Cardiovascular Risk Factor Control and Lifestyle Factors in Young to Middle-Aged Adults with Newly Diagnosed Obstructive Coronary Artery Disease

© 2019 S. Karger AG, Basel. Background: While progress in the prevention of cardiovascular disease (CVD) has been noted over the past several decades, there are still those who develop CVD earlier in life than others. Objective: We investigated traditional and lifestyle CVD risk factors in young to middle-aged patients compared to older ones with obstructive coronary artery disease (CAD). Methods: A retrospective analysis of patients with a new diagnosis of obstructive CAD undergoing coronary intervention was performed. Young to middle-aged patients were defined as those in the youngest quartile (n = 281, mean age 50 ± 6 years, 81% male) compared to the other three older quartiles combined (n = 799, mean age 69 ± 7.5 years, 71% male). Obstructive CAD was determined by angiography. Results: Young to middle-aged patients compared to older ones were more likely to be male (p \u3c 0.01), smokers (21 vs. 9%, p \u3c 0.001), and have a higher body mass index (31 ± 6 vs. 29 ± 6 kg/m2, p \u3c 0.001). Younger patients were less likely to eat fruits, vegetables, and fish and had fewer controlled CVD risk factors (2.7 ± 1.2 vs. 3.0 ± 1.0, p \u3c 0.001). Compared to older patients, higher levels of psychological stress (aOR 1.6, 95% CI 1.1-2.4), financial stress (aOR 1.8, 95% CI 1.3-2.5), and low functional capacity (aOR 3.3, 95% CI 2.4-4.5) were noted in the young to middle-aged population as well. Conclusion: Lifestyle in addition to traditional CVD risk factors should be taken into account when evaluating risk for development of CVD in a younger population

Statin utilization and cardiovascular outcomes in a real-world primary prevention cohort of older adults

Background: Statins are a cost-effective therapy for prevention of atherosclerotic cardiovascular disease (ASCVD). Guidelines on statins for primary prevention are unclear for older adults (\u3e75 years).Objective: Investigate statin utility in older adults without ASCVD events, by risk stratifying in a large healthcare network.Methods: We included 8,114 older adults, without CAD, PVD or ischemic stroke. Statin utilization based on ACC/AHA 10-year ASCVD risk calculation, was evaluated in intermediate (7.5%-19.9%) and high-risk patients (≥ 20%); and categorized using low and \u27moderate or high\u27 intensity statins with a follow up period of ∼7 years. Cox regression models were used to calculate hazard ratios for incident ASCVD and mortality across risk categories stratified by statin utilization. Data was adjusted for competing risk using Elixhauser Comorbidity Index.Results: Compared with those on moderate or high intensity statins, high-risk older patients not on any statin had a significantly increased risk of MI [HR 1.51 (1.17-1.95); p\u3c0.01], stroke [HR 1.47 (1.14-1.90); p\u3c0.01] and all-cause mortality [HR 1.37 (1.19-1.58); p\u3c0.001] in models adjusted for Elixhauser Comorbidity Index. When comparing the no statin group versus the moderate or high intensity statin group in the intermediate risk cohort, although a trend for increased risk was seen, it did not meet statistical significance thresholds for MI, stroke or all-cause mortality.Conclusion: Lack of statin use was associated with increased cardiovascular events and mortality in high-risk older adults. Given the benefits appreciated, statin use may need to be strongly considered for primary ASCVD prevention among high-risk older adults. Future studies will assess the risk-benefit ratio of statin intervention in older adults

Leveraging clinical decision support tools to improve guideline-directed medical therapy in patients with atherosclerotic cardiovascular disease at hospital discharge

Background: Guidelines recommend moderate to high-intensity statins and antithrombotic agents in patients with atherosclerotic cardiovascular disease (ASCVD). However, guideline-directed medical therapy (GDMT) remains suboptimal. Methods: In this quality initiative, best practice alerts (BPA) in the electronic health record (EHR) were utilized to alert providers to prescribe to GDMT upon hospital discharge in ASCVD patients. Rates of GDMT were compared for 5 months pre- and post-BPA implementation. Multivariable regression was used to identify predictors of GDMT. Results: In 5985 pre- and 5568 post-BPA patients, the average age was 69.1 ± 12.8 years and 58.5% were male. There was a 4.0% increase in statin use from 67.3% to 71.3% and a 3.1% increase in antithrombotic use from 75.3% to 78.4% in the post-BPA cohort.  Conclusions: This simple EHR-based initiative was associated with a modest increase in ASCVD patients being discharged on GDMT. Leveraging clinical decision support tools provides an opportunity to influence provider behavior and improve care for ASCVD patients, and warrants further investigation

STRATEGIC THINKING: HOW SPECIAL FORCES OFFICERS CAN INFLUENCE SUCCESS

The Department of Defense has identified deficiencies with Professional Military Education (PME) as officer educational demands are not satisfactorily matching expected requirements within the strategic environment. Many senior military leaders and academics concur with the critiques of PME outlined in the 2018 National Defense Strategy, where former Secretary of Defense James Mattis asserted that the current “PME has stagnated … at the expense of lethality and ingenuity.” PME must evolve to match the demands of the strategic environment, which grows ever more complex, uncertain, ambiguous, and fluid. This evolution is even more significant for Army Special Forces (SF) field grade officers (FGO), who are tasked to provide unique solutions to unconventional problems. SF FGOs require skills commensurate to the tasks they are expected to perform in this strategic environment; they must be adaptive problem solvers. This thesis provides a basis of analysis for demonstration that strategic thinking is a timeless and proven skill that has enabled special operations officers to influence successful outcomes throughout modern military history. Furthermore, this research will show that a PME focused on decision-making, specifically developing SF FGO strategic thinking skills, will prepare them to influence successful outcomes and meet the nation’s strategic objectives now and in the future.http://archive.org/details/strategicthinkin1094564164Major, United States ArmyMajor, United States ArmyApproved for public release; distribution is unlimited

Strategic Thinking: How Special Forces Officers Can Influence Success

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