Prevalence of lipid abnormalities before and after introduction of lipid modifying therapy among Swedish patients with dyslipidemia (PRIMULA)

<p>Abstract</p> <p>Background</p> <p>Data on the prevalence of dyslipidemia and attainment of goal/normal lipid levels in a Swedish population are scarce. The objective of this study is to estimate the prevalence of dyslipidemia and attainment of goal/normal lipid levels in patients treated with lipid modifying therapy (LMT).</p> <p>Methods</p> <p>This longitudinal retrospective observational study covers time periods before and after treatment. Data were collected from 1994-2007 electronic patient records in public primary healthcare centers in Uppsala County, Sweden. Patients were included if they had been treated with LMT and had at least one lipid abnormality indicating dyslipidemia and if complete lipid profile data were available. Thresholds levels for lipids were defined as per Swedish guidelines.</p> <p>Results</p> <p>Among 5,424 patients included, at baseline, the prevalence of dyslipidemia (≥1 lipid abnormality) was by definition 100%, while this figure was 82% at follow-up. At baseline, 60% had elevated low-density lipoprotein (LDL-C) combined with low high-density lipoprotein (HDL-C) and/or elevated triglycerides (TG s), corresponding figure at follow-up was 36%. Low HDL-C and/or elevated TGs at follow-up remained at 69% for patients with type 2 diabetes mellitus (T2DM), 50% among patients with coronary heart disease (CHD) and 66% among patients with 10 year CHD risk >20%. Of the total sample, 40% attained goal levels of LDL-C and 18% attained goal/normal levels on all three lipid parameters.</p> <p>Conclusions</p> <p>Focusing therapy on LDL-C reduction allows 40% of patients to achieve LDL-C goal and helps reducing triglyceride levels. Almost 60% of patients experience persistent HDL-C and/or triglyceride abnormality independently of LDL-C levels and could be candidates for additional treatments.</p

Treatment of hypertension in women and men

Aims: The overall aim of the thesis was to investigate antihypertensive treatment in women and men. First, the aim was to analyze the scientifi c support for treatment recommendations in women and men. Second, the aims were to study achieved blood pressure levels and evaluate differences in antihypertensive treatment in women and men with new-onset and current hypertension and further to study if guidelines were pursued. Finally, the aims were to study the infl uence of comorbidities and psychosocial factors on antihypertensive treatment and achieved target blood pressure in women and men. Methods: Paper I is a review based on “Moderately elevated blood pressure, a systematic literature review” by the Swedish Council on Technology Assessment in Health Care (SBU). Paper I analyses the proportion of women included and gender specifi c data on blood pressure reduction and outcome. Paper II is a retrospective study carried out in primary health care including patients with newly diagnosed hypertension, investigating blood pressure levels, antihypertensive treatment and time to satisfying blood pressure control in women and men. Paper III and IV are retrospective cohort studies carried out in the Swedish Primary Care Cardiovascular Database (SPCCD) including patients with ongoing hypertension. These studies investigate blood pressure levels, achieved target blood pressure, antihypertensive treatment, comorbidities and psychosocial factors in women and men with hypertension. Results: In Paper I, two studies (VALUE and ALLHAT) showed a better blood pressure reduction with calcium channel blockers compared to angiotensin receptor blocker (ARB) and angiotensin converting enzyme inhibitor (ACEI) and this was more pronounced in women. In ALLHAT the calcium channel blocker was superior to both the diuretic and ACEI in reducing stroke incidence in women but not in men. In VALUE, calcium channel blocker-based therapy was superior to the ARB-based therapy in reducing the composite endpoint of cardiac morbidity and mortality in women but not in men (p<0.05). In Paper II, 332 male and 334 female patients were included. There was no gender difference in systolic blood pressure (SBP) before and after treatment. Women had a lower diastolic blood pressure (DBP) before and after intervention. There was no difference between the proportion of women and men reaching the predefi ned goal of treatment. In Paper III and IV, 40 825 patients with current hypertension were included. In patients older than 69 years, women had a higher SBP, except in patients of 90 years of age or older. Achieved DBP dropped with age in both genders and was lower in women in all age groups except in patients 90 years or older. Achieved SBP was higher in women in all subgroups of comorbidities except in patients with asthma. Fewer women than men reached target blood pressure (p<0.0001). Women were more often prescribed thiazide diuretics, loop diuretics and beta receptor blockers and men were more often prescribed ACEI, and this was consistent also after adjusting for age, comorbidities and smoking. The predominant use of ACEI and calcium channel blockers in men was not infl uenced by education, country of birth and psychiatric disorder. However, in well-educated patients women were not prescribed diuretics and beta receptor blockers more often than men. In women, education and psychiatric disorder was associated with reaching target blood pressure. Conclusion: Women and men are treated with different antihypertensive drugs and this is not fully explained by differences in comorbidities. Women with diabetes mellitus are not treated with ACEI or ARB to the same extent as their male counterparts. Women with hypertension reach target blood pressure less often than men and women have a higher achieved SBP in all subgroups of concomitant cardiovascular disease. Higher educational level and psychiatric disorder are associated with reaching target blood pressure in women. Efforts should be made to emphasize the risk evaluation in women with hypertension and concomitant cardiovascular disease to improve blood pressure control

Impact of symptomatic hypoglycemia on medication adherence, patient satisfaction with treatment, and glycemic control in patients with type 2 diabetes

Lotta Walz,1,3 Billie Pettersson,2,3 Ulf Rosenqvist,4 Anna Deleskog,3,5 Gunilla Journath,6 Per W&auml;ndell7 1Department of Oncology-Pathology, Karolinska Institutet, Stockholm, 2Center for Medical Technology Assessment, Link&ouml;ping University, Link&ouml;ping, 3Merck Sharp and Dohme (Sweden) AB, Sollentuna, 4Department of Internal Medicine, Motala Hospital, Motala, 5Department of Molecular Medicine and Surgery, 6Department of Medicine, Karolinska Institutet, Stockholm, 7Department of Neurobiology, Care Sciences and Society, Centre for Family Medicine, Karolinska Institutet, Huddinge, Sweden Background: The purpose of this study was to evaluate the impact of symptomatic hypoglycemia on medication adherence, satisfaction with treatment, and glycemic control in patients with type&nbsp;2&nbsp;diabetes based on the treatment goals stated in the Swedish national guidelines. Methods: This cross-sectional, multicenter study was carried out between January and August&nbsp;2009&nbsp;in&nbsp;430&nbsp;consecutive primary health care patients on stable doses of metformin and sulfonylureas for at least&nbsp;6&nbsp;months. The patients completed questionnaires covering their experiences of low blood glucose and adherence, as well as barriers to and satisfaction with drug treatment (using the Treatment Satisfaction Questionnaire for Medication). Physicians collected the data from medical records. Results: Patients who experienced moderate or worse symptoms of hypoglycemia reported poorer adherence to medication (46% versus&nbsp;67%; P&lt;0.01) and were more likely to perceive barriers such as &ldquo;bothered by medication side effects&rdquo; (36% versus&nbsp;14%; P&lt;0.001) compared with patients with no or mild symptoms. Patients with moderate or worse symptoms of hypoglycemia were less satisfied with their treatment than those with no or mild symptoms as determined by the Treatment Satisfaction Questionnaire for Medication-Global satisfaction (67.0&nbsp;versus&nbsp;71.2; P&lt;0.05). Overall, achievement of target glycated hemoglobin (HbA1c) based on the treatment goals stated in the Swedish national guidelines was&nbsp;40%. Despite poorer adherence, patients who experienced moderate or worse symptoms of hypoglycemia had lower mean HbA1c&nbsp;values than patients with no or mild symptoms (7.0% versus&nbsp;7.3% [Diabetes Control and Complications Trial standard]; P&lt;0.05). Conclusion: Symptomatic hypoglycemia in patients with type&nbsp;2&nbsp;diabetes on metformin and sulfonylureas was associated with nonadherence and decreased treatment satisfaction despite lower mean HbA1c values. A broader understanding of patient preferences and self-reported outcomes could improve the management of patients with type&nbsp;2&nbsp;diabetes. Keywords: hypoglycemia, patient-reported outcomes, primary care, nonadherence, persistence, sulfonylure

Hypertensive smokers have a worse cardiovascular risk profile than non-smokers in spite of treatment - A national study in Sweden

Smoking is a well-established risk factor for cardiovascular disease. Studies have indicated that smoking may outweigh the benefit of blood pressure (BP) control. Our aim was to compare cardiovascular risk factors in smokers vs non-smokers from a national sample of treated hypertensives. Data were collected on smoking habits, BP control, total and low-density lipoprotein (LDL) cholesterol, diabetes, left ventricular hypertrophy (LVH), and microalbuminuria (MA), from records of 4424 consecutive patients by 189 physicians. All technical methods were local. Treated hypertensives who smoked had microalbuminuria significantly more often than non-smokers, 26.2% vs 20.5% (p= 90 mmHg), 32.7% vs 25.0% (p= 140 mmHg) (72.8% vs 68.9%; p<0.01). Both DBP and total cholesterol were higher in smoking vs non-smoking females. An increased prevalence of LVH and microalbuminuria was independently associated with smoking. In summary, smokers with treated hypertension show a higher proportion of LVH (men), microalbuminuria and worse diastolic BP control than non-smokers. This may hypothetically reflect either less compliance with drug treatment in smokers or that smoking impairs the pharmacological effects of antihypertensive drugs

Effects of prescribed antihypertensives and other cardiovascular drugs on mortality in patients with atrial fibrillation and hypertension: a cohort study from Sweden.

Although antihypertensive drugs are known to reduce mortality in individuals with hypertension, the effects of different cardiovascular pharmacotherapies on mortality among patients with hypertension and atrial fibrillation (AF) have been less thoroughly explored. To study mortality rates in men and women separately with hypertension and AF prescribed different cardiovascular pharmacotherapies. A cohort of men (n=2809) and women (n=2793) aged >45 years diagnosed with hypertension and AF were selected using patient records. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox regression, with all-cause mortality as the outcome. Analysis was performed on the whole population and after stratification by age and sex. Independent factors were prescribed pharmacotherapies. Adjustments were made for a propensity score comprising age, comorbidities, education and marital status. The higher the number of antihypertensive drugs prescribed, the lower the mortality rate (P-value for trend 0.005). Individuals prescribed 4-5 antihypertensive drugs had a lower risk of mortality than those prescribed 0-1 drugs (HR: 0.62; 95% CI: 0.45-0.86). The HRs for the following drug classes were: loop diuretics 1.39 (95% CI: 1.08-1.78), non-selective β-blockers 0.68 (95% CI: 0.53-0.88), angiotensin receptor blockers 0.75 (95% CI: 0.56-0.99) and statins 0.68 (95% CI: 0.53-0.88). AF patients with hypertension prescribed statins, non-selective β-blockers and angiotensin receptor blockers had low relative mortality risks, suggesting that these prescribed pharmacotherapies were beneficial. This needs to be further explored in other clinical settings.Hypertension Research advance online publication, 6 March 2014; doi:10.1038/hr.2014.32