Affiliation:
1. Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas City Kansas City Missouri USA
2. Division of Cardiology University of Texas Southwestern Medical Center Dallas Texas USA
3. Baim Institute for Clinical Research Boston Massachusetts USA
4. The Cardiometabolic Disorders Unit Icahn School of Medicine at Mount Sinai New York New York USA
5. Department of Medicine Baylor College of Medicine Houston Texas USA
6. Amgen Inc. Thousand Oaks California USA
7. Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System New York New York USA
8. The George Institute for Global Health Sydney New South Wales Australia
Abstract
AbstractAimTo examine improvement in the use of optimal medical therapy (OMT) for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD) and diabetes.Materials and MethodsPatients with ASCVD (coronary, cerebrovascular, peripheral) and low‐density lipoprotein‐cholesterol of 70 mg/dl or higher were enrolled from December 2016 to July 2018 from 107 US sites/physicians (47% cardiology, 41% primary care, 12% other) and prospectively followed for 2 years (current analysis restricted to subgroup with diabetes). OMT was defined as high‐intensity lipid‐lowering (high‐intensity statin, any statin + ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitor), antithrombotic (antiplatelet or anticoagulant), angiotensin‐converting enzyme‐inhibitor/angiotensin II receptor blocker/angiotensin receptor neprilysin inhibitor (ACE‐I/ARB/ARNI) (excluding glomerular filtration rate [GFR] < 30 ml/min/1.73m2) and sodium‐glucose co‐transporter‐2 inhibitor (SGLT2i)/glucagon‐like peptide‐1 receptor agonist (GLP‐1 RA) (excluding GFR < 30 ml/min/1.73m2 and type 1 diabetes).ResultsAmong 1590 patients with ASCVD and diabetes (96% type 2 diabetes), 58% were on high‐intensity lipid‐lowering therapy at the end of follow‐up, 87% antithrombotic, 71% ACE‐I/ARB/ARNI and 17% SGLT2i/GLP‐1 RA. Overall, 11% of patients received comprehensive OMT, which modestly improved over time (vs. 8% at baseline; P = .002). Patients treated by cardiologists (vs. non‐cardiologists) were more likely to be on high‐intensity lipid lowering, but less likely to be on an SGLT2i/GLP‐1 RA, and thus had lower rates of composite OMT (7.8% vs. 13.7%, P < .001). In a hierarchical multivariable model, older age was associated with lower odds of OMT (OR 0.74 per 10 years, 95% CI 0.60‐0.90), whereas private insurance (OR 1.93, 95% CI 1.32‐2.84) and coronary disease (OR 1.62, 95% CI 1.01‐2.61) were associated with higher odds. The median odds ratio was 1.82 (95% CI 1.03‐7.32), indicating a moderate variability in OMT use, independent of patient factors.ConclusionsWe found suboptimal use of secondary prevention in US patients with ASCVD and diabetes, with minimal improvement over time. Further efforts are needed to improve the use of secondary prevention therapies in these patients with high residual risk.
Subject
Endocrinology,Endocrinology, Diabetes and Metabolism,Internal Medicine