Drug prescription rates in secondary cardiovascular prevention in old age: Do vulnerability and severity of the history of cardiovascular disease matter?

<p><i>Objective</i>: To assess the influence vulnerability and severity of cardiovascular disease (CVD), on prescription rates of secondary cardiovascular preventive drugs in old age.</p> <p><i>Design:</i> Population-based observational study within the ISCOPE study. <i>Setting:</i> General practices in the Netherlands.</p> <p><i>Subjects</i>: A total of 1350 patients with a history of CVD (median age 81 years, 50% female).</p> <p><i>Main outcome measures.</i> One-year prescription rates of lipid-lowering drugs and antithrombotics were obtained from the electronic medical records of 46 general practitioners (GPs). Prescription of both drugs for ≥ 270 days per year was considered optimal. GPs made a judgement of vulnerability. Severity of CVD was expressed as major (myocardial infarction, stroke, or arterial surgery) versus minor (angina, transient ischaemic attack, or claudication).</p> <p><i>Results</i>: GPs considered 411 (30%) participants to be vulnerable and 619 (55%) participants had major CVD. Optimal treatment was prescribed to 680 (50%) participants, whereas 370 (27%) received an antithrombotic drug only, 53 (4%) a lipid-lowering drug only, and 247 (18%) received neither. Optimal treatment was lower in participants aged ≥ 85 years (OR 0.37 [95% CI 0.29–0.48]), in females (OR 0.63 [0.50–0.78]), in vulnerable persons (OR 0.79 [0.62–0.99]) and in participants with minor CVD (OR 0.65 [0.53–0.81]). Multivariate ORs remained similar whereas vulnerability lost its significance (OR 0.88 [0.69–1.1]).</p> <p><i>Conclusion</i>: In old age, GPs’ judgement of vulnerability is not independently associated with lower treatment rates of both lipid-lowering drugs and antithrombotics, whereas a history of minor CVD is. Individual proactive re-evaluation of preventive treatment in older (female) patients, especially those with a history of minor CVD, is recommended.Key points</p><p>Prescriptions of lipid-lowering drugs and antithrombotics in secondary cardiovascular prevention tend to decline with age.</p><p>In this study with median age 81 years, 50% of participants received optimal treatment with both lipid-lowering drugs and antithrombotics.</p><p>GPs’ judgement of vulnerability was not independently associated with optimal treatment.</p><p>A history of less severe cardiovascular disease was independently associated with lower prescription rates of lipid-lowering drugs and antithrombotics.</p><p>Proactive individual re-evaluation of cardiovascular preventive treatment in older (female) patients, especially patients with less severe cardiovascular disease, is recommended.</p><p></p> <p>Prescriptions of lipid-lowering drugs and antithrombotics in secondary cardiovascular prevention tend to decline with age.</p> <p>In this study with median age 81 years, 50% of participants received optimal treatment with both lipid-lowering drugs and antithrombotics.</p> <p>GPs’ judgement of vulnerability was not independently associated with optimal treatment.</p> <p>A history of less severe cardiovascular disease was independently associated with lower prescription rates of lipid-lowering drugs and antithrombotics.</p> <p>Proactive individual re-evaluation of cardiovascular preventive treatment in older (female) patients, especially patients with less severe cardiovascular disease, is recommended.</p

Univariate all-cause mortality risks for sex-dependent quartiles of laboratory results included in the laboratory profile (n = 562).

<p>Data represent hazard ratios and 95% confidence intervals, calculated with the univariate Cox-proportional hazard model.</p><p>Laboratory results are divided into sex-dependent quartiles.</p><p>25th, 50th and 75th percentile limits of laboratory results stratified for sex:</p><p>Hemoglobin: male 12.5–13.4–14.2 g/dL; female 12.0–12.8–13.6 g/dL.</p><p>High-density lipoprotein cholesterol: male 35.5–42.5–51.7 mg/dL; female: 41.7–52.1–61.8 mg/dL.</p><p>Alanine transaminase: male 11–15–20 U/L; female: 11–14–17 U/L.</p><p>Albumin: male: 4.0–4.2–4.4 g/dL; female: 4.0–4.2–4.4 g/dL.</p><p>Creatinin clearance: male: 39.4–47.2–53.9 ml/min; female: 36.8–43.4–50.8 ml/min.</p><p>C-reactive protein: male: 2–4–8 mg/L; female: 1–4–8 mg/L.</p><p>Homocysteine: male: 1.47–19.8–25.6 mg/L; female: 15.0–17.9–22.8 mg/L.</p>*<p>highest to lowest quartile.</p

All-cause and cause-specific absolute and relative mortality risk stratified for sex-dependent quartiles of the laboratory profile, IADL disability score and 6-meter gait speed.

<p>Abbreviations: CI, confidence interval; IADL, instrumental activities of daily living.</p><p>Gait speed and IADL disability were divided into sex-dependent quartiles.</p><p>25th, 50th and 75th percentile limits of laboratory measurements stratified for sex;</p><p>Gait speed: male 1.37–1.81–2.91 m/s; female 1.61–2.15–3.95 m/s.</p><p>IADL disability score: male 11–17–25 points; female 12–19–29 points.</p

Baseline characteristics of the study population at age 85 years stratified according to the number of abnormal laboratory results.

<p>Continuous data are presented as median (IQR); p for trend values were obtained by Jonckheere Terpstra tests.</p><p>Categorical data are presented as number (%); p for trend values were obtained by Linear by Linear tests.</p>*<p>cancer, myocardial infarction, stroke, dementia, diabetes, chronic obstructive pulmonary disease, Parkinson’s disease, hip fracture, arthritis.</p

Kaplan Meier cumulative mortality curves for all cause mortality according to the three models.

<p>(A) laboratory profile based on sex specific quartiles of the seven included laboratory values, (B) sex specific quartiles of gait speed and (C) sex specific quartiles of instrumental activities of daily living (IADL) at age 85 years. <b>A </b><b>- - -</b> no laboratory abnormalities n = 144, <b>-----</b>1 laboratory abnormality n = 165, <b>-----</b>2–4 laboratory abnormalities n = 216, <b>-----</b>5–7 laboratory abnormalities n = 37. <b>B - - -</b> 6-meter gait speed male 0.69 –1.37 m/s; female 0.89–1.61 m/s n = 139, <b>-----</b> 6-meter gait speed male 1.38–1.81 m/s; female 1.61–2.15 m/s n = 142, <b>-----</b> 6-meter gait speed male 1.81–2.81 m/s; female 2.16–3.95 n = 141, <b>-----</b>6-meter gait speed male 2.91–13.0 m/s; female 4.00–13.00 m/s n = 140. <b>C - - -</b> IADL-score male 9–11; female 9–12 n = 136, <b>-----</b> IADL-score male 12–16; female 13–18 n = 141, <b>-----</b> IADL-score male 17–24; female 19–28 n = 145, <b>-----</b> IADL-score male 25–36; female 29–36 n = 139.</p