Measurement of low‐density lipoprotein cholesterol levels in primary and secondary prevention patients: Insights from the PALM registry

Background The 2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommended testing low-density lipoprotein cholesterol ( LDL -C) to identify untreated patients with LDL -C ≥190 mg/dL, assess lipid-lowering therapy adherence, and consider nonstatin therapy. We sought to determine whether clinician lipid testing practices were consistent with these guidelines. Methods and Results The PALM (Patient and Provider Assessment of Lipid Management) registry enrolled primary and secondary prevention patients from 140 US cardiology, endocrinology, and primary care offices in 2015 and captured demographic data, lipid treatment history, and the highest LDL -C level in the past 2 years. Core laboratory lipid levels were drawn at enrollment. Among 7627 patients, 2787 (36.5%) had no LDL -C levels measured in the 2 years before enrollment. Patients without chart-documented LDL -C levels were more often women, nonwhite, uninsured, and non-college graduates (all P\u3c0.01). Patients without prior lipid testing were less likely to receive statin treatment (72.6% versus 76.0%; P=0.0034), a high-intensity statin (21.5% versus 24.3%; P=0.016), nonstatin lipid-lowering therapy (24.8% versus 27.3%; P=0.037), and had higher core laboratory LDL -C levels at enrollment (median 97 versus 92 mg/dL; P\u3c0.0001) than patients with prior LDL -C testing. Of 166 individuals with core laboratory LDL -C levels ≥190 mg/dL, 36.1% had no LDL -C measurement in the prior 2 years, and 57.2% were not on a statin at the time of enrollment. Conclusions In routine clinical practice, LDL -C testing is associated with higher-intensity lipid-lowering treatment and lower achieved LDL -C level

Caracterización de la fibrilación auricular y riesgo tromboembólico en pacientes del Hospital León Cuervo Rubio

Introduction: among cardiac pathologies, atrial fibrillation is related to a high incidence of thromboembolic diseases. Objective: to clinically and epidemiologically characterize atrial fibrillation and thromboembolic risk in patients attended at the León Cuervo Rubio Hospital in Pinar del Río between 2017 and 2019. Methods: an observational, descriptive, cross-sectional, descriptive study was conducted on patients with atrial fibrillation attended at the León Cuervo Rubio Hospital in Pinar del Río from 2017 to 2019. The study universe consisted of 198 patients diagnosed with atrial arrhythmias in that hospital, the sample was constituted by 68 patients who met the inclusion and exclusion criteria. Results: female sex predominated (58.8%). The most representative age group was 75 to 85 years old (45.5 %). Some type of heart disease associated with atrial fibrillation was present in 69.1% of patients. Persistent atrial fibrillation predominated (35.2%). Palpitations predominated as symptoms of atrial fibrillation (91.1%). Most patients with atrial fibrillation were in the moderate thromboembolic risk category (66.1%). Conclusions: the predominant sex was female, the most affected age group was over 85 years, ischemic heart disease was the most prevalent history, persistent atrial fibrillation was the most frequent, palpitations were the main symptom, and according to the thromboembolic risk category, most patients were at moderate risk.Introducción: dentro de las patologías cardiacas, la fibrilación auricular se relaciona con una alta incidencia de enfermedades tromboembólicas. Objetivo: caracterizar clínica y epidemiológicamente la fibrilación auricular y el riesgo tromboembólico en pacientes atendidos en el Hospital León Cuervo Rubio de Pinar del Río entre 2017 y 2019. Método: se realizó un estudio observacional, descriptivo, de corte transversal a pacientes con fibrilación auricular atendidos en el Hospital León Cuervo Rubio de Pinar del Río de 2017 a 2019. El universo de estudio estuvo conformado por 198 pacientes con diagnóstico de arritmias auriculares en dicho hospital, la muestra quedó constituida por 68 pacientes que cumplieron con los criterios de inclusión y exclusión. Resultados: predominó el sexo femenino (58,8 %). El grupo etario más representativo fue el de 75 a 85 años (45,5 %). El 69,1 % presentaban algún tipo de cardiopatía asociada a la fibrilación auricular. Predominó la fibrilación auricular de tipo persistente (35,2 %). Predominaron las palpitaciones como síntomas de la fibrilación auricular (91,1 %). La mayoría de los pacientes con fibrilación auricular estaban en la categoría de riesgo tromboembólico moderado (66,1 %). Conclusiones: el sexo que predominó fue el femenino, el grupo etáreo más afectado fue el de más de 85 años, la cardiopatía isquémica fue el antecedente de mayor prevalencia, la fibrilación auricular de tipo persistente fue la más frecuente, las palpitaciones constituyeron el síntoma principal y según la categoría de riesgo tromboembólico la mayoría de los pacientes presentaban riesgo moderado

Platelet-related biomarkers and their response to inhibition with aspirin and p2y12-receptor antagonists in patients with acute coronary syndrome

The PLATelet inhibition and patient Outcomes (PLATO) trial showed that treatment with ticagrelor reduced the rate of death due to vascular causes, myocardial infarction and stroke when compared to clopidogrel in patients with ST-elevation or non-ST-elevation acute coronary syndrome (ACS). While the comparative benefit of ticagrelor over clopidogrel increased over time, event rates accrued in both groups during the study period. The purpose of our biomarker-based exploratory analysis was to determine whether long-term platelet inhibition may be associated with platelet adaptation. A sample of 4000 participants from the PLATO trial also consented to participate in a prospectively designed biomarker substudy. Blood samples were procured at baseline, immediately prior to hospital discharge and at 1 and 6 months. Markers of platelet activity, including platelet count, serum CD40-ligand and soluble P-selectin were analyzed. Mean levels were compared at discharge, 1 and 6 months following study drug initiation—first for all patients and subsequently stratified by treatment group. A linear mixed model was used to estimate the short-term change rate (baseline to 1 month) and long-term change rate (1–6 months) for each biomarker. A Cox proportional hazards model was used to calculate hazard ratios for each change in biomarker over the two time periods examined: baseline to 1 month and 1 to 6 months. Prior to randomized treatment (baseline), sCD40 ligand and sP-selectin levels were elevated above the normal range of the assay (0.39 and 33.5 µg/L, respectively). The mean level of each biomarker was significantly different at 1 month compared to baseline (p < 0.0001). When stratified by treatment group, at 1 month patients treated with ticagrelor had a larger increase in platelet count compared to those treated with clopidogrel (p < 0.0001). Similarly, when comparing biomarker levels for all patients at 6 months with those at 1 month, each differed significantly (p < 0.05). There was no significant difference between treatment groups during this time period. The rate of change for both platelet count and sP-selectin were significantly different between baseline and 1 month when compared to the 1 to 6-month time period (p < 0.0001). When comparing treatment groups, the rate of increase in platelets from baseline to 1 month was greater for patients treated with ticagrelor (p < 0.0001). This was no longer observed in the 1 to 6-month interval. Using a Cox proportional hazard model, the increase in platelet count from 1 to 6 months was associated with ischemic-thrombotic events, while sCD40 ligand decrease from 1 to 6 months was associated with hemorrhagic events. There were no differences between treatment groups for the associations with clinical endpoints. Dynamic changes in platelet count, sCD-40 ligand and sP-selectin occur over time among patients with ACS. Platelet-directed therapy with a P2Y12 receptor inhibitor in combination with aspirin modestly impacts the expression of these biomarkers. Platelet count and sCD40 ligand may offer modest overall predictive value for future ischemic-thrombotic or hemorrhagic clinical events, respectively. The existence of a platelet adaptome and its overall clinical significance among patients at risk for thrombotic events will require a more in-depth and platelet-biology specific investigation

Studi preliminari sulla germinazione di alcune sottospecie di Centaurea aplolepa Moretti (Asteraceae) ai fini della conservazione della biodiversità.

Germination tests of Centaurea aplolepa subsp. carueliana (Micheletti) Dostál, Centaurea aplolepa subsp. cosana (Fiori) Dostál, Centaurea aplolepa subsp. maremmana (Fiori) Dostál, Centaurea aplolepa subsp. subciliata (DC.) Arcang, were made to the maturation of collected achenes, and then assayed in the experimental tests of germination conducted at temperature 25 ° C and 18 ° C, under a photoperiod of 12/12 and in the complete absence of light, distinguishing, where present, clear and dark achenes. For each group were made 3 replicates from 50 individuals. The obtained data were processed and discussed using parameters such as germination capacity and germination rate (T50). The results make it possible to highlight substantial differences between subspecies relation to the ecological conditions and fruit ripening

Does clinician-reported lipid guideline adoption translate to guideline-adherent care? An evaluation of the patient and provider assessment of lipid management (PALM) registry

Background: The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline recommends statin treatment based on patients\u27 predicted atherosclerotic cardiovascular disease (ASCVD) risk. Whether clinician-reported guideline adoption translates to implementation into practice is unknown. Objectives: We aimed to compare clinician lipid management in hypothetical scenarios versus observed practice. Methods: The PALM Registry asked 774 clinicians how they would treat 4 hypothetical scenarios of primary prevention patients with: (1) diabetes; (2) high 10-year ASCVD risk (≥7.5%) with high low-density lipoprotein cholesterol (LDL-C; ≥130 mg/dL); (3) low 10-year ASCVD risk (\u3c7.5%) with high LDL-C (130-189 mg/dL); or (4) primary and secondary prevention patients with persistently elevated LDL-C (≥130 mg/dL) despite high-intensity statin use. We assessed agreement between clinician survey responses and observed practice. Results: In primary prevention scenarios, 85% of clinicians reported they would prescribe a statin to a diabetic patient and 93% to a high-risk/high LDL-C patient (both indicated by guidelines), while 40% would prescribe statins to a low-risk/high LDL-C patient. In clinical practice, statin prescription rates were 68% for diabetic patients, 40% for high-risk/high LDL-C patients, and 50% for low-risk/high LDL-C patients. Agreement between hypothetical and observed practice was 64%, 39%, and 52% for patients with diabetes, high-risk/high LDL-C, and low-risk/high LDL-C, respectively. Among patients with persistently high LDL-C despite high-intensity statin treatment, 55% of providers reported they would add a non-statin lipid-lowering medication, while only 22% of patients were so treated. Conclusions: While the majority of clinicians report adoption of the 2013 ACC/AHA guideline recommendations, observed lipid management decisions in practice are frequently discordan

Association of clinician knowledge and statin beliefs with statin therapy use and lipid levels (A Survey of US Practice in the PALM Registry)

Guideline implementation requires clinician knowledge but may be influenced by pre-existing beliefs and biases. We assessed the association of these clinician factors with lipid management following the release of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines. In the PALM registry, 774 clinicians completed a survey to assess their knowledge of the 2013 American College of Cardiology/American Heart Association guidelines, belief in statin benefit, and statin safety concerns. The association of these factors with statin use, statin dosing, and low-density lipoprotein cholesterol (LDL-C) levels were assessed in the 6,839 patients treated by these clinicians between May and November 2015. Overall, 63.9% of clinicians responded to at least 3 out of 4 hypothetical scenarios in concordance with guideline recommendations (good tested knowledge), 88.4% reported belief in statin benefit, and 15.4% raised concerns about statin safety. Belief in statin benefit was more prevalent among cardiologists, who represented 48.8% of the clinicians surveyed, and concerns regarding statin safety were higher among noncardiologists and clinicians in an academic setting. Guideline knowledge was not associated with a difference in statin use (74.1% vs 73.8%, p = 0.84) and achievement of LDL-C level \u3c100 mg/dl (54.7% vs 52.4%, p = 0.07). However, patients treated by clinicians who reported belief in statin benefit were more likely to receive guideline-recommended statin intensity (41.9% vs 36.9%, p = 0.03), whereas patients treated by clinicians expressing statin safety concerns were less likely receive statins of at least guideline-recommended intensity (36.8% vs 42.5%, p = 0.001) and to achieve an LDL-C \u3c100 mg/dl (44.1% vs 56.1%, p \u3c0.001); the latter persisted after multivariable adjustment (odds ratio 0.75, 95% confidence interval 0.63 to 0.89). In conclusion, clinician beliefs regarding benefits and risks of statins were significantly associated with guideline adherence and patients\u27 achieved LDL-C levels, whereas clinician knowledge of guideline recommendations was not

Patient perceptions and use of non‐statin

Background: Non-statin lipid lowering therapies (LLTs) provide additional treatment options for patients. Use patterns and patient perceptions of non-statin LLT remain incompletely described.Hypothesis: The guideline-recommended statin intensity remains underutilized in patients treated with and without non-statin LLT.Methods: The PALM Registry collected LLT information on patients with or at risk of ASCVD treated at 125 US clinics in 2015. We compared patient perceptions, lipid levels and statin use among patients treated with and without non-statin LLT.Results: Among 7720 patients, 1930 (25.0%) were treated with a non-statin LLT (1249 fish oil, 417 fibrates, 329 ezetimibe, 196 niacin). Concurrent statin treatment occurred in 73.7%, of which 45.4% were dosed under the guideline-recommended intensity. Compared with patients on statin alone, patients receiving both a statin and non-statin LLT (n = 1423) were more likely to be male, white race and to perceive themselves as higher risk of ASCVD compared with their peers (38.5% vs. 34.9%, p = .047). Only 27.4% of patients treated with non-statin LLT alone perceived themselves at higher risk. Most (75.7%) patients treated with a non-statin LLT alone reported never being treated with a statin, despite ASCVD in 30.8% of these patients. Among those previously treated with a statin, 59.3% reported being willing to try a statin again.Conclusions: Non-statin LLT is used in one in four patients with or at risk for ASCVD; its use is frequently in place of statin therapy or in the absence of guideline-recommended statin intensity. More work is needed to establish statins as first line therapy

Patient perceptions and use of non-statin lipid lowering therapy among patients with or at risk for atherosclerotic cardiovascular disease: Insights from the PALM registry

Background: Non-statin lipid lowering therapies (LLTs) provide additional treatment options for patients. Use patterns and patient perceptions of non-statin LLT remain incompletely described.Hypothesis: The guideline-recommended statin intensity remains underutilized in patients treated with and without non-statin LLT.Methods: The PALM Registry collected LLT information on patients with or at risk of ASCVD treated at 125 US clinics in 2015. We compared patient perceptions, lipid levels and statin use among patients treated with and without non-statin LLT.Results: Among 7720 patients, 1930 (25.0%) were treated with a non-statin LLT (1249 fish oil, 417 fibrates, 329 ezetimibe, 196 niacin). Concurrent statin treatment occurred in 73.7%, of which 45.4% were dosed under the guideline-recommended intensity. Compared with patients on statin alone, patients receiving both a statin and non-statin LLT (n = 1423) were more likely to be male, white race and to perceive themselves as higher risk of ASCVD compared with their peers (38.5% vs. 34.9%, p = .047). Only 27.4% of patients treated with non-statin LLT alone perceived themselves at higher risk. Most (75.7%) patients treated with a non-statin LLT alone reported never being treated with a statin, despite ASCVD in 30.8% of these patients. Among those previously treated with a statin, 59.3% reported being willing to try a statin again.Conclusions: Non-statin LLT is used in one in four patients with or at risk for ASCVD; its use is frequently in place of statin therapy or in the absence of guideline-recommended statin intensity. More work is needed to establish statins as first line therapy

Beliefs, risk perceptions, and lipid management among patients with and without diabetes: Results from the PALM registry

Background: Intensive lipid management is critical to reduce cardiovascular (CV) risk for patients with diabetes mellitus (DM).Methods: We performed an observational study of 7628 patients with (n = 2943) and without DM (n = 4685), enrolled in the Provider Assessment of Lipid Management (PALM) registry and treated at 140 outpatient clinics across the United States in 2015. Patient self-estimated CV risk, patient-perceived statin benefit and risk, observed statin therapy use and dosing were assessed.Results: Patients with DM were more likely to believe that their CV risk was elevated compared with patients without DM (39.1% vs 29.3%, P \u3c .001). Patients with DM were more likely to receive a statin (74.2% vs 63.5%, P \u3c .001) but less likely to be treated with guideline-recommended statin intensity (36.5% vs 46.9%, P \u3c .001), driven by the low proportion (16.5%) of high risk (ASCVD risk ≥7.5%) primary prevention DM patients treated with a high intensity statin. Patients with DM treated with guideline-recommended statin intensity were more likely to believe they were at high CV risk (44.9% vs 38.4%, P = .005) and that statins can reduce this risk (41.1% vs 35.6%, P = .02), compared with patients treated with lower than guideline-recommended statin intensity. Compared with patients with an elevated HgbA1c, patients with well-controlled DM were no more likely to be on a statin (77.9% vs 79.3%, P = .43).Conclusions: In this nationwide study, the majority of patients with DM were treated with lower than guideline-recommended statin intensity. Patient education and engagement may help providers improve lipid therapy for these high-risk patients