use. Other modifiable factors that influence the long-term use of these agents must be identified if we are to bridge the gap between the current evidence base and practice of preventive medicine,” the researchers concluded.

Atorvastatin Appears to Reduce Arterial Stiffness in Rheumatoid Arthritis Patients

 

Atorvastatin may reduce arterial stiffness, reducing the risk of cardiovascular disease in patients with rheumatoid arthritis (RA), according to Australian researchers. Their findings were presented in a poster session on October 28th at the American College of Rheumatology 67th Annual Scientific Meeting.

”Our study suggests that this drug, atorvastatin, may reduce the risk of heart disease in patients with rheumatoid arthritis,” said lead investigator Sharon Van Doonum, a consultant from Royal Melbourne Hospital , Parkville , Australia . “This drug improved vascular stiffness, which is a possible surrogate marker of cardiovascular disease. So, the idea is that perhaps this drug can reduce the risk of heart disease in rheumatoid arthritis patients.”

For this investigation, researchers enrolled 30 patients with rheumatoid arthritis, evaluating them before and after 6 weeks of treatment with atorvastatin 20 mg daily. They included patients with both normal and elevated LDL cholesterol levels and measured fasting lipids, ESR, CRP and arterial stiffness, which was noted as an augmentation index (AIx).

The research team found that the augmentation index in their RA patients improved from 34.1±11.4% to 30.7±11% (p<0.0001) after 6 weeks of treatment with atorvastatin. They also noted that fasting LDL cholesterol improved from 3.4±0.8 mmol/L to 1.8±0.5 mmol/L (p<0.0001) with no significant change in blood pressure, pulse rate, CRP or ESR during the study.

They concluded that treatment with atorvastatin significantly reduced arterial stiffness in patients with RA but did not reduce serum CRP, suggesting a possible role for statins in the prevention of cardiovascular disease in RA patients.

 

Five years of simvastatin therapy, compared with placebo, significantly reduced the risk of ischaemic stroke in a large population of men and women between 40 and 80 years old, the Heart Protection Study Collaborative Group reports.

”Cholesterol-lowering statin therapy rapidly produces a definite and substantial reduction in ischaemic stroke, irrespective of the patient's age, sex, or blood lipid concentrations when treatment is initiated,” according to researchers with the Heart Protection Study, Radcliffe Infirmary, Oxford, United Kingdom.

They randomised 20,536 individuals with non-fasting total blood cholesterol concentrations of at least 3.5 mmol/L and a history of cerebrovascular disease, coronary disease, other occlusive arterial disease, diabetes mellitus, or treated hypertension (if male and at least 65 years old) to receive either 40 mg simvastatin per day or placebo. Overall, 3,280 patients had cerebrovascular disease and 17,256 participants did not, and were followed for a mean of 4.8 years and 5.0 years, respectively.

Among the 10,269 simvastatin-treated participants, 4.3% had a first stroke compared with 5.7% of the 10,267 placebo participants, for a 25% proportional reduction in the first event rate for stroke. This was primarily due to fewer ischaemic strokes in the simvastatin group: 2.8% versus 4.0% in the placebo group, since both groups showed a 0.5% rate of haemorrhagic strokes.

The simvastatin group showed a non-significant trend towards fewer strokes during the first year of follow-up, which increased to a highly significant 30% proportional reduction by the end of the second year. “During each separate subsequent year of follow-up there were further reductions of about one-quarter in the stroke rates,” the authors noted, adding that during an average of 5 years, 4.3% of the simvastatin compared with 5.7% of the placebo group had 1 or more stroke (Figure).

 

Transient cerebral ischaemic attacks alone occurred in 2.0% and carotid endarterectomy or angioplasty was necessary in 0.4% of the simvastatin group compared with 2.4% and 0.8%, respectively, in the placebo group. However, patients with pre-existing cerebrovascular disease showed no apparent reduction in stroke rate, even though this group had a 20% reduction in the rate of any major vascular event.

”Given that stroke is one of the major causes of mortality and major morbidity worldwide, these findings indicate that statin therapy should now be considered routinely for all patients at high risk of stroke, irrespective of their initial cholesterol concentrations or the presence of coronary disease,” the authors concluded.

 

In patients undergoing infra-inguinal vascular surgery, preoperative treatment with statins appears to be associated with a shorter hospital stay, improved long-term survival, and trends towards fewer myocardial infarctions (MIs) and combined cardiovascular end points.

What's more, the benefits occurred independently of age, significant co-morbidities, beta-blocker use, and year of operation, according to results reported on March 7th at the American College of Cardiology 53rd Annual Scientific Session.

R. Parker Ward, MD, Assistant Professor of Medicine, Director, Cardiology Clinic, University of Chicago Hospitals, Chicago , Illinois , who presented the findings, said his group reviewed 561 infra-inguinal vascular surgeries on 446 patients during a recent 7-year period.

Patients undergoing vascular surgery are at high risk of perioperative cardiovascular complications, Dr. Ward noted. This risk is due to a variety of factors, including a high prevalence of coexisting cardiovascular disease and unique surgical stresses such as arterial cross clamping. Beta-blocker therapy is the only proven way to reduce such complications.

Statins have multiple beneficial effects in patients with peripheral vascular disease. For example, they reduce cardiovascular events and claudication. These favourable effects may be due to the non-cholesterol effects of statins, including stabilization of atherosclerotic plaque, reduction of vascular inflammation, and improvement in endothelial cell function.

While preoperative statin use has recently been associated with reduced mortality in patients undergoing major cardiovascular surgery, the effect of preoperative statin therapy on perioperative cardiovascular morbidity, including length of hospital stay and long-term survival, has not been known.

Among the 561 infra-inguinal vascular surgeries reviewed by Dr. Ward's team, pre-operative statins and beta-blockers were used in 16% and 23% of procedures, respectively.

Overall, coronary artery disease was present in 59% of patients, history of coronary bypass surgery in 19%, diabetes mellitus in 54%, prior stroke in 5%, smoking in 55%, hypertension in 76%, chronic obstructive pulmonary disease in 8%, and end-stage renal disease in 18%.

Perioperative events included 30-day death in 2.9% of patients, 30-day cardiovascular death in 2.0%, MI in 5.2%, cerebrovascular accident in 0.9%, and major vascular events in 13.4%. Statin therapy was associated with a shorter length of stay compared to beta-blocker therapy (6.4 versus 9.7 days, P<.0001).

Multivariate analysis that controlled for multiple surgeries within patients as well as co-morbidities, age, and operative year, showed that independent predictors of shorter length of stay were statin therapy (P=.008), absence of end-stage renal disease (P=.01), and later operative year (P=.02). Beta-blocker therapy was associated with fewer MIs (P=.02), and fewer cases of combined cardiovascular death, MI, and cerebrovascular accidents (P=.04). Statin therapy was associated with trends towards fewer MIs (P=.09), and fewer cases of combined death, MI, and cerebrovascular accidents (P=.08).

Overall, 48% of patients died during a mean follow-up of 5.5 years. Statin therapy was associated with improved long-term survival (P=.004) on Cox hazard regression analysis, controlling for co-morbidities, age, beta-blocker use, and operative year.

Dr. Ward said that a randomized, prospective trial is needed to determine the effect of preoperative statin therapy on perioperative cardiovascular outcomes. Statins, he added, may represent a low-risk, low-cost means of reducing the most frequent complications of vascular surgery. He added that the study's findings highlight the benefits of statin therapy in patients with peripheral vascular disease.

 

Furthermore, the long-lived men and women were between 1.5 and 3.6 times more likely to be homozygous for the 405 valine allele of the cholesteryl ester transfer protein (CETP) gene (VV genotype). Parents with the VV genotype had increased lipoprotein sizes and lower serum CETP concentrations.

“Further elucidation of the genetic and biological mechanisms that determine lipoprotein particle sizes may provide key insights into preventive and therapeutic interventions for several age-related disease that imparts significant morbidity and mortality to elderly individuals,” the study authors concluded.