User login
Dark spots in multiple locations
The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)
The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)
The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)
The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
Epinephrine linked with more refractory cardiogenic shock after acute MI
Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.
Study design: A multicenter, prospective, randomized, double-blind study.
Setting: ICUs in nine French hospitals.
Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.
This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.
Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.
Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.
Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.
Study design: A multicenter, prospective, randomized, double-blind study.
Setting: ICUs in nine French hospitals.
Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.
This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.
Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.
Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.
Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
Background: Norepinephrine and epinephrine are the most commonly used vasopressors in clinical practice and in septic shock have been found to be equivalent in effectiveness. Their different physiological effects may influence their effectiveness in cardiogenic shock, and previous retrospective studies have suggested that epinephrine may have worse clinical outcomes in this setting.
Study design: A multicenter, prospective, randomized, double-blind study.
Setting: ICUs in nine French hospitals.
Synopsis: Adults (older than 18 years old) who suffered cardiogenic shock following successful revascularization after AMI were enrolled. Fifty-seven patients were randomly assigned to receive either norepinephrine or epinephrine with patients, nurses, and physicians unaware of which study drug was being used. The primary outcome variable was change in cardiac index within the first 72 hours, and refractory cardiogenic shock served as the main safety endpoint. This study was stopped early because of the higher risk of refractory cardiogenic shock noted in the epinephrine group, compared with that seen in the norepinephrine group (10 of 27 vs. 2 of 30; P = .011). There was no difference in evolution of cardiac index (P = .43) between the two groups. Potentially harmful metabolic and physiologic changes were noted in the epinephrine group including greater lactic acidosis and increased heart rate.
This study was underpowered for clinical endpoints because of the study’s early termination. It also did not include patients in cardiogenic shock from other causes, such as myositis or postcardiopulmonary bypass.
Bottom line: For patients in cardiogenic shock after AMI with successful reperfusion, epinephrine use was associated with increased refractory cardiogenic shock, compared with norepinephrine use.
Citation: Levy B et al. Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-82.
Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
ICYMI: Anti-CD4 antibody maintains viral suppression in HIV patients post ART
according to results from a small, nonrandomized, open-label, phase 2 trial published in the New England Journal of Medicine (2019 Apr 17. doi: 10.1056/NEJMoa1802264).
We reported on this story at the 2017 Conference on Retroviruses & Opportunistic Infections before it was published in the journal. Find our coverage at the link below.
according to results from a small, nonrandomized, open-label, phase 2 trial published in the New England Journal of Medicine (2019 Apr 17. doi: 10.1056/NEJMoa1802264).
We reported on this story at the 2017 Conference on Retroviruses & Opportunistic Infections before it was published in the journal. Find our coverage at the link below.
according to results from a small, nonrandomized, open-label, phase 2 trial published in the New England Journal of Medicine (2019 Apr 17. doi: 10.1056/NEJMoa1802264).
We reported on this story at the 2017 Conference on Retroviruses & Opportunistic Infections before it was published in the journal. Find our coverage at the link below.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
ACP governmental affairs leaders discuss ACA, Title X
PHILADELPHIA – in a video interview conducted during the annual meeting of the American College of Physicians.
Robert B. Doherty, the ACP’s senior vice president, governmental affairs and public policy, and Shari M. Erickson, the organization’s vice president of governmental affairs and medical practice, addressed the future of the Affordable Care Act (ACA), cuts to the funding of Title X clinics, and the National Rifle Association’s urging of Congress to vote against the Violence Against Women Reauthorization Act.
“We’re very, very concerned by a decision by a Texas judge that, if upheld on appeal, would gut the entire ACA and the decision by the administration not to defend any part of the ACA,” said Mr. Doherty.
Ms. Erikson later discussed a final rule released by the administration that she said “significantly impacts access to care for women,” particularly for those in low-income and underserved areas who may be seen by clinics that receive Title X funding.
She also addressed the rule’s effects on federally qualified health centers and other health clinics near Title X–funded clinics that are forced to close.
On a positive note, Mr. Doherty noted that the ACP is supporting legislation that has been introduced in the House to stabilize the current insurance markets.
Mr. Doherty and Ms. Erikson concluded by discussing an ACP initiative focused on reducing administrative burden for ACP members.
PHILADELPHIA – in a video interview conducted during the annual meeting of the American College of Physicians.
Robert B. Doherty, the ACP’s senior vice president, governmental affairs and public policy, and Shari M. Erickson, the organization’s vice president of governmental affairs and medical practice, addressed the future of the Affordable Care Act (ACA), cuts to the funding of Title X clinics, and the National Rifle Association’s urging of Congress to vote against the Violence Against Women Reauthorization Act.
“We’re very, very concerned by a decision by a Texas judge that, if upheld on appeal, would gut the entire ACA and the decision by the administration not to defend any part of the ACA,” said Mr. Doherty.
Ms. Erikson later discussed a final rule released by the administration that she said “significantly impacts access to care for women,” particularly for those in low-income and underserved areas who may be seen by clinics that receive Title X funding.
She also addressed the rule’s effects on federally qualified health centers and other health clinics near Title X–funded clinics that are forced to close.
On a positive note, Mr. Doherty noted that the ACP is supporting legislation that has been introduced in the House to stabilize the current insurance markets.
Mr. Doherty and Ms. Erikson concluded by discussing an ACP initiative focused on reducing administrative burden for ACP members.
PHILADELPHIA – in a video interview conducted during the annual meeting of the American College of Physicians.
Robert B. Doherty, the ACP’s senior vice president, governmental affairs and public policy, and Shari M. Erickson, the organization’s vice president of governmental affairs and medical practice, addressed the future of the Affordable Care Act (ACA), cuts to the funding of Title X clinics, and the National Rifle Association’s urging of Congress to vote against the Violence Against Women Reauthorization Act.
“We’re very, very concerned by a decision by a Texas judge that, if upheld on appeal, would gut the entire ACA and the decision by the administration not to defend any part of the ACA,” said Mr. Doherty.
Ms. Erikson later discussed a final rule released by the administration that she said “significantly impacts access to care for women,” particularly for those in low-income and underserved areas who may be seen by clinics that receive Title X funding.
She also addressed the rule’s effects on federally qualified health centers and other health clinics near Title X–funded clinics that are forced to close.
On a positive note, Mr. Doherty noted that the ACP is supporting legislation that has been introduced in the House to stabilize the current insurance markets.
Mr. Doherty and Ms. Erikson concluded by discussing an ACP initiative focused on reducing administrative burden for ACP members.
REPORTING FROM INTERNAL MEDICINE 2019
Role of Diet in Treating Skin Conditions
Reviews of Self-Instructional Materials
An Integrated System for the Recording and Retrieval of Medical Data in a Primary Care Setting: Part 2: Classification of Diseases
Reviews of Self-Instructional Materials
Poor response to statins hikes risk of cardiovascular events
About half of patients taking statins for hyperlipidemia don’t adequately respond, leaving them at a 22% increased risk of cardiovascular disease, compared with optimal responders. 
Over 6 years, there were about 2,000 more cardiovascular events among those who failed to experience the national treatment target of at least a 40% reduction in LDL cholesterol, according to Stephen F. Weng, MD, and his colleagues. The report is in Heart.
Physicians’ choice of initial statin weighed heavily in the outcomes. Patients who ended up with an optimal response were more likely to get a more potent statin right off, while those with a poorer response were more likely to get a less-potent statin.
“This study provides ‘real world evidence’ that 50% of patients started on statins do not derive the intended therapeutic benefit from them, significantly increasing their risk of future cardiovascular disease,” wrote Dr. Weng of the University of Nottingham, England, and his colleagues. “These findings contribute to the debate on the effectiveness of statin therapy and highlight the need for personalized medicine in lipid management for patients.”
The study comprised 165,411 primary care patients who had hypercholesterolemia but were free of cardiovascular disease at baseline. Statins were prescribed with the goal of at least a 40% reduction in baseline LDL within 24 months of the start of therapy.
Patients had a mean age of 62 years, with a mean baseline LDL of 4.1 mmol/L (158 mg/dL). About 49% were women.
The primary endpoints were the number of patients who did not achieve the 40% or higher reduction in baseline LDL and the between-group risk differences in cardiovascular events (coronary heart disease, stroke or transient ischemic attack, peripheral vascular disease, cardiovascular death).
After 24 months, 51.2% of patients experienced a suboptimal LDL response, with a mean reduction of 2.1 mmol/L (81 mg/dL) compared with 3.1 mmol/L (120 mg/dL). Compared with optimal responders, these patients were significantly more likely to have received a low-potency statin (29% vs. 18%).
Incident cardiovascular events occurred in 14% of the overall group (coronary artery disease, 8%; stroke/TIA, 3%; peripheral vascular disease 1.9%; cardiovascular death, 1%). All of these outcomes were significantly more common among suboptimal responders than optimal responders.
During a mean of 6 years of follow-up, there were 22,798 cardiovascular disease events overall, with significantly more occurring in suboptimal than optimal responders (12,142 vs. 10,656). This translated to a cardiovascular disease rate of 22.6 and 19.7 per 1,000 person-years, respectively.
In a multivariate analysis controlling for age and baseline LDL level, suboptimal responders were 22% more likely to have a cardiovascular disease incident than were optimal responders.
Among suboptimal responders, every unit decrease of 1 mmol/L (39 mg/dL) conferred a significant 6% risk reduction in cardiovascular disease (odds ratio, 0.94).
The benefit was not universal, the authors pointed out. “In this group, the decreased risk remained significant for only stroke/TIA and was not significant for other constituent cardiovascular disease outcomes. However, in patients with an optimal response, an even greater protective effect of LDL reduction and future cardiovascular disease was seen [13%; OR, 0.87],” and this reduction was significant for all of the individual outcomes.
“The study also highlights the benefit of reducing LDL to optimal values, which would lead to better cardiovascular disease outcomes for patients currently on statins,” the authors concluded.
None of the authors had any relevant financial disclosures.
SOURCE: Weng S. et al. Heart 2019 Apr. doi: 10.1136/heartjnl-2018-314253.
Guidelines always look good on paper, but they’re only as good as their implementation, Márcio S. Bittencourt, MD, wrote in an accompanying editorial.
In the United Kingdom, the National Institute for Health and Care Excellence (NICE) guideline pinned effective statin therapy as a lowering of LDL cholesterol by at least 40%. This target aligns well with data accumulated in randomized controlled studies, but it doesn’t benefit patients unless it can be put into practice.
“An important step after a guideline publication is the assessment of its uptake among health practitioners and patients in the real world, as well as of the impact of its adherence on clinical outcomes. These analyses may not only verify its appropriateness, providing feedback for continuous improvement of recommendations, but also identify targets to optimize delivery of health to the society.”
To understand suboptimal statin response, we must understand the many possible reasons behind it – on the part of both physicians and patients.
Physicians may prefer to prescribe low-potency statins for several reasons, including unawareness of guideline recommendations, doubtfulness of better outcomes with higher potent statins or when a lower LDL is attained, and fear of adverse reactions or drug interactions, Dr. Bittencourt noted. “Moreover, doctors may be reluctant to up-titrate drugs when the treatment goals are not achieved, the so-called therapeutic inertia.”
In this study, for example, optimal responders were more likely to initially receive moderately potent statins. Suboptimal responders, on the other hand, were more likely to receive low-potency statins.
“This probably explains why baseline LDL was higher in optimal responders, indicating that higher LDL motivates the physician to be more aggressive upfront.”
Patients bring their own issues to the treatment table.
“Although an inter-individual response to statins may occur according to the genetic background, most cases where LDL response is less than expected are probably due to lack of adherence or persistence to the treatment. ... Of note, poor adherence to lipid-lowering therapy, together with low-intensity therapy, as opposed to high-intensity treatment, is associated with higher cardiovascular risk.”
Effective implementation of guidelines “has been a challenge for a long time. Both physicians and patients should be targets for approaches aiming at improving adherence to guidelines.”
For clinicians, these could include continuing medical education and simplified treatment algorithms. Patients, too, would benefit from some teaching.
“Patients and society should be educated on the scientific evidence documenting the benefits of lipid-lowering therapy, and antistatin propaganda based on pseudoscience should be strongly disavowed and demystified by health authorities.”
Dr. Bittencourt is an internist at the University Hospital San Paolo, Brazil.
Guidelines always look good on paper, but they’re only as good as their implementation, Márcio S. Bittencourt, MD, wrote in an accompanying editorial.
In the United Kingdom, the National Institute for Health and Care Excellence (NICE) guideline pinned effective statin therapy as a lowering of LDL cholesterol by at least 40%. This target aligns well with data accumulated in randomized controlled studies, but it doesn’t benefit patients unless it can be put into practice.
“An important step after a guideline publication is the assessment of its uptake among health practitioners and patients in the real world, as well as of the impact of its adherence on clinical outcomes. These analyses may not only verify its appropriateness, providing feedback for continuous improvement of recommendations, but also identify targets to optimize delivery of health to the society.”
To understand suboptimal statin response, we must understand the many possible reasons behind it – on the part of both physicians and patients.
Physicians may prefer to prescribe low-potency statins for several reasons, including unawareness of guideline recommendations, doubtfulness of better outcomes with higher potent statins or when a lower LDL is attained, and fear of adverse reactions or drug interactions, Dr. Bittencourt noted. “Moreover, doctors may be reluctant to up-titrate drugs when the treatment goals are not achieved, the so-called therapeutic inertia.”
In this study, for example, optimal responders were more likely to initially receive moderately potent statins. Suboptimal responders, on the other hand, were more likely to receive low-potency statins.
“This probably explains why baseline LDL was higher in optimal responders, indicating that higher LDL motivates the physician to be more aggressive upfront.”
Patients bring their own issues to the treatment table.
“Although an inter-individual response to statins may occur according to the genetic background, most cases where LDL response is less than expected are probably due to lack of adherence or persistence to the treatment. ... Of note, poor adherence to lipid-lowering therapy, together with low-intensity therapy, as opposed to high-intensity treatment, is associated with higher cardiovascular risk.”
Effective implementation of guidelines “has been a challenge for a long time. Both physicians and patients should be targets for approaches aiming at improving adherence to guidelines.”
For clinicians, these could include continuing medical education and simplified treatment algorithms. Patients, too, would benefit from some teaching.
“Patients and society should be educated on the scientific evidence documenting the benefits of lipid-lowering therapy, and antistatin propaganda based on pseudoscience should be strongly disavowed and demystified by health authorities.”
Dr. Bittencourt is an internist at the University Hospital San Paolo, Brazil.
Guidelines always look good on paper, but they’re only as good as their implementation, Márcio S. Bittencourt, MD, wrote in an accompanying editorial.
In the United Kingdom, the National Institute for Health and Care Excellence (NICE) guideline pinned effective statin therapy as a lowering of LDL cholesterol by at least 40%. This target aligns well with data accumulated in randomized controlled studies, but it doesn’t benefit patients unless it can be put into practice.
“An important step after a guideline publication is the assessment of its uptake among health practitioners and patients in the real world, as well as of the impact of its adherence on clinical outcomes. These analyses may not only verify its appropriateness, providing feedback for continuous improvement of recommendations, but also identify targets to optimize delivery of health to the society.”
To understand suboptimal statin response, we must understand the many possible reasons behind it – on the part of both physicians and patients.
Physicians may prefer to prescribe low-potency statins for several reasons, including unawareness of guideline recommendations, doubtfulness of better outcomes with higher potent statins or when a lower LDL is attained, and fear of adverse reactions or drug interactions, Dr. Bittencourt noted. “Moreover, doctors may be reluctant to up-titrate drugs when the treatment goals are not achieved, the so-called therapeutic inertia.”
In this study, for example, optimal responders were more likely to initially receive moderately potent statins. Suboptimal responders, on the other hand, were more likely to receive low-potency statins.
“This probably explains why baseline LDL was higher in optimal responders, indicating that higher LDL motivates the physician to be more aggressive upfront.”
Patients bring their own issues to the treatment table.
“Although an inter-individual response to statins may occur according to the genetic background, most cases where LDL response is less than expected are probably due to lack of adherence or persistence to the treatment. ... Of note, poor adherence to lipid-lowering therapy, together with low-intensity therapy, as opposed to high-intensity treatment, is associated with higher cardiovascular risk.”
Effective implementation of guidelines “has been a challenge for a long time. Both physicians and patients should be targets for approaches aiming at improving adherence to guidelines.”
For clinicians, these could include continuing medical education and simplified treatment algorithms. Patients, too, would benefit from some teaching.
“Patients and society should be educated on the scientific evidence documenting the benefits of lipid-lowering therapy, and antistatin propaganda based on pseudoscience should be strongly disavowed and demystified by health authorities.”
Dr. Bittencourt is an internist at the University Hospital San Paolo, Brazil.
About half of patients taking statins for hyperlipidemia don’t adequately respond, leaving them at a 22% increased risk of cardiovascular disease, compared with optimal responders.
Over 6 years, there were about 2,000 more cardiovascular events among those who failed to experience the national treatment target of at least a 40% reduction in LDL cholesterol, according to Stephen F. Weng, MD, and his colleagues. The report is in Heart.
Physicians’ choice of initial statin weighed heavily in the outcomes. Patients who ended up with an optimal response were more likely to get a more potent statin right off, while those with a poorer response were more likely to get a less-potent statin.
“This study provides ‘real world evidence’ that 50% of patients started on statins do not derive the intended therapeutic benefit from them, significantly increasing their risk of future cardiovascular disease,” wrote Dr. Weng of the University of Nottingham, England, and his colleagues. “These findings contribute to the debate on the effectiveness of statin therapy and highlight the need for personalized medicine in lipid management for patients.”
The study comprised 165,411 primary care patients who had hypercholesterolemia but were free of cardiovascular disease at baseline. Statins were prescribed with the goal of at least a 40% reduction in baseline LDL within 24 months of the start of therapy.
Patients had a mean age of 62 years, with a mean baseline LDL of 4.1 mmol/L (158 mg/dL). About 49% were women.
The primary endpoints were the number of patients who did not achieve the 40% or higher reduction in baseline LDL and the between-group risk differences in cardiovascular events (coronary heart disease, stroke or transient ischemic attack, peripheral vascular disease, cardiovascular death).
After 24 months, 51.2% of patients experienced a suboptimal LDL response, with a mean reduction of 2.1 mmol/L (81 mg/dL) compared with 3.1 mmol/L (120 mg/dL). Compared with optimal responders, these patients were significantly more likely to have received a low-potency statin (29% vs. 18%).
Incident cardiovascular events occurred in 14% of the overall group (coronary artery disease, 8%; stroke/TIA, 3%; peripheral vascular disease 1.9%; cardiovascular death, 1%). All of these outcomes were significantly more common among suboptimal responders than optimal responders.
During a mean of 6 years of follow-up, there were 22,798 cardiovascular disease events overall, with significantly more occurring in suboptimal than optimal responders (12,142 vs. 10,656). This translated to a cardiovascular disease rate of 22.6 and 19.7 per 1,000 person-years, respectively.
In a multivariate analysis controlling for age and baseline LDL level, suboptimal responders were 22% more likely to have a cardiovascular disease incident than were optimal responders.
Among suboptimal responders, every unit decrease of 1 mmol/L (39 mg/dL) conferred a significant 6% risk reduction in cardiovascular disease (odds ratio, 0.94).
The benefit was not universal, the authors pointed out. “In this group, the decreased risk remained significant for only stroke/TIA and was not significant for other constituent cardiovascular disease outcomes. However, in patients with an optimal response, an even greater protective effect of LDL reduction and future cardiovascular disease was seen [13%; OR, 0.87],” and this reduction was significant for all of the individual outcomes.
“The study also highlights the benefit of reducing LDL to optimal values, which would lead to better cardiovascular disease outcomes for patients currently on statins,” the authors concluded.
None of the authors had any relevant financial disclosures.
SOURCE: Weng S. et al. Heart 2019 Apr. doi: 10.1136/heartjnl-2018-314253.
About half of patients taking statins for hyperlipidemia don’t adequately respond, leaving them at a 22% increased risk of cardiovascular disease, compared with optimal responders.
Over 6 years, there were about 2,000 more cardiovascular events among those who failed to experience the national treatment target of at least a 40% reduction in LDL cholesterol, according to Stephen F. Weng, MD, and his colleagues. The report is in Heart.
Physicians’ choice of initial statin weighed heavily in the outcomes. Patients who ended up with an optimal response were more likely to get a more potent statin right off, while those with a poorer response were more likely to get a less-potent statin.
“This study provides ‘real world evidence’ that 50% of patients started on statins do not derive the intended therapeutic benefit from them, significantly increasing their risk of future cardiovascular disease,” wrote Dr. Weng of the University of Nottingham, England, and his colleagues. “These findings contribute to the debate on the effectiveness of statin therapy and highlight the need for personalized medicine in lipid management for patients.”
The study comprised 165,411 primary care patients who had hypercholesterolemia but were free of cardiovascular disease at baseline. Statins were prescribed with the goal of at least a 40% reduction in baseline LDL within 24 months of the start of therapy.
Patients had a mean age of 62 years, with a mean baseline LDL of 4.1 mmol/L (158 mg/dL). About 49% were women.
The primary endpoints were the number of patients who did not achieve the 40% or higher reduction in baseline LDL and the between-group risk differences in cardiovascular events (coronary heart disease, stroke or transient ischemic attack, peripheral vascular disease, cardiovascular death).
After 24 months, 51.2% of patients experienced a suboptimal LDL response, with a mean reduction of 2.1 mmol/L (81 mg/dL) compared with 3.1 mmol/L (120 mg/dL). Compared with optimal responders, these patients were significantly more likely to have received a low-potency statin (29% vs. 18%).
Incident cardiovascular events occurred in 14% of the overall group (coronary artery disease, 8%; stroke/TIA, 3%; peripheral vascular disease 1.9%; cardiovascular death, 1%). All of these outcomes were significantly more common among suboptimal responders than optimal responders.
During a mean of 6 years of follow-up, there were 22,798 cardiovascular disease events overall, with significantly more occurring in suboptimal than optimal responders (12,142 vs. 10,656). This translated to a cardiovascular disease rate of 22.6 and 19.7 per 1,000 person-years, respectively.
In a multivariate analysis controlling for age and baseline LDL level, suboptimal responders were 22% more likely to have a cardiovascular disease incident than were optimal responders.
Among suboptimal responders, every unit decrease of 1 mmol/L (39 mg/dL) conferred a significant 6% risk reduction in cardiovascular disease (odds ratio, 0.94).
The benefit was not universal, the authors pointed out. “In this group, the decreased risk remained significant for only stroke/TIA and was not significant for other constituent cardiovascular disease outcomes. However, in patients with an optimal response, an even greater protective effect of LDL reduction and future cardiovascular disease was seen [13%; OR, 0.87],” and this reduction was significant for all of the individual outcomes.
“The study also highlights the benefit of reducing LDL to optimal values, which would lead to better cardiovascular disease outcomes for patients currently on statins,” the authors concluded.
None of the authors had any relevant financial disclosures.
SOURCE: Weng S. et al. Heart 2019 Apr. doi: 10.1136/heartjnl-2018-314253.
FROM HEART
