cardiovascular events

Atorvastatin / therapeutic use

statins

MeSH

Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events

myocardial infarction

RPR Commentary: Older patients with no history of CV disease who took a statin had fewer CV events but didn't live longer or have less disability. My conclusion is that statins should be used selectively in older people who are at increased risk of CV events. James W. Mold, MD, MPH

Free full text

View

Abstract
Background
The effectiveness and safety of statins for the primary prevention of cardiovascular events and the extension of disability-free survival among older adults remain uncertain.
Methods
We conducted a double-blind, randomized, placebo-controlled trial at general medical practices across Australia. Community-dwelling adults at least 70 years of age with no history of cardiovascular disease, diabetes, or dementia were randomly assigned in a 1:1 ratio to receive atorvastatin at a dose of 40 mg once daily or identical placebo. The two primary end points were a composite of death from cardiovascular causes, nonfatal myocardial infarction or stroke, or coronary revascularization (to assess effects on major cardiovascular events) and a composite of death from any cause, dementia, or persistent physical disability (to assess effects on disability-free survival). Analyses were performed according to a hierarchical testing plan.
Results
A total of 9971 participants were enrolled: 4984 were assigned to receive atorvastatin and 4987 to receive placebo. The mean (±SD) age of the participants was 74.7±4.5 years, and 51.9% were women. After a median of 5.9 years, a primary cardiovascular event had occurred in 297 participants (10.9 events per 1000 person-years) in the atorvastatin group and in 412 participants (15.5 events per 1000 person-years) in the placebo group (hazard ratio, 0.70; 95% confidence interval [CI], 0.61 to 0.82; P<0.001). Death from any cause, dementia, or persistent physical disability occurred in 637 participants (21.6 events per 1000 person-years) in the atorvastatin group and in 676 participants (23.0 events per 1000 person-years) in the placebo group (hazard ratio, 0.94; 95% CI, 0.84 to 1.05; P=0.25). Serious adverse events occurred in 131 participants (2.7%) in the atorvastatin group and in 129 (2.7%) in the placebo group, with musculoskeletal, hepatobiliary, and diabetes-related adverse events occurring more commonly in the atorvastatin group.
Conclusions
Treatment with atorvastatin led to a lower risk of major cardiovascular events than placebo at a median of 5.9 years but did not result in longer disability-free survival among community-dwelling older adults without clinical cardiovascular disease. (Funded by the National Health and Medical Research Council and others; STAREE ClinicalTrials.gov number, NCT02099123.)

Author/s:

Sophia Zoungas, Rory Wolfe, Chris Moran, Stephen J. Nicholls, Geoffrey C. Cloud, Christopher M. Reid, Andrew M. Tonkin, Lawrence Beilin, Anthony S. Wierzbicki, Trevor T.-J. Chong, Jonathan C. Broder, Andrea J. Curtis, Zachary Flanagan, Ingrid Hopper, Joanne Ryan, Simone Spark, John J. McNeil, Mark R. Nelson

Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events

Aubrey Delammermore — Mon, 19 Dec 2022 06:00:00 +0000

Date Added:

December 19, 2022

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

December 14, 2022

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa2212270

Keywords

hypertension

Sodium Chloride Symporter Inhibitors

heart failure

veterans

infarction

PMID (1):

36516076

MeSH

Hydrochlorothiazide

Hypokalemia

Angina, Unstable

Chlorthalidone

HCYZ seems to be as effective as chlorthalidone for reducing the risk of major CV events. James W. Mold, MD, MPH

Free full text

View

Background: Whether chlorthalidone is superior to hydrochlorothiazide for preventing major adverse cardiovascular events in patients with hypertension is unclear.

Methods: In a pragmatic trial, we randomly assigned adults 65 years of age or older who were patients in the Department of Veterans Affairs health system and had been receiving hydrochlorothiazide at a daily dose of 25 or 50 mg to continue therapy with hydrochlorothiazide or to switch to chlorthalidone at a daily dose of 12.5 or 25 mg. The primary outcome was a composite of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non-cancer-related death. Safety was also assessed.

Results: A total of 13,523 patients underwent randomization. The mean age was 72 years. At baseline, hydrochlorothiazide at a dose of 25 mg per day had been prescribed in 12,781 patients (94.5%). The mean baseline systolic blood pressure in each group was 139 mm Hg. At a median follow-up of 2.4 years, there was little difference in the occurrence of primary-outcome events between the chlorthalidone group (702 patients [10.4%]) and the hydrochlorothiazide group (675 patients [10.0%]) (hazard ratio, 1.04; 95% confidence interval, 0.94 to 1.16; P = 0.45). There were no between-group differences in the occurrence of any of the components of the primary outcome. The incidence of hypokalemia was higher in the chlorthalidone group than in the hydrochlorothiazide group (6.0% vs. 4.4%, P<0.001).

Conclusions: In this large pragmatic trial of thiazide diuretics at doses commonly used in clinical practice, patients who received chlorthalidone did not have a lower occurrence of major cardiovascular outcome events or non-cancer-related deaths than patients who received hydrochlorothiazide. (Funded by the Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT02185417.).

Author/s:

Ishani, A., Cushman, W. C., Leatherman, S. M., R. A., Woods, P., Glassman, P. A., Taylor, A. A., Hau, C., Klint, A., Huang, G. D., Brophy, M. T., Fiore, L. D., Ferguson, R. E., Diuretic Comparison Project Writing Group

Impact of Diabetes Medications on Cardiovascular Events and Mortality

John Bayhi — Thu, 02 Apr 2020 17:49:16 +0000

Date Added:

April 2, 2020

Publication Date:

April 2, 2020

Type:

Clinical Decision Aids

Format:

Poster

Keywords

diabetes

Statin Use Over 65 Years of Age and All-Cause Mortality: A 10-Year Follow-Up of 19 518 People

mortality

risk

medication

A table showing the size of the risks and risk reductions of several classes of diabetes medications on cardiovascular events. The data was derived from 232 meta-analyses in Zhu J, Zheng Y, et al in Lancet Diabetes Endocrinol 2020; 8(3): 192-205. James W. Mold, MD, MPH.

Free full text

No abstract available.

Author/s:

Mold, James W.

Statin Use Over 65 Years of Age and All-Cause Mortality: A 10-Year Follow-Up of 19 518 People

Brian Desmarais — Sat, 14 Mar 2020 20:02:11 +0000

Date Added:

March 14, 2020

Journal/Publication:

Journal of the American Geriatrics Society

Publication Date:

October 1, 2019

Issue:

Volume:

URL:

Type:

Meta-analyses, Reviews, and Guidelines, Practice Management Reviews and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1111/jgs.16060

Keywords

all-cause mortality

hypercholesterolemia

older adults

Hydroxymethylglutaryl-CoA Reductase Inhibitors

MeSH

Aspirin for the Primary Prevention of Cardiovascular Disease: Weighing Up the Evidence

Statins appear to significantly reduce all-cause mortality in patients over 65 and in those over 75 as well. James W. Mold, MD, MPH

View

Abstract

OBJECTIVES

As life expectancy continues to rise, the burden of cardiovascular disease among older people is expected to increase, making cardiovascular prevention in older people an issue of growing interest and public health importance. We aimed to explore the long‐term effects of adherence to statins on mortality and cardiovascular morbidity among older adults.

DESIGN

A historical population‐based cohort study using routinely collected data.

SETTING

Clalit Health Services Northern District.

PARTICIPANTS

We followed members of Clalit Health Services aged 65 years or older who were eligible for primary cardiovascular prevention for a period of 10 years.

MEASUREMENTS

We fitted Cox regression models to assess the association between the adherence to statin therapy and all‐cause mortality and cardiovascular morbidity, adjusting for cardiovascular risk factors and associated morbidity as time‐updated variables.

RESULTS

The analysis included 19 518 older adults followed during 10 years (median = 9.7 y). All‐cause mortality rates were 34% lower among those who had adhered to statin treatment, compared with those who had not (hazard ratio [HR] = .66; 95% confidence interval [CI] = .56‐.79). Adherence to statins was also associated with fewer atherosclerotic cardiovascular disease events (HR = .80; 95% CI = .71‐.81). The benefit of statin use did not diminish among beyond age 75 and was evident for both women and men.

CONCLUSION

Adherence to statins may be associated with reduced mortality and cardiovascular morbidity among older adults, regardless of age and sex. J Am Geriatr Soc 67:2038–2044, 2019

Author/s:

Eilat-Tsanani, S., Schonmann, Y., Mor, E.

Aspirin for the Primary Prevention of Cardiovascular Disease: Weighing Up the Evidence

Jeffrey Wilson — Mon, 18 Mar 2019 14:43:45 +0000

Date Added:

March 18, 2019

Journal/Publication:

The American Journal of Medicine

Publisher:

Elsevier

Publication Date:

March 12, 2019

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.amjmed.2019.02.025

Keywords

PMID (1):

30871925

MeSH

Association of Aspirin Use for Primary Prevention With Cardiovascular Events and Bleeding Events: A Systematic Review and Meta-analysis

secondary prevention

A nice review of the effectiveness of aspirin for primary prevention of CV events with a particular focus on the question of weight-based dosing. Bottom line is that primary prevention of CV events with aspirin, regardless of dose, is rarely justifiable.

Free full text

Aspirin is one of the most universally recognized and commonly prescribed medications worldwide. It is estimated that 48.7 million U.S. adults are taking aspirin for cardiovascular disease prevention; the majority (~73%) for primary prevention. The benefit of aspirin for secondary prevention of cardiovascular disease is well-established, with meta-analysis results favoring low dose (75–150 mg/day) over high dose (>150 mg/day) aspirin given similar efficacy but lower bleeding risk. In contrast, the role of aspirin in primary cardiovascular disease prevention is more controversial; historical trials found benefit but trials since 2008 have shown either null effects on all-cause and cardiovascular disease mortality or a signal for increased mortality in the context of excess bleeding.

Author/s:

Murphy, Sean, McCarthy, Cian P., McEvoy, John W.

Association of Aspirin Use for Primary Prevention With Cardiovascular Events and Bleeding Events: A Systematic Review and Meta-analysis

Tracy Ashby — Mon, 11 Feb 2019 06:00:00 +0000

Date Added:

February 11, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

January 22, 2019

Issue:

Volume:

321

Pages:

277-287

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2018.20578 Free full text

Keywords

bleeding events

PMID (1):

30667501

MeSH

hemorrhage

Prediction of individual life-years gained without cardiovascular events from lipid, blood pressure, glucose, and aspirin treatment based on data of more than 500 000 patients with Type 2 diabetes mellitus.

Consistent with the findings of the USPSTF, in adults with no history of cardiovascular disease, aspirin reduces the incidence of adverse cardiovascular events and increases the rate of major bleeding episodes. It has little or no effect on mortality.

Commercial full text (fees may apply)

View

IMPORTANCE:

The role for aspirin in cardiovascular primary prevention remains controversial, with potential benefits limited by an increased bleeding risk.

OBJECTIVE:

To assess the association of aspirin use for primary prevention with cardiovascular events and bleeding.

DATA SOURCES:

PubMed and Embase were searched on Cochrane Library Central Register of Controlled Trials from the earliest available date through November 1, 2018.

STUDY SELECTION:

Randomized clinical trials enrolling at least 1000 participants with no known cardiovascular disease and a follow-up of at least 12 months were included. Included studies compared aspirin use with no aspirin (placebo or no treatment).

DATA EXTRACTION AND SYNTHESIS:

Data were screened and extracted independently by both investigators. Bayesian and frequentist meta-analyses were performed.

MAIN OUTCOMES AND MEASURES:

The primary cardiovascular outcome was a composite of cardiovascular mortality, nonfatal myocardial infarction, and nonfatal stroke. The primary bleeding outcome was any major bleeding (defined by the individual studies).

RESULTS:

A total of 13 trials randomizing 164 225 participants with 1 050 511 participant-years of follow-up were included. The median age of trial participants was 62 years (range, 53-74), 77 501 (47%) were men, 30 361 (19%) had diabetes, and the median baseline risk of the primary cardiovascular outcome was 9.2% (range, 2.6%-15.9%). Aspirin use was associated with significant reductions in the composite cardiovascular outcome compared with no aspirin (57.1 per 10 000 participant-years with aspirin and 61.4 per 10 000 participant-years with no aspirin) (hazard ratio [HR], 0.89 [95% credible interval, 0.84-0.95]; absolute risk reduction, 0.38% [95% CI, 0.20%-0.55%]; number needed to treat, 265). Aspirin use was associated with an increased risk of major bleeding events compared with no aspirin (23.1 per 10 000 participant-years with aspirin and 16.4 per 10 000 participant-years with no aspirin) (HR, 1.43 [95% credible interval, 1.30-1.56]; absolute risk increase, 0.47% [95% CI, 0.34%-0.62%]; number needed to harm, 210).

CONCLUSIONS AND RELEVANCE:

The use of aspirin in individuals without cardiovascular disease was associated with a lower risk of cardiovascular events and an increased risk of major bleeding. This information may inform discussions with patients about aspirin for primary prevention of cardiovascular events and bleeding.

Author/s:

Zheng, Sean L., Roddick, Alistair J.

Prediction of individual life-years gained without cardiovascular events from lipid, blood pressure, glucose, and aspirin treatment based on data of more than 500 000 patients with Type 2 diabetes mellitus

Jeffrey Wilson — Sun, 03 Feb 2019 21:22:07 +0000

Date Added:

February 3, 2019

Journal/Publication:

European Heart Journal

Publisher:

Oxford University Press

Publication Date:

January 9, 2019

URL:

Type:

Clinical Decision Aids

DOI (1):

10.1093/eurheartj/ehy839

Keywords

cardiovascular disease

diabetes mellitus, type 2

PMID (1):

30629157

MeSH

glycated hemoglobin, A

lipoprotein cholesterol

blood pressure

insulin

glucose

RPR Commentary: The authors have developed and validated several calculators that predict lifetime risk of CV events based upon age, gender, smoking, blood pressure, lipids, A1c, and use of antiplatelet agents. They can be accessed at www.U-Prevent.com.

Commercial full text (fees may apply)

View

AIMS:

Although group-level effectiveness of lipid, blood pressure, glucose, and aspirin treatment for prevention of cardiovascular disease (CVD) has been proven by trials, important differences in absolute effectiveness exist between individuals. We aim to develop and validate a prediction tool for individualizing lifelong CVD prevention in people with Type 2 diabetes mellitus (T2DM) predicting life-years gained without myocardial infarction or stroke.

METHODS AND RESULTS:

We developed and validated the Diabetes Lifetime-perspective prediction (DIAL) model, consisting of two complementary competing risk adjusted Cox proportional hazards functions using data from people with T2DM registered in the Swedish National Diabetes Registry (n = 389 366). Competing outcomes were (i) CVD events (vascular mortality, myocardial infarction, or stroke) and (ii) non-vascular mortality. Predictors were age, sex, smoking, systolic blood pressure, body mass index, haemoglobin A1c, estimated glomerular filtration rate, non- high-density lipoprotein cholesterol, albuminuria, T2DM duration, insulin treatment, and history of CVD. External validation was performed using data from the ADVANCE, ACCORD, ASCOT and ALLHAT-LLT-trials, the SMART and EPIC-NL cohorts, and the Scottish diabetes register (total n = 197 785). Predicted and observed CVD-free survival showed good agreement in all validation sets. C-statistics for prediction of CVD were 0.83 (95% confidence interval: 0.83-0.84) and 0.64-0.65 for internal and external validation, respectively. We provide an interactive calculator at www.U-Prevent.com that combines model predictions with relative treatment effects from trials to predict individual benefit from preventive treatment.

CONCLUSION:

Cardiovascular disease-free life expectancy and effects of lifelong prevention in terms of CVD-free life-years gained can be estimated for people with T2DM using readily available clinical characteristics. Predictions of individual-level treatment effects facilitate translation of trial results to individual patients.

Author/s:

Berkelmans, Gijs F N, Gudbjörnsdottir, Soffia, Visseren, Frank L J, Wild, Sarah H, Franzen, Stefan, Chalmers, John, Davis, Barry R, Poulter, Neil R, Spijkerman, Annemieke M, Woodward, Mark, Pressel, Sara L, Gupta, Ajay K, van der Schouw, Yvonne T, Svensson, Ann-Marie

Aspirin Use in Primary Care

Tracy Ashby — Fri, 25 Jan 2019 06:00:00 +0000

Date Added:

January 25, 2019

Journal/Publication:

Healthy Hearts for Oklahoma (H2O)

Publisher:

The Oklahoma Cooperative

Publication Date:

January 25, 2019

Type:

Clinical Decision Aids

Format:

Article

Keywords

secondary prevention

MeSH

secondary prevention

This is the material used in the Healthy Hearts for OK project to update clinicians on the role of low-dose aspirin for prevention of cardiovascular events.

Free full text

An update for clinicians on the role of low-dose aspirin for prevention of cardiiovascular events from the Healthy Hearts for OK project.

Author/s:

Mold, James W.

Blood Pressure Control in Primary Care

Tracy Ashby — Fri, 25 Jan 2019 06:00:00 +0000

Date Added:

January 25, 2019

Journal/Publication:

Healthy Hearts for Oklahoma (H2O)

Publisher:

The Oklahoma Cooperative

Publication Date:

January 25, 2019

Type:

Clinical Decision Aids

Format:

Article

Keywords

blood pressure

MeSH

blood pressure

hypertension

This is the material used in the Healthy Hearts for OK project to update clinicians on the role of BP control to prevent cardiovascular events.

Free full text

An update for clinicians on the role of blood pressure for prevention of cardiiovascular events from the Healthy Hearts for OK project.

Author/s:

Mold, James W.

Cholesterol Management in Primary Care

Tracy Ashby — Fri, 25 Jan 2019 06:00:00 +0000

Date Added:

January 25, 2019

Journal/Publication:

Healthy Hearts for Oklahoma (H2O)

Publisher:

The Oklahoma Cooperative

Publication Date:

January 25, 2019

Type:

Clinical Decision Aids

Format:

Article

Keywords

statins

cardiovascular disease

MeSH

Hydroxymethylglutaryl-CoA Reductase Inhibitors

This is the material used in the Healthy Hearts for OK project to update clinicians on the use of statins to prevent cardiovascular events.

Free full text

An update for clinicians on the use of statins to prevent cardiiovascular events from the Healthy Hearts for OK project.

Author/s:

Mold, James W.

Smoking Cessation in Primary Care

Tracy Ashby — Fri, 25 Jan 2019 06:00:00 +0000

Date Added:

January 25, 2019

Journal/Publication:

Healthy Hearts for Oklahoma (H2O)

Publisher:

The Oklahoma Cooperative

Publication Date:

January 25, 2019

Type:

Clinical Decision Aids

Format:

Article

Keywords

smoking cessation

MeSH

smoking cessation

Effects of an Angiotensin-Converting–Enzyme Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients

This is the material used in the Healthy Hearts for OK project to update clinicians on the importance of smoking cessation for prevention of cardiovascular events.

Free full text

An update for clinicians on the importance of smoking cessation for the prevention of cardiiovascular events from the Healthy Hearts for OK project.

Author/s:

Mold, James W.

Effects of an Angiotensin-Converting–Enzyme Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients

Jeffrey Wilson — Wed, 26 Sep 2018 13:40:47 +0000

Date Added:

September 26, 2018

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

January 20, 2000

Issue:

Volume:

342

Pages:

145-153

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJM200001203420301

Keywords

rampril

PMID (1):

10639539

MeSH

rampril

ventricular dysfunction, left

This article was published in 2000. We have added it to RPR because of its importance. In patients at high risk for cardiovascular events, ramipril reduced all-cause mortality and a variety of adverse cardiovascular events by about 20%. The effects were largely independent of blood pressure reduction. Ramipril was chosen because of its intracellular ACEI effects.

Free full text

BACKGROUND:

Angiotensin-converting-enzyme inhibitors improve the outcome among patients with left ventricular dysfunction, whether or not they have heart failure. We assessed the role of an angiotensin-converting-enzyme inhibitor, ramipril, in patients who were at high risk for cardiovascular events but who did not have left ventricular dysfunction or heart failure.

METHODS:

A total of 9297 high-risk patients (55 years of age or older) who had evidence of vascular disease or diabetes plus one other cardiovascular risk factor and who were not known to have a low ejection fraction or heart failure were randomly assigned to receive ramipril (10 mg once per day orally) or matching placebo for a mean of five years. The primary outcome was a composite of myocardial infarction, stroke, or death from cardiovascular causes. The trial was a two-by-two factorial study evaluating both ramipril and vitamin E. The effects of vitamin E are reported in a companion paper.

RESULTS:

A total of 651 patients who were assigned to receive ramipril (14.0 percent) reached the primary end point, as compared with 826 patients who were assigned to receive placebo (17.8 percent) (relative risk, 0.78; 95 percent confidence interval, 0.70 to 0.86; P<0.001). Treatment with ramipril reduced the rates of death from cardiovascular causes (6.1 percent, as compared with 8.1 percent in the placebo group; relative risk, 0.74; P<0.001), myocardial infarction (9.9 percent vs. 12.3 percent; relative risk, 0.80; P<0.001), stroke (3.4 percent vs. 4.9 percent; relative risk, 0.68; P<0.001), death from any cause (10.4 percent vs. 12.2 percent; relative risk, 0.84; P=0.005), revascularization procedures (16.3 percent vs. 18.8 percent; relative risk, 0.85; P<0.001), cardiac arrest (0.8 percent vs. 1.3 percent; relative risk, 0.62; P=0.02), [corrected] heart failure (9.1 percent vs. 11.6 percent; relative risk, 0.77; P<0.001), and complications related to diabetes (6.4 percent vs. 7.6 percent; relative risk, 0.84; P=0.03).

CONCLUSIONS:

Ramipril significantly reduces the rates of death, myocardial infarction, and stroke in a broad range of high-risk patients who are not known to have a low ejection fraction or heart failure.

Author/s:

Yusuf, Salim

Effects of Aspirin on Risks of Vascular Events and Cancer According to Bodyweight and Dose: Analysis of Individual Patient Data from Randomised Trials

Jeffrey Wilson — Tue, 28 Aug 2018 19:33:50 +0000

Date Added:

September 26, 2018

Journal/Publication:

Lancet

Publisher:

Elsevier

Publication Date:

August 4, 2018

Issue:

10145

Volume:

392

Pages:

387-399

URL:

Effects of Aspirin on Risks of Vascular Events and Cancer According to Bodyweight and Dose: Analysis of Individual Patient Data from Randomised Trials

Type:

Meta-analyses, Reviews, and Guidelines, Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/S0140-6736(18)31133-4

Keywords

cancer

PMID (1):

30017552

MeSH