S-EPMC10326072 - Association between statin therapy and mortality in patients on dialysis after atherosclerotic cardiovascular diseases. - OmicsDI

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Association between statin therapy and mortality in patients on dialysis after atherosclerotic cardiovascular diseases.

ABSTRACT: Statin therapy is essential for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD). However, the effects of statin therapy in patients receiving chronic dialysis remain uncertain. We aimed to evaluate the effect of statin therapy on long-term mortality in patients on dialysis after a first-time ASCVD. Patients receiving maintenance dialysis aged ≥ 18 years with a first-time ASCVD event between 2013 and 2018 were included in the Korean National Health Insurance Service database. Associations of statin use with long-term mortality were examined using Cox proportional hazards regression models adjusted for demographics and comorbidities. Among 17,242 patients on dialysis, 9611 (55.7%) were prescribed statins after a first-time ASCVD event. Among statin users, 7376 (76.7%) used moderate-intensity statins. During a mean follow-up of 32.6 ± 20.9 months, statin use was associated with a lower risk of all-cause mortality than statin nonuse after adjusting for confounding factors (hazard ratio [HR]: 0.92; 95% confidence interval [CI] 0.88-0.97; p = 0.0009). Despite a lack of evidence, more than half of patients on dialysis were prescribed statins after an ASCVD event. In patients on dialysis after ASCVD, statin therapy significantly reduced the risk of long-term all-cause mortality.

SUBMITTER: Lee M

PROVIDER: S-EPMC10326072 | biostudies-literature | 2023 Jul

REPOSITORIES: biostudies-literature

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Association between statin therapy and mortality in patients on dialysis after atherosclerotic cardiovascular diseases.

Lee Myunhee M Choi Won Jung WJ Lee Yunhee Y Lee Kyusup K Park Mahn-Won MW Myong Jun-Pyo JP Kim Dae-Won DW

Scientific reports 20230706 1

Statin therapy is essential for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD). However, the effects of statin therapy in patients receiving chronic dialysis remain uncertain. We aimed to evaluate the effect of statin therapy on long-term mortality in patients on dialysis after a first-time ASCVD. Patients receiving maintenance dialysis aged ≥ 18 years with a first-time ASCVD event between 2013 and 2018 were included in the Korean National Health Insurance S ...[more]

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Project description:ImportanceDe novo statin therapy in patients receiving chronic dialysis has failed to demonstrate cardiovascular (CV) protection in randomized clinical trials and thus is not recommended by current guidelines. However, current guidelines recommend the continuation of statin therapy if initiated before transition to dialysis.ObjectiveTo investigate whether the continuation of statins from advanced chronic kidney disease into the dialysis therapy period is associated with improved survival.Design, setting, and participantsRetrospective cohort study of US veterans transitioning to dialysis between October 1, 2007, and March 30, 2014. Participants were 14 298 US veterans who were receiving statins during the 12-month period before transition to dialysis and survived the first year of dialysis. Data analysis was conducted between August 2, 2017, and June 28, 2018.ExposuresPatients were characterized as statin continuers (n = 11 936) if statin therapy was continued for at least 6 months during the first year after dialysis initiation and as statin discontinuers (n = 2362) if therapy with statins was stopped or no statin therapy was received in the year posttransition.Main outcomes and measuresAssociations of statin continuation with 12-month all-cause mortality and CV mortality after 1 year of dialysis initiation were examined using Cox proportional hazards regression models adjusted for demographics and comorbidities.ResultsThe mean (SD) age of the cohort was 71 (10) years; the cohort was 96.7% (n = 13 828) male and 21.3% (n = 3043) African American, and 74.6% (n = 10 627) had diabetes. The 12-month all-cause mortality and CV mortality rates after 1 year of transition to dialysis were lower in statin continuers: deaths per 100 person-years were 21.9 (95% CI, 20.9-22.8) and 8.1 (95% CI, 7.5-8.6) in statin continuers vs 30.3 (95% CI, 27.8-32.8) and 9.8 (95% CI, 8.3-11.2) in statin discontinuers. Moreover, lower all-cause mortality and CV mortality risks with statin continuation persisted in adjusted analyses, with hazard ratios of 0.72 (95% CI, 0.66-0.79) and 0.82 (95% CI, 0.69-0.96), respectively. Associations were similar across subgroups, including age, race, and diabetes status.Conclusions and relevanceIn this study, the continuation of statin therapy after transition to dialysis was associated with reduced all-cause mortality and CV mortality. The study findings suggest that future studies are needed to examine potential CV benefits of continuing statin therapy after dialysis initiation.

Project description:BackgroundRisk evaluation of atherosclerotic cardiovascular disease (ASCVD) remains the cornerstone of primary prevention. The cardiovascular risk assessment can guide the decision-making on various preventive measures such as initiating or deferring statin therapy. Thus, our study aimed to assess the physicians' knowledge, attitude, and practices regarding atherosclerotic cardiovascular diseases risk assessment. Also, we evaluated the physician-patient discussion and counseling practices before statin therapy initiation in concordance with recommendations from the latest clinical practice guideline.MethodsA cross-sectional study was conducted between November 2020 and January 2021. A self-administered questionnaire was distributed to 350 physicians (GPs, residents, specialists, and consultants). Two trained pharmacists distributed the questionnaires in 5 major tertiary governmental hospitals and more than ten private hospitals. Also, private clinics were targeted so that we get a representative sample of physicians at different workplaces.ResultsA total of 270 physicians filled the questionnaire out of 350 physicians approached, with 14 being excluded due to high missing data, giving a final response rate of 73%. Participants had suboptimal knowledge and practices with a high positive attitude toward atherosclerotic cardiovascular diseases risk assessment. The knowledge and practices were higher among consultants, participants from the cardiology department, those with experience years of more than nine years, and those who reported following a specific guideline for cholesterol management or using a risk calculator in their practice. Notably, the risk assessment and counseling practices were lower among physicians who reported seeing more patients per day.ConclusionPhysicians had overall low knowledge, suboptimal practices, and a high positive attitude toward cardiovascular risk assessment. Therefore, physicians' training and continuing medical education regarding cholesterol management and primary prevention clinical practice guidelines are recommended. Also, the importance of adherence to clinical practice guidelines and their impact on clinical outcomes should be emphasized.

Project description:ImportanceIn the 1930s, the government-sponsored Home Owners' Loan Corporation (HOLC) established maps of US neighborhoods that identified mortgage risk (grade A [green] characterizing lowest-risk neighborhoods in the US through mechanisms that transcend traditional risk factors to grade D [red] characterizing highest risk). This practice led to disinvestments and segregation in neighborhoods considered redlined. Very few studies have targeted whether there is an association between redlining and cardiovascular disease.ObjectiveTo evaluate whether redlining is associated with adverse cardiovascular outcomes in US veterans.Design, setting, and participantsIn this longitudinal cohort study, US veterans were followed up (January 1, 2016, to December 31, 2019) for a median of 4 years. Data, including self-reported race and ethnicity, were obtained from Veterans Affairs medical centers across the US on individuals receiving care for established atherosclerotic disease (coronary artery disease, peripheral vascular disease, or stroke). Data analysis was performed in June 2022.ExposureHome Owners' Loan Corporation grade of the census tracts of residence.Main outcomes and measuresThe first occurrence of major adverse cardiovascular events (MACE), comprising myocardial infarction, stroke, major adverse extremity events, and all-cause mortality. The adjusted association between HOLC grade and adverse outcomes was measured using Cox proportional hazards regression. Competing risks were used to model individual nonfatal components of MACE.ResultsOf 79 997 patients (mean [SD] age, 74.46 [10.16] years, female, 2.9%; White, 55.7%; Black, 37.3%; and Hispanic, 5.4%), a total of 7% of the individuals resided in HOLC grade A neighborhoods, 20% in B neighborhoods, 42% in C neighborhoods, and 31% in D neighborhoods. Compared with grade A neighborhoods, patients residing in HOLC grade D (redlined) neighborhoods were more likely to be Black or Hispanic with a higher prevalence of diabetes, heart failure, and chronic kidney disease. There were no associations between HOLC and MACE in unadjusted models. After adjustment for demographic factors, compared with grade A neighborhoods, those residing in redlined neighborhoods had an increased risk of MACE (hazard ratio [HR], 1.139; 95% CI, 1.083-1.198; P < .001) and all-cause mortality (HR, 1.129; 95% CI, 1.072-1.190; P < .001). Similarly, veterans residing in redlined neighborhoods had a higher risk of myocardial infarction (HR, 1.148; 95% CI, 1.011-1.303; P < .001) but not stroke (HR, 0.889; 95% CI, 0.584-1.353; P = .58). Hazard ratios were smaller, but remained significant, after adjustment for risk factors and social vulnerability.Conclusions and relevanceIn this cohort study of US veterans, the findings suggest that those with atherosclerotic cardiovascular disease who reside in historically redlined neighborhoods continue to have a higher prevalence of traditional cardiovascular risk factors and higher cardiovascular risk. Even close to a century after this practice was discontinued, redlining appears to still be adversely associated with adverse cardiovascular events.

Project description:Statins failed to reduce cardiovascular (CV) events in trials of patients on dialysis. However, trial populations used criteria that often excluded those with atherosclerotic heart disease (ASHD), in whom statins have the greatest benefit, and included outcome composites with high rates of nonatherosclerotic CV events that may not be modified by statins. Here, we study whether statin use associates with lower atherosclerotic CV risk among patients with known ASHD on dialysis, including in those likely to receive a kidney transplant, a group excluded within trials but with lower competing mortality risks.MethodsUsing data from the United States Renal Data System including Medicare claims, we identified adults initiating dialysis with ASHD. We matched statin users 1:1 to statin nonusers with propensity scores incorporating hard matches for age and kidney transplant listing status. Using Cox models, we evaluated associations of statin use with the primary composite of fatal/nonfatal myocardial infarction and stroke (including within prespecified subgroups of younger age [<50 years] and waitlisting status); secondary outcomes included all-cause mortality and the composite of all-cause mortality, nonfatal myocardial infarction, or stroke.ResultsOf 197,716 patients with ASHD, 47,562 (24%) were consistent statin users from which we created 46,186 matched pairs. Over a median 662 days, statin users had similar risk of fatal/nonfatal myocardial infarction or stroke overall (hazard ratio [HR] 1.00, 95% CI 0.97-1.02), or in subgroups (age< 50 years [HR = 1.05, 95% CI 0.95-1.17]; waitlisted for kidney transplant [HR 0.99, 95% CI 0.97-1.02]). Statin use was modestly associated with lower all-cause mortality (HR 0.96, 95% CI 0.94-0.98; E value = 1.21) and, similarly, a modest lower composite risk of all-cause mortality, nonfatal myocardial infarction, or stroke over the first 2 years (HR 0.90, 95% CI 0.88-0.91) but attenuated thereafter (HR 0.98, 95% CI 0.96-1.01).ConclusionsOur large observational analyses are consistent with trials in more selected populations and suggest that statins may not meaningfully reduce atherosclerotic CV events even among incident dialysis patients with established ASHD and those likely to receive kidney transplants.