Secondary prevention strategies in ASCVD continue to be underused
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Suboptimal uses of statin therapy, aspirin prescription and lifestyle counseling persist for adults with atherosclerotic CVD, despite new guidelines emphasizing their effect on reduced mortality, researchers reported.
In a cross-sectional study assessing office-based patient visits for adults with ASCVD from 2006 to 2016, researchers found statin therapy and aspirin prescriptions have shown only modest increases in recent years; however, gender and racial differences persist.
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“Primary care practitioners are well-positioned to reduce cardiovascular risk factors due to continuity with patients and comprehensiveness of care,” Ambar Kulshreshtha, MD, PhD, associate professor in the division of family and preventive medicine at Emory University School of Medicine, and colleagues wrote in the study background. “They also see a higher volume of patients with chronic diseases and people from minority racial and ethnic groups, including Black and Hispanic patients, positioning them optimally to improve health disparities among these populations.”
Small increases in statin, aspirin use
Kulshreshtha and colleagues analyzed data from the National Ambulatory Medical Care Survey (NAMCS), an annual survey assessing ambulatory office-based patient visits, including medical conditions, services provided and demographic characteristics. Researchers identified patients with prevalent ASCVD between 2006 and 2016, separated by time: 2006 to 2013 and 2014 to 2016. Outcomes included statin therapy, aspirin prescription and lifestyle counseling service provided at clinic visits.
The findings were published in JAMA Network Open.
There were 11,033 visits for adults with ASCVD, representing a weighted total of 275.3 million visits nationwide. Within the cohort, 40.7% were women; 9.2% were Hispanic; 9.9% were non-Hispanic Black, 90.1% were white; and 40.6% of patients were from cardiology clinics.
Researchers found that across all visits, 49.9% of patients were prescribed statin therapy, 46.8% were using aspirin and 20.2% received lifestyle counseling.
Statin therapy increased from 45.3% in 2006 to 46.5% in 2016; aspirin prescriptions increased from 41.3% in 2006 to 47.5% in 2016.
Compared with men, women were less likely to receive statin therapy (adjusted OR = 0.79; 95% CI, 0.68-0.92) and aspirin (aOR = 0.81; 95% CI, 0.7-0.95). There was no difference by sex in receipt of lifestyle counseling. Additionally, Black patients were less likely to receive statin therapy compared with white patients (OR = 0.72; 95% CI, 0.57-0.92); however, this was attenuated in adjusted models. There was no difference by race in receipt of aspirin therapy or lifestyle counseling.
“There is a critical need to increase quality improvement and implementation programs in the primary care setting to address these gaps for secondary prevention of ASCVD,” the researchers wrote.
New approaches needed
In a related editorial, JD Schwalm, MD, MSc, FRCPC, associate professor at McMaster University and an interventional cardiologist at the Hamilton General Hospital, Hamilton, Ontario, Canada, and colleagues noted that a polypill strategy has been shown to benefit high-income and low-income countries and in diverse settings for primary and secondary prevention. “Nonphysician health workers using polypills and providing counselling to patients and their families is a low-cost and scalable model of health care delivery and should be the foundation for widespread prevention strategies for ASCVD,” Schwalm and colleagues wrote. “Furthermore, such a strategy will reduce the potential disparities in management of CVD across gender, race and socioeconomic levels. In individuals with complex or resistant problems, or those experiencing side effects, additional care provided by physicians could lead to further benefit. Such a broad and tiered health systems approach could transform prevention worldwide, including the U.S.”
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