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https://www.ahajournals.org/doi/10.1161/JAHA.124.040464
Abstract
Background
Many patients with diabetes do not accept statin therapy despite being at increased risk for cardiovascular events compared with the general population. The effects of delaying statin therapy are not well‐understood.
Methods
This is a retrospective cohort study that followed adults with diabetes and no preexisting atherosclerotic cardiovascular disease at the Mass General Brigham integrated health system between 2000 and 2018. The exposure was immediate versus delayed statin acceptance by patients who were recommended statin therapy. The primary outcome was the composite incidence of myocardial infarction and ischemic stroke.
Results
Among the 7239 study patients, the median age was 55.0 years, and 52.0% were women. Within this cohort, 1280 (17.7%) delayed statin therapy by a mean±SD of 2.7±3.1 years. Patients who delayed statin therapy had higher mean low‐density lipoprotein cholesterol levels while they were not prescribed a statin (126.4 versus 99.2 mg/dL, P<0.001).
The cumulative 10‐year rate of myocardial infarctions and ischemic strokes was 6.4% for patients who initiated statins immediately versus 8.5% for patients who delayed statin therapy (P=0.001).
In a multivariable analysis adjusted for demographic characteristics and comorbidities, statin nonacceptance was an independent risk factor for myocardial infarction and ischemic stroke (hazard ratio [HR], 1.49 [95% CI, 1.16–1.90]; P=0.002). Mediation analysis showed that greater low‐density lipoprotein cholesterol exposure induced a higher incidence of adverse cardiovascular events (HR, 1.62 [95% CI, 1.46–1.80]; P<0.001).
Conclusions
Among patients with diabetes, patients who delayed statin therapy had a significantly higher cardiovascular risk; this relationship was mediated by higher low‐density lipoprotein cholesterol levels. These findings underscore the importance of timely lipid‐lowering for this high‐risk patient population and can help guide decision‐making by patients and clinicians.
Clinical Perspective
What Is New?
• Nearly one‐fifth of patients with diabetes may delay statin therapy despite meeting clinical indications, and this results in higher low‐density lipoprotein cholesterol levels compared with patients who immediately begin statin therapy.
• Patients with diabetes who delay statin therapy are at 50% greater risk for myocardial infarctions and cerebrovascular events.
What Are the Clinical Implications?
Clinicians should recognize the increased cardiovascular risk associated with delaying statin therapy for patients with diabetes and use this information to guide shared decision‐making conversations with their patients.
Among patients with diabetes, cardiovascular events remain the leading causes of complications and mortality. Lowering low‐density lipoprotein cholesterol (LDL‐C) levels significantly attenuates the cardiovascular risk for these patients.1
Based on this evidence, clinical guidelines universally recommend statin therapy for all patients with diabetes aged 40 to 75 years.2, 3, 4 Nevertheless, studies have shown that up to 50% of patients with diabetes are not being treated with statins.5, 6 The reasons behind statin nonuse are multifactorial, including statin‐associated side effects, patient hesitancy, and guideline‐discordant practice from clinicians.6
In particular, recent literature has brought to the fore the importance of nonacceptance of statin therapy recommendations by patients. Studies have shown that as many as 1 in 5 patients with guideline‐based indications for statin therapy do not accept their clinician’s initial recommendation for treatment with a statin; these patients subsequently have significantly higher LDL‐C levels than patients who start statins right away. Patients with diabetes have a particularly high rate of nonacceptance of statin therapy recommendations.7 However, the effect of nonacceptance of statin therapy on long‐term clinical outcomes remains unknown. It is possible that in most cases of statin nonacceptance, patients ultimately begin statin therapy after only a brief delay that does not lead to a major impact on their cardiovascular health, or that they use other strategies to lower their cholesterol, including nonstatin therapies or lifestyle changes. We therefore performed a study to analyze the impact of statin therapy delays due to initial nonacceptance among patients with diabetes on long‐term cardiovascular outcomes.
Läs abstract och hela artikeln pdf free
https://www.ahajournals.org/doi/10.1161/JAHA.124.040464
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