Lipid Profiles in Out-of-Hospital Sudden Unexpected Death.

OBJECTIVE: To determine the association between serum lipid measurements and the occurrence of out-of-hospital sudden unexpected death (OHSUD). PATIENTS AND METHODS: We compared 139 OHSUD cases (43 female patients [30.9%]) and 968 controls (539 female patients [55.7%]) from Wake County, North Carolina, from March 1, 2013, through February 28, 2015. Individuals were included if they were aged 18 to 64 years and had lipid measurements in the 5 years before their death (cases) or the most recent health care encounter (controls). Covariates were abstracted from medical records for all subjects, and those with triglyceride (TG) levels greater than 400 mg/dL (to convert to mmol/L, multiply by 0.0259) were excluded for low-density lipoprotein (LDL)-related analyses. RESULTS: By linear regression using age- and sex-adjusted models, cases of OHSUD had lower adjusted mean total cholesterol (170.3±52.2 mg/dL vs 188.9±39.7 mg/dL; P<.001), LDL cholesterol (90.9±39.6 mg/dL vs 109.6±35.2 mg/dL; P<.001), and non-high-density lipoprotein (HDL) (121.6±49.8 mg/dL vs 134.3±39.6 mg/dL; P<.001) levels and a higher adjusted TG/HDL-C ratio (4.7±7 vs 3±2.7; P<.001) than did controls. By logistic regression using age- and sex-adjusted models, the odds of OHSUD were elevated per unit increase in TG/HDL-C ratio (1.08; 95% CI, 1.03-1.12). CONCLUSION: Out-of-hospital sudden unexpected death cases had more favorable levels of total cholesterol, LDL cholesterol, and non-HDL, possibly indicating a lack of association between traditional lipid cardiovascular risk factors and sudden unexpected death. A comparatively elevated TG/HDL-C ratio in cases may corroborate an evolving hypothesis of how vasoactive and prothrombotic remnant-like lipoprotein particles contribute to sudden unexpected death.

Economic Burden of Undiagnosed Nonvalvular Atrial Fibrillation in the United States.

Atrial fibrillation (AF) may be clinically silent and therefore undiagnosed. To date, no estimates of the direct medical cost of undiagnosed AF exist. We estimated the United States (US) incremental cost burden of undiagnosed nonvalvular AF nationally using administrative claims data. To calculate the incremental costs of undiagnosed AF, we compared annual medical costs (in 2014 US Dollars) for patients with AF compared to propensity-matched controls and multiplied this by estimates of undiagnosed AF prevalence derived from the same data sources. The study population included US residents aged ≥18 years with 24 months of continuous enrollment drawn from 2 large administrative claims databases. Mean per capita medical spending for patients with AF aged from 18 to 64 year was $38,861 (95% confidence interval [CI] $35,781 to $41,950) compared to $28,506 (95% CI $28,409 to $28,603) for similar patients without AF (incremental cost difference $10,355, p <0.001); total spending for patients aged ≥65 years with AF was $25,322 (95% CI $25,049 to $25,595) compared to $21,706 (95% CI $21,563 to $21,849) for similar patients without AF (incremental cost difference $3,616, p <0.001). Using estimates of the US prevalence of undiagnosed AF (596,000) drawn from the same data, we estimated that the US incremental cost burden of undiagnosed nonvalvular AF is $3.1 billion (95% CI $2.7 to $3.7 billion). In conclusion, the direct medical costs for patients with undiagnosed AF are greater than patients with similar observable characteristics without AF and strategies to identify and treat patients with undiagnosed AF could lead to sizable reductions in stroke sequelae and associated costs.

Adaptation of the health literacy universal precautions toolkit for rheumatology and cardiology - applications for pharmacy professionals to improve self-management and outcomes in patients with chronic disease.

Over a decade of research in health literacy has provided evidence of strong links between literacy skills of patients and health outcomes. At the same time, numerous studies have yielded insight into efficacious action that health providers can take to mitigate the negative effects of limited literacy. This small study focuses on the adaptation, review and use of two new health literacy toolkits for health professionals who work with patients with two of the most prevalent chronic conditions, arthritis and cardiovascular disease. Pharmacists have a key role in communicating with patients and caregivers about various aspects of disease self-management, which frequently includes appropriate use of medications. Participating pharmacists and staff offered suggestions that helped shape revisions and reported positive experiences with brown bag events, suggestions for approaches with patients managing chronic diseases, and with concrete examples related to several medicines [such as Warfarin(©)] as well as to common problems [such as inability to afford needed medicine]. Although not yet tested in community pharmacy sites, these publically available toolkits can inform professionals and staff and offer insights for communication improvement.

Beyond statins: lipid management to reduce cardiovascular risk.

The discovery that elevated total cholesterol levels and the subsequent understanding that low-density lipoprotein cholesterol levels are associated with higher risk for cardiovascular disease (CVD) has led to the development of lipid management strategies that seek to reduce the burden of CVD. Although substantive progress has been made in reducing death and cardiovascular events, questions remain regarding the optimal approach to further reduce CVD-associated death and disability. Based on current evidence, statins are the clear first-line agents for the management of hyperlipidemia in patients at high risk for cardiovascular events. However, due to the failure of recent clinical trials evaluating antihyperlipidemic drugs, the most appropriate lipid management strategy in patients who cannot tolerate statin therapy or who warrant antihyperlipidemic therapies in addition to statins is a major therapeutic controversy. In this review, we summarize the clinical trial evidence evaluating the efficacy of second-line antihyperlipidemic drug classes for reducing cardiovascular risk, provide recommendations for appropriate use of nonstatin lipid-altering drugs, and identify key areas of future research to support evidence-based lipid management. Given the complexity, magnitude, and burden of CVD, opportunities to improve processes of care and identify new therapeutic options clearly exist.

The effects of adherence and persistence on clinical outcomes in patients treated with statins: a systematic review.

BACKGROUND: In clinical practice, medication adherence and persistence are important for disease management and can significantly improve outcomes and enhance the quality of patient care. Quantifying the relationship between medication adherence/persistence and clinical outcomes with statins can serve as an important therapeutic model and complement our understanding of the critical relationship between medication use and improved patient care. METHODS AND RESULTS: A PubMed search was conducted for literature published between 1999 and 2009 using the terms adherence, compliance, HMG CoA, nonadherence, noncompliance, persistency, persistence, and statin. Data on the direct relationship between adherence or persistence to statin monotherapy and clinical outcomes were extracted. A total of 19 articles met the inclusion criteria, including the clinical impact of adherence (n = 15) and persistence (n = 4). High levels of adherence were associated with reductions in adverse clinical outcomes, including all-cause mortality and fatal and nonfatal cardiovascular events; the most consistent benefits were witnessed at adherence levels 80% or greater. In primary prevention cohorts, clinical benefits were seen after 1 year of therapy. Longer durations of treatment were associated with incremental improvements in clinical outcomes as length of therapy increased. CONCLUSIONS: High levels of adherence and longer durations of persistence with statins are associated with progressively increasing clinical benefits in primary and secondary prevention patient populations at risk for cardiovascular events. Efforts to improve adherence and persistence are warranted.

Prevalence and coexistence of cardiovascular comorbidities among the US dyslipidemic population aged ≥ 65 years by lipid-lowering medication use status.

Using data from the 2001-2002, 2003-2004, and 2005-2006 National Health and Nutrition Examination Surveys, we generated current estimates of the prevalence and overlap of cardiovascular comorbidities among older US adults (aged ≥ 65 years) with dyslipidemia, stratified by lipid-lowering medication use. We estimated that among the 32.5 million older US adults, 67% (21.8 million) are dyslipidemic. Among these subjects, the prevalence of congestive heart failure (CHF) is 9.9% (2.2 million); coronary heart disease (CHD): 27.0% (5.9 million); history of stroke: 10.4% (2.3 million); diabetes: 26.5% (5.8 million); and ≥ 1 of these comorbidities: 51.2% (11.1 million). Among dyslipidemic subjects who are receiving lipid-lowering medication (10.4 million), these figures are CHF: 10.1% (1.0 million); CHD: 29.6% (3.1 million); history of stroke: 12.3% (1.3 million); diabetes: 31.5% (3.3 million); and ≥ 1 of these comorbidities: 55.3% (5.7 million); compared with those who are not receiving lipid-lowering medication (11.4 million), CHF: 9.8% (1.1 million); CHD: 24.7% (2.8 million); history of stroke: 8.6% (1 million); diabetes: 21.9% (2.5 million); and ≥ 1 of these comorbidities: 47.5% (5.4 million). Among older US adults with dyslipidemia, 51.2% have ≥ 1 of the cardiovascular conditions studied. Among those who are receiving lipid-lowering medication, 55.3% report having comorbidities that put them at high risk for new or recurring cardiovascular events. Even more noteworthy is that 47.5% of dyslipidemic older adults who are not taking statins also have significant comorbidities. This highlights a critical unmet medical need for this growing population, which, solely based on age, is more likely to be at risk for cardiovascular events.