Effects of lipid-lowering treatment intensity and adherence on cardiovascular outcomes in patients with a recent myocardial infarction: a Swedish register-based study

DOI: https://doi.org/10.48101/ujms.v127.8296
Keywords: Adherence, ezetimibe, statins, treatment intensity, lipid-lowering therapy, major adverse cardiovascular events, myocardial infarction

Abstract

Background: Oral lipid-lowering treatment (LLT) is the standard of care for patients with cardiovascular disease (CVD). However, insufficient treatment intensity and poor adherence can lead to suboptimal treatment benefit, rendering patients at increased risk of CVD.

Aims: The objective of this study was to evaluate trends in LLT intensity and adherence in Sweden over time, and their association with major adverse cardiovascular events (MACE) after recent myocardial infarction (MI), and also to assess the impact of transition from secondary to primary care on intensity and adherence.

Methods and results: This retrospective observational cohort study used data from Swedish nationwide patient registers and included patients on LLT after an MI in the years 2010–2016 (n = 50,298; mean age, 68 years; 69% men). LLT intensity was evaluated over time (overall, for 2010–2013 and for 2014–2016) as the proportion of patients prescribed low-, moderate-, and high-intensity LLT. Adherence was assessed as the proportion of days covered. A combined measure of intensity and adherence was also considered. Differences in treatment patterns and MACE were assessed. Initiation of high-intensity LLT increased over the two time periods studied (2010–2013, 32%; 2014–2016, 91%). Adherence varied by LLT intensity and was highest in patients receiving high-intensity LLT (>80%), especially during the first time period. Little change in treatment intensity or the combined measure of intensity and adherence was observed after transition to primary care. There was a significant association between the combined measure of intensity and adherence and MACE reduction (hazard ratio [95% confidence interval] per 10% increase in the combined measure: 0.84 [0.82–0.86]; P < 0.01).

Conclusion: The proportion of post-MI patients with high LLT intensity and adherence has increased in recent years, with little change after transfer from specialist to primary care. The combination of LLT intensity and adherence is important for preventing future cardiovascular events.

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References


  1. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;14:111–88. doi: 10.1093/eurheartj/ehz455
  2. American Heart Association. Cardiovascular disease: a costly burden for America. Projections through 2035. Available from: http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_491543.pdf (accessed January 2022).
  3. Mendis S. Global progress in prevention of cardiovascular disease. Cardiovasc Diagn Ther. 2017;7:S32–8. doi: 10.21037/cdt.2017.03.06
  4. Townsend N, Wilson L, Bhatnagar P, Wickramasinghe K, Rayner M, Nichols M. Cardiovascular disease in Europe: epidemiological update 2016. Eur Heart J. 2016;37:3232–45. doi: 10.1093/eurheartj/ehw334
  5. Bhatnagar D, Soran H, Durrington PN. Hypercholesterolaemia and its management. BMJ. 2008;337:a993. doi: 10.1136/bmj.a993
  6. Roth GA, Fihn SD, Mokdad AH, Aekplakorn W, Hasegawa T, Lim SS. High total serum cholesterol, medication coverage and therapeutic control: an analysis of national health examination survey data from eight countries. Bull World Health Organ. 2011;89:92–101. doi: 10.2471/BLT.10.079947
  7. Journath G, Hambraeus K, Hagstrom E, Pettersson B, Lothgren M. Predicted impact of lipid lowering therapy on cardiovascular and economic outcomes of Swedish atherosclerotic cardiovascular disease guideline. BMC Cardiovasc Disord. 2017;17:224. doi: 10.1186/s12872-017-0659-2
  8. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. [2016 European guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts. Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation]. G Ital Cardiol (Rome). 2017;18:547–612.
  9. Kotseva K, De Backer G, De Bacquer D, Ryden L, Hoes A, Grobbee D, et al. Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: results from the European Society of Cardiology ESC-EORP EUROASPIRE V registry. Eur J Prev Cardiol. 2019;26:824–35. doi: 10.1177/2047487318825350
  10. Schubert J, Lindahl B, Melhus H, Renlund H, Leosdottir M, Yari A, et al. Low-density lipoprotein cholesterol reduction and statin intensity in myocardial infarction patients and major adverse outcomes: a Swedish nationwide cohort study. Eur Heart J. 2021;42:243–52. doi: 10.1093/eurheartj/ehaa1011
  11. Khalaf K, Johnell K, Austin PC, Tyden P, Midlov P, Perez-Vicente R, et al. Low adherence to statin treatment during the first year after an acute myocardial infarction is associated with increased second year mortality risk – an inverse probability of treatment weighted study on 54,872 patients. Eur Heart J Cardiovasc Pharmacother. 2021;7:141–7. doi: 10.1093/ehjcvp/pvaa010
  12. Karlsson SA, Eliasson B, Franzen S, Miftaraj M, Svensson AM, Andersson Sundell K. Risk of cardiovascular event and mortality in relation to refill and guideline adherence to lipid-lowering medications among patients with type 2 diabetes mellitus in Sweden. BMJ Open Diabetes Res Care. 2019;7:e000639. doi: 10.1136/bmjdrc-2018-000639
  13. Nilsson G, Samuelsson E, Soderstrom L, Mooe T. Low use of statins for secondary prevention in primary care: a survey in a northern Swedish population. BMC Fam Pract. 2016;17:110. doi: 10.1186/s12875-016-0505-0
  14. Kotseva K, Wood D, De Bacquer D, De Backer G, Ryden L, Jennings C, et al. EUROASPIRE IV: a European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2016;23:636–48. doi: 10.1177/2047487315569401
  15. Modig S, Hoglund P, Troein M, Midlov P. GP’s adherence to guidelines for cardiovascular disease among elderly: a quality development study. ScientificWorldJournal. 2012;2012:767892. doi: 10.1100/2012/767892
  16. Hallberg S, Banefelt J, Fox KM, Mesterton J, Johansson G, Levin LA, et al. Lipid-lowering treatment patterns in patients with new cardiovascular events – estimates from population-based register data in Sweden. Int J Clin Pract. 2016;70:222–8. doi: 10.1111/ijcp.12769
  17. Ludvigsson JF, Andersson E, Ekbom A, Feychting M, Kim JL, Reuterwall C, et al. External review and validation of the Swedish national inpatient register. BMC Public Health. 2011;11:450. doi: 10.1186/1471-2458-11-450
  18. Ludvigsson JF, Otterblad-Olausson P, Pettersson BU, Ekbom A. The Swedish personal identity number: possibilities and pitfalls in healthcare and medical research. Eur J Epidemiol. 2009;24:659–67. doi: 10.1007/s10654-009-9350-y
  19. Wettermark B, Hammar N, Fored CM, Leimanis A, Olausson PO, Bergman U, et al. The new Swedish Prescribed Drug Register – opportunities for pharmacoepidemiological research and experience from the first six months. Pharmacoepidemiol Drug Saf. 2007;16:726–35. doi: 10.1002/pds.1294
  20. Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). The fifth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2012;33:1635–701. doi: 10.1093/eurheartj/ehs092
  21. Läkemedelsverket. Att förebygga aterosklerotisk hjärt-kärlsjukdom med läkemedel – behandlingsrekommendation. 2014;25: 20–33. Available from: https://www.lakemedelsverket.se/sv/behandling-och-forskrivning/behandlingsrekommendationer/sok-behandlingsrekommendationer/lakemedel-for-att-forebygga-aterosklerotisk-hjart-karlsjukdom--behandlingsrekommendation (accessed January 2022).
  22. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S1–45. doi: 10.1161/01.cir.0000437738.63853.7a
  23. Reiner Z, De Backer G, Fras Z, Kotseva K, Tokgozoglu L, Wood D, et al. Lipid lowering drug therapy in patients with coronary heart disease from 24 European countries – findings from the EUROASPIRE IV survey. Atherosclerosis. 2016;246:243–50. doi: 10.1016/j.atherosclerosis.2016.01.018
  24. Steg PG, James SK, Atar D, Badano LP, Blomstrom-Lundqvist C, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33:2569–619. doi: 10.1093/eurheartj/ehs215
  25. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34:2949–3003. doi: 10.1093/eurheartj/eht296
  26. Khunti K, Danese MD, Kutikova L, Catterick D, Sorio-Vilela F, Gleeson M, et al. Association of a combined measure of adherence and treatment intensity with cardiovascular outcomes in patients with atherosclerosis or other cardiovascular risk factors treated with statins and/or ezetimibe. JAMA Netw Open. 2018;1:e185554. doi: 10.1001/jamanetworkopen.2018.5554
  27. Ahrens I, Khachatryan A, Monga B, Dornstauder E, Sidelnikov E. Association of treatment intensity and adherence to lipid-lowering therapy with major adverse cardiovascular events among post-MI patients in Germany. Adv Ther. 2021;38:2532–41. doi: 10.1007/s12325-021-01697-8
  28. Schiele F, Quignot N, Khachatryan A, Gusto G, Villa G, Kahangire D, et al. Clinical impact and room for improvement of intensity and adherence to lipid lowering therapy: five years of clinical follow-up from 164,565 post-myocardial infarction patients. Int J Cardiol. 2021;332:22–8. doi: 10.1016/j.ijcard.2021.03.007
  29. Lindh M, Banefelt J, Fox KM, Hallberg S, Tai MH, Eriksson M, et al. Cardiovascular event rates in a high atherosclerotic cardiovascular disease risk population: estimates from Swedish population-based register data. Eur Heart J Qual Care Clin Outcomes. 2019;5:225–32. doi: 10.1093/ehjqcco/qcy058
  30. Banefelt J, Lindh M, Svensson MK, Eliasson B, Tai M. Statin dose titration patterns and subsequent major cardiovascular events in very high-risk patients – estimates from Swedish population-based registry data. Eur Heart J Qual Care Clin Outcomes. 2020;6:323–31. doi: 10.1093/ehjqcco/qcaa023
Published
2022-05-04
How to Cite
Svensson M. K., Sorio Vilela F., Leósdóttir M., Banefelt J., Lindh M., Rieem Dun A., Norhammar A., & Villa G. (2022). Effects of lipid-lowering treatment intensity and adherence on cardiovascular outcomes in patients with a recent myocardial infarction: a Swedish register-based study. Upsala Journal of Medical Sciences, 127(1). https://doi.org/10.48101/ujms.v127.8296
Issue
Vol. 127 (2022): Upsala J Med Sci
Section
Original Articles
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