BACKGROUND:Low-density lipoprotein cholesterol (LDL-C), among other lipids, is a strong causal and modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD). However, lipid-lowering therapy (LLT) is underutilized and many patients do not reach LDL-C goals. OBJECTIVES:This study aimed to evaluate patient preferences for LLT attributes to inform shared decision-making and improve treatment adoption and adherence. METHODS:Adults ≥40 years with elevated LDL-C and a recommendation for LLT completed a cross-sectional, web-based survey assessing treatment experiences and preferences. A discrete choice experiment elicited preferences across 7 attributes: LDL-C reduction, stroke risk, heart attack risk, revascularization risk, new-onset diabetes, musculoskeletal pain, and regimen/mode of administration. Survey responses were analyzed using univariate and bivariate methods. Preference weights (PW) and relative importance were estimated using hierarchical Bayesian modeling. RESULTS:Among 508 participants (mean age: 62.8 ± 11.4 years), 49.0% had prior ASCVD, 55.3% were female, and 43.9% were current or former smokers. Participants prioritized immediate and tangible treatment features over long-term benefits. Mode of administration was the most influential attribute (relative importance = 25.9). A once-daily oral pill was most preferred (PW = 1.75), followed by a daily pill plus a second oral pill before breakfast (PW = 0.17), whereas regimens including biweekly injections were least preferred (PW = -1.13). Higher perceived ASCVD risk was associated with greater emphasis on cardiovascular risk reduction and less emphasis on regimen. CONCLUSIONS:Mode of administration is a key driver of LLT preferences. Incorporating patient preferences into shared decision-making may improve adherence and implementation of guideline-directed therapy.

BACKGROUND AND AIMS:This study aimed to estimate consequences of myocardial infarction (MI) on long-term outcomes and resource needs by comparing outcomes, healthcare resource use, and associated costs between first-time MI patients and matched controls. METHODS:First-time MI patients from the nationwide SWEDEHEART registry, along with matched controls without prior MI (matched by sex, age, and region) 2012-2022, were included. Follow-up continued through November 2024 and assessed major adverse cardiovascular events (MACE), defined as cardiovascular death, MI, ischemic stroke, acute limb ischemia, or urgent arterial revascularization, as well as, healthcare resource use and associated costs. RESULTS:Among 118,810 first-time MI patients and 588,687 matched controls, followed for a median (IQR) of 6.6 (4.2-9.4) years, the 10-year MACE probability was 48.5% vs. 21.1% (HR [95% CI] 3.65 [3.61-3.69]), mainly due to higher rate of cardiovascular death (21.7% vs. 11.1%), MI (18.4% vs. 5.9%), and arterial revascularization (22.9% vs. 4.2%). Associations attenuated after adjustment for baseline characteristics but remained significant (MACE: adjHR[95%CI]: 3.18[3.15-3.22]). Cases had twice as many inpatient visits (0.65 vs. 0.32/patient year) and inpatient days (3.05 vs. 1.67/patient year), with nearly double the mean annual total costs (€7,266 vs. €3,934) when outpatient visits and medication also were included. Differences were greatest in the first year but persisted, especially among females and those with risk factors such as hypertension or diabetes. CONCLUSIONS:First-time MI patients have persistently higher risks of cardiovascular death, MI, and ischemic stroke, along with greater healthcare use and costs, underscoring the need for effective prevention.

Guideline-recommended lipid-lowering therapy (LLT) can reduce healthcare utilization and costs for patients with and at-risk for atherosclerotic cardiovascular disease (ASCVD). We examined healthcare utilization and associated costs among adult LLT users in Kaiser Permanente Southern California ≥21 years of age having ASCVD or intermediate (≥7.5% to <20%) or high (≥20%) 10-year ASCVD risk between 2015 and 2021. LLT adherence trajectories were determined using group-based trajectory modeling over 12 months. All-cause and ASCVD-related annualized adjusted costs were calculated through 2023. High versus low LLT adherence was associated with lower all-cause costs (−$999; 95% CI: −$1100, −$897) and varied across subgroups by ASCVD risk. Adults missing a follow-up low-density lipoprotein cholesterol (LDL-C) measure had +$8312 (95% CI +$7955, +$8669) higher all-cause costs compared to adults with LDL-C < 55 mg/dL. Improving LDL-C management through optimized LLT treatment strategies can reduce economic burdens in high-risk patients.

Background: Major bleeding is common in dialysis-dependent end-stage kidney disease (ESKD). Objectives: To compare healthcare resource utilization (HCRU) and costs of major bleeding events between dialysis and non-dialysis populations. Methods: We identified fee-for-service Medicare beneficiaries aged ≥66 years with a first (index) major bleeding event in 2015-2018. Patients with ESKD receiving in-center hemodialysis (HD) and home dialysis from the US Renal Data System were each compared to patients without ESKD from a 20% Medicare sample. HCRU and cost outcomes were compared using model-based standardization, adjusted for age, sex, and race, during the index major bleeding event and a 1-year follow-up period. Results: Patients receiving in-center HD had index major bleeding hospitalizations that were longer and costlier (adjusted mean differences: 0.7 days [95% CI, 0.6-0.8] and $3.4K [95% CI, $3.2K-$3.7K]) than those without ESKD. During 1-year follow-up, bleeding-related hospitalizations were more common (adjusted rate difference: 37.6 per 100 person-years [95% CI, 35.2-40.1]) and costly (adjusted per-person per-year cost difference: $6.2K [95% CI, $5.8K-$6.7K]) in patients receiving in-center HD than in those without ESKD. Other than blood transfusions, which were more common in home dialysis than in-center HD (adjusted rates per 100 person-years: 255.8 [95% CI, 241.8-269.8] vs 202.1 [95% CI, 199.2-205.0]), HCRU outcomes were generally similar between the dialysis groups. Conclusion: Patients receiving dialysis had longer and costlier major bleeding hospitalizations and accrued substantially higher costs after 1 year versus those without ESKD. Readmissions were a key driver of higher HCRU and costs in ESKD.

Background Statins are the cornerstone of lipid‐lowering therapy, reducing low‐density lipoprotein cholesterol in adults. However, residual atherosclerotic cardiovascular disease (ASCVD) risk among statin users remains unclear. This study estimated residual ASCVD risk in statin users in practice. Methods We conducted a systematic literature review and meta‐analyses following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, including observational studies published January 1, 2013, to August 1, 2023, that reported ASCVD risk in adult statin users. Five outcomes were assessed: composite risk (major adverse cardiovascular events or all‐cause death), myocardial infarction, ischemic stroke, cardiovascular‐related death, and coronary revascularization. Meta‐analysis methods were used to synthesize individual study estimates. For each outcome, forest plots present study‐level estimates and the pooled incidence rate per 1000 person‐years (PPY). Results The meta‐analysis of residual composite risk (major adverse cardiovascular events or all‐cause death) in the overall population was 12.3 PPY (range, 0.2–72.0). Rates were lower in adults at risk of ASCVD (6.4 PPY [range, 3.7–9.8 PPY]) and higher in adults with prior ASCVD (15.8 PPY [range, 0.2–72.0 PPY]). Meta‐analysis for myocardial infarction showed 8.23 PPY (range, 1.1–88.82 PPY) in the overall patient population, and a lower rate of ischemic stroke with a rate of 6.0 PPY (range, 1.4–18.8 PPY). A rate of 4.3 PPY (range, 0.4–22.9 PPY) was estimated for cardiovascular‐related death, and 7.4 PPY for coronary revascularization (range, 3.1–27.6 PPY). Conclusions Despite substantial between‐study variability, this real‐world meta‐analysis indicates meaningful residual ASCVD risk among statin users, underscoring persistent treatment gaps and need for comprehensive, optimized risk management.

Rationale & Objective:Patients with kidney failure requiring maintenance dialysis have a high risk of cardiovascular events warranting antithrombotic therapies, including oral anticoagulant (OAC) or antiplatelet therapy (APT). However, chronic use of antithrombotic therapy can increase the bleeding risk in patients receiving dialysis. However, little is known about medication use patterns and risk of bleeding events in real-world clinical practice. Study Design:Retrospective analysis of data from 2 prospective cohort studies. Setting & Participants:We included 27,612 patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS) and 5,289 patients from the Peritoneal DOPPS (PDOPPS), international cohorts of hemodialysis (HD) and peritoneal dialysis (PD) patients. Exposures:Patient demographics and comorbid conditions; OAC and APT use. Outcomes:OAC and APT use; a bleeding composite outcome including a hospitalization or death because of a major bleeding event. Analytical Approach:Descriptive analyses to explore OAC and APT utilization and crude rates of the bleeding composite outcome and Kaplan-Meier analyses to estimate medication discontinuation. Results:Baseline OAC and APT use was 9% and 10% in HD patients and 4% and 7% in PD patients, respectively. Patients prescribed antithrombotic drugs were older and more likely to have a history of cardiovascular disease. After 36 months, the Kaplan-Meier estimated proportions of baseline users who remained on therapy were 57% for OAC and 53% for APT. The composite bleeding rates per 100 patient-years among patients with baseline OAC use versus baseline APT use versus neither were 8.6, 5.6, and 4.1 in HD patients and 12.0, 6.1, and 3.9 in PD patients, respectively. Limitations:Potential for event misclassification; no over-the-counter medication data; rates unadjusted. Conclusions:Antithrombotic drugs are infrequently prescribed and often discontinued in patients receiving HD or PD. With major bleeding event rates high among antithrombotic users, new strategies are needed to optimize the risks and benefits of antithrombotic agents in the dialysis setting.

BACKGROUND:Contemporary data regarding uptake of vericiguat for treatment of heart failure (HF), including achievement of target dose (10 mg), are lacking. METHODS:A retrospective analysis of TriNetX claims data was conducted. The study included US adults with HF receiving vericiguat from January 20, 2021, to November 20, 2023. Baseline patient characteristics, health care resource use, and follow-up vericiguat titration were described. Multivariable logistic regression models identified factors associated with reaching the vericiguat target dose. RESULTS:The study sample included 5149 patients (mean age 68 years, 67% male, 55% White). Common comorbidities included hypertension (89%) and hyperlipidemia (81%). Over a 12-month baseline, 35%, 44%, and 38% of patients experienced worsening HF events, all-cause hospitalizations, and emergency department visits, respectively. Common guideline-directed medical therapy (GDMT) classes received at baseline included beta-blockers (74%), angiotensin receptor neprilysin inhibitors (ARNi; 52%), sodium glucose cotransporter-2 inhibitors (SGLT2i; 44%), and mineralocorticoid receptor antagonists (MRAs; 40%). Approximately 36% of patients reached the vericiguat target dose over a median (interquartile range) follow-up of 433 (247-606) days. Factors associated with reaching the target dose included age, baseline medication with MRAs, beta-blockers, or combination therapy with ARNi and SGLT2i, and the Charlson Comorbidity Index score. CONCLUSION:Approximately one-third of patients treated with vericiguat reached the 10-mg target dose during follow-up, with receipt of a beta blocker, MRA, or ARNi + SGLT2i combination at baseline associated with achievement of the target dose. These data inform contemporary use of novel GDMT and may support quality improvement efforts to enhance the effective implementation of GDMT in appropriate patients.

Despite their safety and effectiveness, lipid-lowering therapy (LLT) remains underutilized among adults with and at-risk for atherosclerotic cardiovascular disease (ASCVD) in terms of prescriber-guideline concordance and patient adherence. We examined LLT use, adherence, and outcomes among primary and secondary prevention populations. Adults ≥21 years of age in Kaiser Permanente Southern California with a history of ASCVD or intermediate (≥7.5% to <20%) or high (≥20%) 10-year ASCVD risk between January 1, 2015 and March 31, 2021 were included. LLT use was described within subgroups including baseline risk. LLT adherence trajectories were determined using group-based trajectory modeling over 12 months. Hazard ratios (HR) were calculated for the association of adherence with ASCVD outcomes, identified starting in month 13 until death, disenrollment, or March 31, 2023. Among 730,941 adults (mean age 63 years; 42.1% female; 33.7% Hispanic and 41.3% non-Hispanic White), 30.3% and 47.4%, respectively, were intermediate- and high-risk for ASCVD, and 22.3% had ASCVD. Overall, 21% were not taking LLT, including 24% with ASCVD, and 32.4% of LLT users discontinued treatment at 12 months. High, intermediate, and low LLT adherence trajectories accounted for 64.1%, 24.3%, and 11.6% of the population, respectively. Adherence to LLT was associated with risk of ASCVD regardless of baseline statin intensity: adjusted HR of composite ASCVD associated with low and intermediate adherence was 1.20 (95% CI 1.16, 1.23) and 1.13 (95% CI 1.11, 1.15), respectively compared to patients with high adherence. LLT was underutilized in this contemporary population within an integrated health system in Southern California. In conclusion, addressing clinical inertia, enhancing medication management and lipid testing, and assessing clinical quality and metrics around guideline-appropriate care are critical given the persistent burden of CVD.

BACKGROUND:Major adverse thrombotic events (MATEs) are an important cause of morbidity and mortality in people with end-stage kidney disease (ESKD) receiving dialysis. Information on the extent to which the healthcare resource utilization (HCRU) and costs of treating MATEs differ between the dialysis and non-dialysis populations is limited. METHODS:Fee-for-service Medicare beneficiaries aged ≥66 years who experienced a first (index) MATE in 2015-2018 were studied using an observation cohort design. Individuals with ESKD receiving dialysis from the US Renal Data System were compared to individuals without ESKD from a 20% Medicare sample. MATEs were identified using claims-based algorithms. Outcomes included HCRU and Medicare payments during the index MATE and during a 1-year follow-up period. Costs of maintenance dialysis were excluded. Age-, sex-, and race-adjusted outcomes were estimated using model-based standardization. Separately for each MATE type, outcomes were compared for each of two ESKD cohorts (in-center hemodialysis [ICHD] and home dialysis) vs. a non-ESKD cohort. RESULTS:Index MATE hospitalizations were roughly 1.2-1.3 times as long and 1.2-1.5 times as costly for patients with ESKD receiving ICHD (adjusted mean length of stay 7.0-10.3 days and cost $15.1K-$26.6K) than for patients without ESKD (5.6-7.6 days and $10.2K-$19.1K). Furthermore, in the 1-year follow-up, rates and per-person per-year costs of subsequent MATE-related hospitalizations were 2-3 times as high in patients receiving ICHD as in those without ESKD. HCRU and costs in patients receiving home dialysis were generally similar to, or higher than, in those receiving ICHD. CONCLUSIONS:Among older adults with a MATE, those receiving dialysis had greater HCRU and costs compared to those without ESKD. Reducing HCRU and costs related to MATEs should be a focus of treatment for people receiving dialysis.

Hypercholesterolemia is widely undertreated. To project anticipated improvements in treatment and outcomes under full implementation of US and European pharmacologic treatment recommendations. The study sample included a total of 4980 adults aged 40–75 years from the 2013 through March 2020 US National Health and Nutrition Examination Survey (NHANES). We estimated the number of individuals eligible to receive versus currently receiving lipid lowering therapy (LLT) after applying: (1) the AHA/ACC guideline (“2018 US guideline”); (2) the ESC/EAS guideline (“2019 EU guideline”); and (3) the ACC expert decision pathway (“2022 US pathway”). (1) Number of individuals eligible for LLT; and (2) expected reduction in LDL-C and major cardiovascular events. The study sample represented 131 million US adults. A total of 23

Background and Aims:Improving care of patients with hyperlipidemia requires an understanding of the barriers physicians perceive in prescribing low-density lipoprotein cholesterol (LDL-C)-lowering therapies. This study explores physicians' perceptions of time and resource burdens, identify perceived patient adherence barriers, and examine factors influencing physicians' decision-making in LDL-C management. Methods:This is a non-interventional, cross-sectional, online survey of US-based primary care practitioners (PCP) and cardiologists who recommended or provided lipid-lowering therapy (LLT) to ≥50 adults per month, practiced for ≥2 years, and completed the survey in English. The survey comprised multiple-choice, constant sum, and numerical questions about physician decision-making, patient management, and perceptions of patient attitudes/behaviors regarding LDL-C management. Descriptive univariate analyses were conducted. Results:200 PCPs and 200 cardiologists completed the survey. Most physicians reported prescribing lipid-lowering therapy (LLT) and that patients declined injectable proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i). They attributed this refusal to cost/insurance, fear/discomfort taking injections, and a preference for oral therapies. Physicians viewed patients with a history of ASCVD, with LLT experience, and those with greater understanding of ASCVD risk to have higher LLT adherence compared to those without. Most physicians spent a median of 10 min in shared decision-making conversations, regardless of therapies they prescribed. They reported needing longer to instruct patients during adherence counseling for PCSK9is than for oral therapies. Conclusions:Our findings suggest patient, clinician, and system barriers may all hinder LDL-C management and adherence. A greater understanding of the association between perceived barriers and real-world behaviors will help optimize lipid management.