Abstract Background Monitoring trends in cardiovascular events can provide key insights into the effectiveness of prevention efforts. Leveraging data from electronic health records provides a unique ...opportunity to examine contemporary, community-based trends in acute myocardial infarction hospitalizations. Methods We examined trends in hospitalized acute myocardial infarction incidence among adults aged ≥25 years in 13 US health plans in the Cardiovascular Research Network. The first hospitalization per member for acute myocardial infarction overall and for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction was identified by International Classification of Diseases, Ninth Revision, Clinical Modification primary discharge codes in each calendar year from 2000 through 2008. Age- and sex-adjusted incidence was calculated per 100,000 person-years using direct adjustment with 2000 US census data. Results Between 2000 and 2008, we identified 125,435 acute myocardial infarction hospitalizations. Age- and sex-adjusted incidence rates (per 100,000 person-years) of acute myocardial infarction decreased an average 3.8%/y from 230.5 in 2000 to 168.6 in 2008. Incidence of ST-segment elevation myocardial infarction decreased 8.7%/y from 104.3 in 2000 to 51.7 in 2008, whereas incidence of non-ST-segment elevation myocardial infarction increased from 126.1 to 129.4 between 2000 and 2004 and then decreased thereafter to 116.8 in 2008. Age- and sex-specific incidence rates generally reflected similar patterns, with relatively larger decreases in ST-segment elevation myocardial infarction rates in women compared with men. As compared with 2000, the age-adjusted incidence of ST-segment elevation myocardial infarction in 2008 was 48% lower among men and 61% lower among women. Conclusions and Relevance Among a large, diverse, multicenter community-based insured population, there were significant decreases in incidence of hospitalized acute myocardial infarction and the more serious ST-segment elevation myocardial infarctions between 2000 and 2008. Decreases in ST-segment elevation myocardial infarctions were most pronounced among women. While ecologic in nature, these secular decreases likely reflect, at least in part, results of improvement in primary prevention efforts.
Background Metabolic impairments that precede type 2 diabetes, such as metabolic syndrome, may contribute to the development of chronic kidney disease (CKD). This study documents the prevalence and ...incidence of CKD and the prospective association between metabolic syndrome and CKD in American Indians without diabetes in the Strong Heart Study. Study Design Prospective cohort study. Setting & Participants American Indians aged 45 to 74 years from 3 geographic regions were recruited by using tribal records and were assessed every 3 years from 1989 to 1999 as part of the Strong Heart Study. Participants with type 2 diabetes, on dialysis therapy, or who received a kidney transplant at baseline examination were excluded. Predictor Metabolic syndrome, defined using Adult Treatment Panel III criteria. Outcomes & Measurements CKD was measured by using estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (ACR) dichotomized at conventional cutoff values. The association between metabolic syndrome and incident CKD was evaluated by using multivariable Cox proportional hazards models and binomial regression, with statistical adjustment for confounders (age, sex, study center, education, and smoking). Results Metabolic syndrome was present in 896 (37.7%) and absent in 1,484 participants (62.3%) at baseline. The prevalence of ACR of 30 mg/g or greater at baseline examination was 12.1%, with 290 new cases and an incidence of 233/10,000 person-years. The prevalence of eGFR less than 60 mL/min/1.73 m2 was 7.8%, with 189 new cases and an incidence of 138/10,000 person-years. The prevalence of CKD was 17.8%, with 388 new cases and an incidence of 342/10,000 person-years. The adjusted hazard ratio for CKD associated with metabolic syndrome was 1.3 (95% confidence interval CI, 1.1 to 1.6). Equivalent hazard ratios for ACR greater than 30 mg/g and eGFR less than 60 mL/min/1.73 m2 were 1.4 (95% CI, 1.0 to 1.9) and 1.3 (95% CI, 1.0 to 1.6), respectively. The relationship between metabolic syndrome and kidney outcomes was stronger in those who developed diabetes during follow-up. Limitations Intraindividual variability in serum creatinine and ACR measures may have resulted in some misclassification of participants by outcome status. Conclusions Metabolic syndrome is associated with an increased risk of developing CKD in American Indians without diabetes. The mechanism through which metabolic syndrome may cause CKD in this population likely is the development of diabetes.
Low statin adherence and discontinuation of statins are common in patients with coronary heart disease. We hypothesized that low antihypertensive medication adherence would be associated with future ...statin discontinuation and low adherence in patients initiating statins. Using a 5% national sample of Medicare beneficiaries, we conducted a cohort study of Medicare beneficiaries initiating statins after hospitalization for acute myocardial infarction or coronary revascularization in 2007, 2008, and 2009. Antihypertensive medication adherence, defined using the average proportion of days covered across 5 classes during the 365 days before hospitalization, was categorized as ≥80% (high), 50% to <80% (medium), and <50% (low). Statin discontinuation was defined as failure to refill a statin within 365 days of hospital discharge, and low adherence was defined as proportion of days covered for statins <80%. In 2,695 Medicare beneficiaries who initiated statins after hospital discharge, 6.0%, 8.4%, and 14.5% with high, medium, and low antihypertensive medication adherence discontinued statins. After multivariable adjustment, the risk ratios (95% confidence interval) for statin discontinuation were 1.38 (0.98 to 1.95) and 2.41 (1.51 to 3.87) for beneficiaries with medium and low versus high antihypertensive medication adherence, respectively. In beneficiaries who did not discontinue statins, 36.2% had low statin adherence. Compared with high adherence, medium and low antihypertensive medication adherences were associated with multivariable adjusted risk ratios (95% confidence interval) for low statin adherence of 1.33 (1.14 to 1.55) and 1.62 (1.25 to 2.10), respectively. In conclusion, low antihypertensive medication adherence before initiating statins is associated with future statin discontinuation and low statin adherence.
Backgound Adiposity is associated with cystatin C. Cystatin C–based glomerular filtration rate (GFR) equations may result in overestimation of chronic kidney disease (CKD) prevalence at greater body ...mass index (BMI) levels. Study Design Cross-sectional. Setting & Participants 6,709 US adult Third National Health and Nutrition Examination Survey participants. Factor BMI. Outcome Absolute percentage of difference in prevalence of stage 3 or 4 CKD between creatinine- and cystatin C–based estimating equations by level of BMI. Measurements Normal weight, overweight, and obesity were defined as BMI of 18.5 to less than 25.0, 25 to less than 30.0, and 30 kg/m2 or greater, respectively. Stage 3 or 4 CKD (estimated glomerular filtration rate eGFR, 15 to 59 mL/min/1.73 m2 ) was defined using the 4-variable creatinine-based Modification of Diet in Renal Disease Study equation (eGFRMDRD ); cystatin C level, age, sex, and race equation (eGFRCysC,age,sex,race ); cystatin C–only equation (eGFRCysC ); cystatin C level of 1.12 mg/L or greater (increased cystatin C); and an equation incorporating serum creatinine level, cystatin C level, age, sex, and race (eGFRCr,CysC,age,sex,race ). Results Differences in stage 3 or 4 CKD prevalence estimates between eGFRCysC,age,sex,race , eGFRCysC , and increased cystatin C, separately, and eGFRMDRD were greater at higher BMI levels. Specifically, compared with estimates derived using eGFRMDRD for normal-weight, overweight, and obese participants, estimated prevalences of stage 3 or 4 CKD were 2.1%, 3.0%, and 6.5% greater when estimated by using eGFRCysC,age,sex,race ( P trend = 0.005); 0.1%, 0.6%, and 2.2% greater for eGFRCysC ( P trend = 0.03); 2.9%, 5.2%, and 9.5% greater for increased cystatin C ( P trend < 0.001); and −0.1%, −0.4%, and 0.0% greater for eGFRCr,CysC,age,sex,race , respectively ( P trend = 0.7). Limitations No gold-standard measure of GFR was available. Conclusions BMI may influence the estimated prevalence of stage 3 or 4 CKD when cystatin C–based equations are used.
Chronic kidney disease and cardiovascular disease share many risk factors. Injury to the vascular endothelium, measured by elevated levels of serum C-reactive protein (CRP), may play a role in kidney ...and cardiovascular disease. We therefore examined the association of CRP with microalbuminuria, a marker of early kidney injury. We conducted a cross-sectional analysis of a nationally representative, population-based survey. Weighted multiple logistic regression was used to study the association between CRP and microalbuminuria, adjusting for well-known risk factors. CRP was analyzed by a continuous variable and two categorized variables using quartiles and clinically recommended cutpoints. CRP concentration was positively associated with microalbuminuria. In the multivariate model, a one unit (in milligrams per liter) increase in CRP concentration was associated with a 2% increased odds of microalbuminuria (odds ratio 1.02, 95% confidence interval CI 1.01 to 1.02, p = 0.0003). When CRP concentrations were stratified by clinically recommended cutpoints, compared with persons with CRP concentrations <1 mg/dl, persons with CRP concentrations between 1 and 3 mg/L and >3 mg/L were 1.15 times (95% CI 0.94 to 1.42) and 1.33 times (95% CI 1.08 to 1.65) more likely to have microalbuminuria, respectively. In subgroup analyses, the strength of association was comparable or stronger. In conclusion, elevated CRP levels were associated with microalbuminuria in a large, nationally representative data set. Vascular inflammation, as measured by CRP, may be a common contributor to early heart and kidney disease.
Background Persons belonging to the working class or living in an adverse social environment at particular periods of their life course may have an increased risk of chronic kidney disease (CKD). ...Methods This hypothesis was examined among participants of the Life Course Socioeconomic Status Study, an ancillary study of the Atherosclerosis Risk in Communities Study, conducted in 2001 (mean age, 67.4 years; N = 12,631). CKD was defined by hospital discharge diagnosis and/or estimated glomerular filtration rate less than 45 mL/min/1.73 m2 (<0.75 mL/s/1.73 m2 ). Social class was categorized as working class or non–working class at ages 30, 40, or 50 years. Area-level socioeconomic status was based on a composite of census scores during the same period. Adjusted odds ratios were obtained within strata of white and African-American race. Results The adjusted odds ratio of CKD for persons belonging to the working class versus non–working class at age 30 was 1.4 (95% confidence interval, 1.0 to 2.0) in whites and 1.9 (95% confidence interval, 1.1 to 3.0) in African Americans. Working class membership was associated with CKD, even at earlier stages of adult life, and class was associated more strongly with CKD than was education. Working class membership also suggested a stronger association with CKD among African Americans than whites, independent of diabetes and hypertension status. At later periods in the life course, area socioeconomic status was associated with CKD. Conclusion Socioeconomic factors, including area socioeconomic status and social class, are associated with CKD and may account for some of the racial disparity in kidney disease.
Abstract Objectives Preplanned economic analysis of a pragmatic trial using electronic-medical-record–linked interactive voice recognition (IVR) reminders for enhancing adherence to cardiovascular ...medications (i.e., statins, angiotensin-converting enzyme inhibitors ACEIs, and angiotensin receptor blockers ARBs). Methods Three groups, usual care (UC), IVR, and IVR plus educational materials (IVR+), with 21,752 suboptimally adherent patients underwent follow-up for 9.6 months on average. Costs to implement and deliver the intervention (from a payer perspective) were tracked during the trial. Medical care costs and outcomes were ascertained using electronic medical records. Results Per-patient intervention costs ranged from $9 to $17 for IVR and from $36 to $47 for IVR+. For ACEI/ARB, the incremental cost-effectiveness ratio for each percent adherence increase was about 3 times higher with IVR+ than with IVR ($6 and $16 for IVR and IVR+, respectively). For statins, the incremental cost-effectiveness ratio for each percent adherence increase was about 7 times higher with IVR+ than with IVR ($6 and $43 for IVR and IVR+, respectively). Considering potential cost offsets from reduced cardiovascular events, the probability of breakeven was the highest for UC, but the IVR-based interventions had a higher probability of breakeven for subgroups with a baseline low-density lipoprotein (LDL) level of more than 100 mg/dl and those with two or more calls. Conclusions We found that the use of an automated voice messaging system to promote adherence to ACEIs/ARBs and statins may be cost-effective, depending on a decision maker’s willingness to pay for unit increase in adherence. When considering changes in LDL level and downstream medical care offsets, UC is the optimal strategy for the general population. However, IVR-based interventions may be the optimal choice for those with elevated LDL values at baseline.
Abstract Background Whether there is a kidney function threshold to statin effectiveness in patients with acute myocardial infarction is poorly understood. Our study sought to help fill this gap in ...clinical knowledge. Methods We undertook a new-user cohort study of the effectiveness of statin therapy by level of estimated glomerular filtration rate (eGFR) in adults who were hospitalized for myocardial infarction between 2000 and 2008. Data came from the Cardiovascular Research Network. The primary clinical outcomes were 1-year all-cause mortality and cardiovascular hospitalizations, with adverse outcomes of myopathy and development of diabetes mellitus. We calculated incidence rates, the number needed to treat, and used Cox proportional hazards regression with propensity score matching and adjustment to control for confounding, with testing for variation of effect by level of kidney function. Results Compared with statin non-initiators (n = 5583), statin initiators (n = 5597) had a lower propensity score-adjusted risk for death (hazard ratio 0.79; 95% confidence interval CI, 0.71-0.88) and cardiovascular hospitalizations (hazard ratio 0.90; 95% CI, 0.82-1.00). We found little evidence of variation in effect by level of eGFR ( P = .86 for death; P = .77 for cardiovascular hospitalization). Adverse outcomes were similar for statin initiators and statin non-initiators. The number needed to treat to prevent 1 additional death over 1 year of follow-up ranged from 15 (95% CI, 11-28) for eGFR <30 mL/min/1.73 m2 requiring statin treatment over 2 years to prevent 1 additional death, to 67 (95% CI, 49-118) for patients with eGFR >90 mL/min/1.73 m2. Conclusions Our findings suggest that there is potential for important public health gains by increasing the routine use of statin therapy for patients with lower levels of kidney function.
The association between the changes in high-density lipoprotein (HDL) cholesterol and the risk of cardiovascular (CVD) or cerebrovascular hospitalization among patients with type 2 diabetes remains ...unclear. We conducted a retrospective observational cohort study of 30,067 members of the Kaiser Permanente Northwest and Georgia regions, who had type 2 diabetes and 2 HDL cholesterol measurements 6 to 24 months apart in 2001 to 2006. We followed up the cohort for ≤8 years (through 2009) to determine whether the change in HDL cholesterol was associated with subsequent CVD hospitalization. We examined the HDL cholesterol change continuously and by 3 categories: HDL cholesterol increased ≥6.5 mg/dl, decreased ≥6.5 mg/dl, or remained within ±6.4 mg/dl. The Cox regression models were adjusted for the baseline HDL cholesterol and demographic and clinical risk factors. During a mean follow-up of 55.8 ± 23.8 months, 3,023 patients (10.1%) experienced a CVD hospitalization. After multivariate adjustment, each 5 mg/dl of baseline HDL cholesterol was significantly associated with a 6% lower CVD hospitalization risk (hazard ratio 0.94 per 5 mg/dl, 95% confidence interval 0.92 to 0.95, p <0.0001) and each 5-mg/dl increase in HDL cholesterol was associated with a 4% CVD risk reduction (hazard ratio 0.96, 95% confidence interval 0.94 to 0.99, p <0.003). In the categorical analysis, a ≥6.5-mg/dl HDL cholesterol decrease was associated with an 11% increased CVD risk (hazard ratio 1.11, 95% confidence interval 1.00 to 1.24, p = 0.047) and a ≥6.5-mg/dl increase was associated with an 8% CVD risk reduction (hazard ratio 0.92, 95% confidence interval 0.84 to 1.01, p = 0.077) relative to those with stable HDL cholesterol. In conclusion, our results add to the growing body of evidence that increasing the HDL cholesterol levels might be an important strategy for CVD risk reduction. The prevention of HDL cholesterol decreases could be equally important.
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