Limited evidence exists regarding the benefits and hazards of intensive lipid-lowering therapy among patients 75 years or older. In a prespecified secondary analysis of the IMPROVE-IT trial, Bach and coauthors investigated outcomes after acute coronary syndrome in 18 144 patients stratified by age. During a median follow-up of 6 years, treatment with a combination of simvastatin and ezetimibe resulted in lower rates of major cardiovascular events than treatment with simvastatin and placebo, with the greatest absolute risk reduction of 8.7% for patients 75 years or older. Rates of adverse events did not differ between those receiving simvastatin and ezetimibe vs simvastatin and placebo among younger or older patients. In an Invited Commentary, Gotto notes that these data address an important evidence gap regarding efficacy and safety of more intensive lipid lowering in elderly patients.
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National variation in high-intensity statin therapy after myocardial infarction (MI) has not been extensively studied. Bittner and coauthors studied 139 643 Medicare beneficiaries with a statin prescription claim within 30 days of discharge for a hospitalization for MI from January 2011 through June 2015. High-intensity statin use increased from 23.4% in 2011 to 55.6% in 2015, but treatment gaps persisted across 9 US regions, with highest use in New England (74.6%) and lowest use in the West South Central region (44.3%). Hospital factors associated with high-intensity statins included not-for-profit status, bed size, and academic affiliation; patient factors included age of 75 years or older, male sex, and stent implantation.
Whether ideal cardiovascular health metrics reduce risk of cardiovascular events among patients with prediabetes is unclear. Wang and coauthors evaluated outcomes of participants in the prospective China Cardiometabolic Disease and Cancer Cohort Study free from cardiovascular disease at baseline. Among 61 024 participants with prediabetes, compared with 24 881 with normal glucose regulation, the adjusted hazard ratio for incident cardiovascular events was higher for participants who had 1 ideal cardiovascular health metric or less but lower for those with at least 5 ideal cardiovascular health metrics. These associations were more prominent for individuals younger than 55 years old. These findings, Smith emphasizes in an Invited Commentary, make a compelling argument for a global focus on promoting ideal lifestyle behaviors.
There are insufficient data for risk stratification during hospitalization for Takotsubo syndrome. Santoro and coauthors developed an admission risk score in 1007 consecutive patients in the German and Italian Stress Cardiomyopathy (GEIST) registry and externally validated the risk score in 946 patients in the Spanish Registry for Takotsubo Cardiomyopathy (RETAKO). A score based on 4 variables (male sex, history of neurologic disorder, right ventricular involvement, and left ventricular ejection fraction) was developed using stepwise multivariable regression analysis. Score accuracy on area under the receiver operating characteristic curve analysis in predicting in-hospital complications was 0.71 in the GEIST cohort and 0.73 in the RETAKO cohort.