Disparities continue in secondary prevention for CHD
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Significant disparities persist regarding secondary prevention for CHD, particularly for treatment, risk factor control and medical therapy adherence, researchers found.
This presentation was an early career research winner at the virtual American Society for Preventive Cardiology Congress on CVD Prevention.
“This particularly affects younger patients, females and Hispanics,” Kimberly Vu, MD, third-year internal medicine resident at the University of California, Irvine, said during the presentation. “This concerns me as someone who wants to do cardiology because ideally all patients regardless of their ethnic group, their age and their gender should be receiving the appropriate medical therapy. This warrants further investigation and efforts to reduce disparities, whether that’s from a systemic standpoint or health care delivery standpoint to ensure that patients from all backgrounds receive the appropriate and high-quality care to improve their cardiovascular health.”
Researchers assessed the rates of achieving lifestyle targets, risk factor control and preventative medication use in 13.4 million patients (mean age, 66 years; 7.7 million men; 75% non-Hispanic white; 9% Hispanic; 9% non-Hispanic Black; 3% non-Hispanic Asian) with CHD from the 2011-2016 National Health and Nutrition Examination Surveys (NHANES). All patients were aged 18 years and older and had self-reported CHD, angina or MI.
The 2011 American Heart Association/American College of Cardiology for secondary prevention of CHD guidelines were used along with additional guidelines updating goals for BP (< 130 mm Hg systolic over 80 mm Hg diastolic) and LDL where if remaining at 70 mg/dL or greater while on maximally tolerated statin prompts the need for additional nonstatin therapy. Other factors assessed included age, sex, socioeconomic status, ethnicity and educational status. NHANES sample weights were used, resulting in a sample size of 1,125 patients.
Lifestyle targets
There were significant differences between men and women regarding mean systolic BP (127.3 mm Hg vs. 131.6 mm Hg, respectively; P < .05), mean diastolic BP (68 mm Hg vs. 64 mm Hg, respectively; P < .01), mean LDL (92.3 mg/dL vs. 101.2 mg/dL, respectively; P < .05) and mean HDL (46.1 mg/dL vs. 55.1 mg/dL, respectively; P < .01).
With regards to lifestyle targets in the overall population, 11.5% achieved targets for physical activity, 88.1% achieved ideal alcohol consumption and 16.3% met goals for sodium intake of less than 1,500 mg per day. In addition, 19% achieved BMI between 18 kg/m2 and 24.9 kg/m2, and 36.4% had a waist circumference of less than 35 inches for women and less than 40 inches for men.
Men were less likely to achieve sodium intake targets (11% vs. 23.6%) and BMI goals (16.5% vs. 22.4%) but more likely to meet waist circumference goals (42.7% vs. 27.8%) compared with women. Patients younger than 65 years were less adherent to alcohol consumption guidelines compared with those older than 65 years (79.5% vs. 94%).
Hispanic and Black patients were less likely to get enough physical activity (8% and 5.8%, respectively) compared with non-Hispanic white and non-Hispanic Asian patients (12% and 17%, respectively). Patients from lower-income households consumed higher amounts of salt compared with middle- and high-income households (20.6%, 13.1% and 11.2%, respectively). Lower educational status was linked with higher BMI (26.1%) and higher waist circumference (44%) compared with patients who completed high school (elevated BMI, 14%; elevated waist circumference, 30.6%) and an associate’s degree or higher (elevated BMI, 18.6%; elevated waist circumference, 36.1%).
Compared with patients older than 65, those younger than 65 years were less likely to be at goal for non-smoking (57.1% vs. 85.9%), BP (47.7% vs. 58.4%), LDL (16.5% vs. 28.2%), hemoglobin A1c (43.8% vs. 55.3%) and all four of these goals (7.6% vs. 11.5%). Black patients were more likely to smoke compared with non-Hispanic white, Hispanic and non-Hispanic Asian patients; in addition, those with lower incomes were more likely to smoke than those with higher incomes. Among the overall patient population, 9.9% of patients met all four of these goals. Men were more likely to achieve an LDL less than 70 mg/dL (24.9% vs. 19%; P < .01) and achieve all four risk factor goals (13.9% vs. 5.4%; P < .05) compared with women.
Patients younger than 65 years were less likely to be taking beta-blockers (36.1% vs. 51.3%); ACE inhibitors, angiotensin II receptor antagonists or aldosterone antagonists (46.4% vs. 56.8%); lipid-lowering agents (57.3% vs. 75.4%); aspirin for patients 40 years and older (63.2% vs. 72.1%), or take all four categories of these medications (18.4% vs. 20.8%). Patients from underrepresented backgrounds were also less likely to be taking lipid-lowering agents or aspirin compared with white patients. Similar findings were observed in lower-income households vs. middle- and high-income households. For the overall population, 19.9% of patients aged 40 years and older were taking all four of these pharmacologic therapies.
Sex differences were observed for pharmacologic therapies, as more men were taking ACE inhibitors, angiotensin II receptor antagonists or aldosterone antagonists (58% vs. 45.2%; P < .01); aspirin (72% vs. 64%; P < .05) or all four therapies (24.4% vs. 13.4%; P < .01) compared with women.
Guidelines can help
“NHANES is a cross-sectional dataset only looking at one snapshot in time, and a lot of these variables are self-reported, so some of the individuals may have some recall bias,” Vu said during the presentation. “As a result, we can’t really assess causality between guideline adherence and cardiovascular mortality. However, a lot of the guidelines that we talked about have been rigorously tested in the past in individual studies and are highly recommended by many medical societies.”
“Improved education of health care providers and patients about the guidelines, as well as systems approaches such as automatic reminders in EMR systems, can improve overall adherence and reduce the disparities noted,” Nathan D. Wong, PhD, professor and director of the Heart Disease Prevention Program at the University of California, Irvine, told Healio.
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Vu K. Abstract #112. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 25-26, 2020 (virtual).
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