Cardiovascular Risk Assessment and Follow-Up of Women After Hypertensive Disorders of Pregnancy:A Prospective Cohort Study.

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) comprise an independent, sex-specific risk factor for cardiovascular disease (CVD) in women. This study examined the utility of CVD risk models proposed in the 2016 Canadian Cardiovascular Society (CCS) lipid guidelines to identify women requiring further screening or lipid treatment following HDP. METHODS: Using data collected from the postpartum Maternal Health Clinic (MHC) at Kingston General Hospital in Kingston, Ontario and the Preeclampsia New Emerging Team (PE-NET) cohort study, the study investigators used the models recommended by the CCS guidelines and the cardiometabolic model of life expectancy in each cohort to estimate CVD risk in women after HDP. (Canadian Task Force Classification II-2). RESULTS: Using the 10-Year Modified Framingham Risk Score, all women were classified by the 2016 CCS Guidelines as low risk, requiring no follow-up. The 30-Year and Lifetime Risk Scores resulted in significant reclassification of women at risk in the PE-NET control and HDP groups (P < 0.001 and P < 0.0001, respectively); 49.2% of women with HDP were classified as high risk, requiring follow-up, compared with 14.3% of control subjects. Using the cardiometabolic model, median life expectancy was significantly lower and expected onset of CVD was earlier in the HDP group compared with the control group (P < 0.0001). CONCLUSION: The 2016 CCS lipid guidelines' risk classification recommendations significantly underestimated lifelong CVD risk in the HDP group compared with the control group. Women with HDP also had a significant decrease in cardiometabolic life expectancy and an earlier predicted age at onset of CVD. Early primary prevention in this at-risk population may improve CVD outcomes and reduce the future burden on the health care system.

Determinants and benefits of physical activity maintenance in hospital employees.

This study investigated whether the positive behavioral and anthropometric outcomes of a pedometer-based physical activity 8-week challenge were maintained 6 months after the end of the program. It further investigated the motivational profile of those who maintained their physical activity levels in the months following the end of the program and of those who did not. Hospital employees from a university-affiliated multisite health care center in Canada participated using a questionnaire. Of the 235 participants who completed the 8-week challenge, 157 questionnaires were returned 6 months later. Paired-samples t tests were conducted between the baseline and follow-up scores as well as between the postprogram and follow-up scores to detect significant differences between the measurement points. This study shows that the pedometer-based physical activity helped hospital employees maintain a high level of physical activity as well as maintain a healthy body mass index after 6 months. The results demonstrated that during maintenance the high physical activity group obtained higher scores for identified regulation and intrinsic regulation compared with the other groups. The results of the study revealed that identified and intrinsic regulations are important contributors to maintaining physical activity among hospital employees.

Outpatient Therapies for COVID-19: How Do We Choose?

BACKGROUND: Several outpatient coronavirus disease 2019 (COVID-19) therapies have reduced hospitalization in randomized controlled trials. The choice of therapy may depend on drug efficacy, toxicity, pricing, availability, and available infrastructure. To facilitate comparative decision-making, we evaluated the efficacy of each treatment in clinical trials and estimated the cost per hospitalization prevented. METHODS: Wherever possible, we obtained relative risk for hospitalization from published randomized controlled trials. Otherwise, we extracted data from press releases, conference abstracts, government submissions, or preprints. If there was >1 study, the results were meta-analyzed. Using relative risk, we estimated the number needed to treat (NNT), assuming a baseline hospitalization risk of 5%, and compared the cost per hospitalization prevented with the estimate for an average Medicare COVID-19 hospitalization ($21 752). Drug pricing was estimated from GoodRx, from government purchases, or manufacturer estimates. Administrative and societal costs were not included. Results will be updated online as new studies emerge and/or final numbers become available. RESULTS: At a 5% risk of hospitalization, the estimated NNT was 80 for fluvoxamine, 91 for colchicine, 72 for inhaled corticosteroids, 24 for nirmatrelvir/ritonavir, 50 for molnupiravir, 28 for remdesivir, 25 for sotrovimab, 29 for casirivimab/imdevimab, and 29 for bamlanivimab/etesevimab. For drug cost per hospitalization prevented, colchicine, fluvoxamine, inhaled corticosteroids, and nirmatrelvir/ritonavir were below the Medicare estimated hospitalization cost. CONCLUSIONS: Many countries are fortunate to have access to several effective outpatient therapies to prevent COVID-19 hospitalization. Given differences in efficacy, toxicity, cost, and administration complexity, this assessment serves as one means to frame treatment selection.

Gambling With Cardiovascular Disease Risk Models: How to Choose and How to Use.

Cardiovascular risk assessment has been shown to improve physicians' and patients' understanding of an individual's future risk of cardiovascular disease (CVD). It has also been shown to improve the management of cardiovascular risk factors including hypertension and dyslipidemia. Given the challenges of engaging patients to adhere to healthy lifestyle habits or take medications for hypertension and dyslipidemia, the primary role of CVD risk assessment should be to open a discussion about the patient's risk for CVD and associated conditions like adult-onset diabetes. Calculating a patient's long-term risk and estimating the benefits of lifestyle changes or risk factor management may then be used to support long-term patient adherence. However, risk assessment is only a first step and must be followed by evidence-based health-promotion strategies and risk factor medications that have been proven to work.

2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults.

The 2021 guidelines primary panel selected clinically relevant questions and produced updated recommendations, on the basis of important new findings that have emerged since the 2016 guidelines. In patients with clinical atherosclerosis, abdominal aortic aneurysm, most patients with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy continues to be recommended. We have introduced the concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with nonstatin agents, and have identified the secondary prevention patients who have been shown to derive the largest benefit from intensification of therapy with these agents. For all other patients, we emphasize risk assessment linked to lipid/lipoprotein evaluation to optimize clinical decision-making. Lipoprotein(a) measurement is now recommended once in a patient's lifetime, as part of initial lipid screening to assess cardiovascular risk. For any patient with triglycerides ˃ 1.5 mmol/L, either non-high-density lipoprotein cholesterol or apolipoprotein B are the preferred lipid parameter for screening, rather than low-density lipoprotein cholesterol. We provide updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision tool to aid the decision to initiate statin therapy. There are new recommendations on the preventative care of women with hypertensive disorders of pregnancy. Health behaviour modification, including regular exercise and a heart-healthy diet, remain the cornerstone of cardiovascular disease prevention. These guidelines are intended to provide a platform for meaningful conversation and shared-decision making between patient and care provider, so that individual decisions can be made for risk screening, assessment, and treatment.

Discussing coronary risk with patients to improve blood pressure treatment: secondary results from the CHECK-UP study.

OBJECTIVES: Hypertension is common among patients with dyslipidemia but is often poorly treated. The objective of this analysis was to evaluate how a decision aid, used by primary care physicians to improve lipid therapy, impacted on the treatment of hypertension. STUDY DESIGN: Data were analyzed from patients enrolled in a randomized trial focusing primarily on the treatment of dyslipidemia. Patients received usual care or a coronary risk profile every three months to monitor the risk reduction following lifestyle changes and/or pharmacotherapy to treat dyslipidemia. Hypertension management was assessed based on a post hoc analysis of individuals whose blood pressure exceeded current national hypertension guidelines. RESULTS: There were 2,631 subjects who completed the study. Among 1,352 patients without diagnosed hypertension, 30% were above target on at least three consecutive visits. Among 1,279 individuals with known hypertension, 69% were above target on at least two consecutive visits. Overall, patients receiving risk profiles were more likely to receive appropriate antihypertensive therapy (OR = 1.40, 95% CI 1.11-1.78) compared to those receiving usual care. After adjustment for inter-physician variability and potential confounders, the use of the risk profile was associated with an increased likelihood of starting therapy (OR = 1.78, 95% CI 1.06-3.00) or modifying therapy (OR = 1.40, 95% CI 1.03-1.91). CONCLUSIONS: In this clinical trial of dyslipidemia management, inadequately controlled hypertension was common, occurring in nearly 50% of individuals. Ongoing coronary risk assessment was associated with more appropriate blood pressure management. Cardiovascular risk assessment decision aids should be further evaluated in a randomized trial of hypertension therapy.

The Sustainability of a Workplace Wellness Program That Incorporates Gamification Principles: Participant Engagement and Health Benefits After 2 Years.

PURPOSE: To evaluate the results of a workplace wellness program that incorporates gamification principles. DESIGN: In this prospective cohort study, the participation rate and observed health outcomes were evaluated after approximately 2 years. SETTING AND PARTICIPANTS: All permanent employees (n = 775) of a national company located in Canada were eligible to participate. INTERVENTION: The wellness program included web-based challenges (team or individual) incorporating gamification strategies to improve exercise, nutrition, weight reduction, and mental health management behaviors. MEASURES AND ANALYSIS: The primary outcomes were employee participation rates. The secondary pre-specified outcomes were the sustained benefits of the program on physical and mental health measures. RESULTS: Participation rates in the health screenings were 78% (baseline), 54% (year 1), and 56% (year 2). Participation in the 4 team web-based challenges ranged from 33% to 68% with 76% to 86% of participants tracking their activity on at least half of the days. After 2 years, there were significant clinical improvements in systolic blood pressure (-1.3mm Hg), total cholesterol/high-density lipoprotein (HDL) ratio (-0.14), glycated haemoglobin (HbA1c; -0.1%), weekly physical activity (+264 Metabolic Equivalents [METs]), perceived stress score (-17%), insomnia severity index (-16%), general fatigue (-10%), and reductions in the cardiovascular age gap (-0.3 years). Greater benefits occurred among employees at higher risk. CONCLUSIONS: Workplace wellness programs that evolve over time and focus primarily on fun and competitive challenges may support long-term participation, behavior change, and sustained improvements in clinical outcomes.

Patient knowledge of coronary risk profile improves the effectiveness of dyslipidemia therapy: the CHECK-UP study: a randomized controlled trial.

BACKGROUND: Despite increasing evidence that treating dyslipidemia reduces cardiovascular events, many patients do not achieve recommended lipid targets. METHODS: To determine whether showing physicians and patients the patient's calculated coronary risk can improve the effectiveness of treating dyslipidemia in a primary care setting, patients were randomized to receive usual care or ongoing feedback regarding their calculated coronary risk and the change in this risk after lifestyle changes, pharmacotherapy, or both to treat dyslipidemia. Outcomes, based on intention-to-treat analysis, included changes in blood lipid levels, coronary risk, and the frequency of reaching lipid targets. RESULTS: Two hundred thirty primary care physicians enrolled 3,053 patients. After 12 months of follow-up, 2,687 patients (88.0%) remained in the study. After adjustment for baseline lipid values, significantly greater mean reductions in low-density lipoprotein cholesterol levels and the total cholesterol to high-density lipoprotein cholesterol ratio were observed in patients receiving risk profiles (51.2 mg/dL [to convert to millimoles per liter, multiply by 0.0259] and 1.5, respectively) vs usual care (48.0 mg/dL and 1.3, respectively), but the differences were small (-3.3 mg/dL; 95% confidence interval [CI], -5.4 to -1.1 mg/dL; and -0.1; 95% CI, -0.2 to -0.1, respectively). Patients in the risk profile group were also more likely to reach lipid targets (odds ratio, 1.26; 95% CI, 1.07 to 1.48). A significant dose-response effect was also noted when the impact of the risk profile was stronger in those with worse profiles. CONCLUSIONS: Discussing coronary risk with the patient is associated with a small but measurable improvement in the efficacy of lipid therapy. The value of incorporating risk assessment in preventive care should be further evaluated.

Evaluation of the cost-effectiveness of evolocumab in the FOURIER study: a Canadian analysis.

BACKGROUND: Evolocumab, a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor, has been shown to reduce low-density lipoprotein levels by up to 60%. Despite the absence of a reduction in overall or cardiovascular mortality in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk (FOURIER) trial, some believe that, with longer treatment, such a benefit might eventually be realized. Our aim was to estimate the potential mortality benefit over a patient's lifetime and the cost per year of life saved (YOLS) for an average Canadian with established coronary artery disease. We also sought to estimate the price threshold at which evolocumab might be considered cost-effective for secondary prevention in Canada. METHODS: We calibrated the Cardio-metabolic Model, a well-validated tool for predicting cardiovascular events and life expectancy, to the reduction in nonfatal events seen in the FOURIER trial. Assuming that long-term treatment will eventually result in mortality benefits, we estimated YOLSs and cost per YOLS with evolocumab treatment plus a statin compared to a statin alone. We then estimated the annual drug costs that would provide a 50% chance of being cost-effective at willingness-to-pay values of $50 000 and $100 000. RESULTS: In secondary prevention in patients similar to those in the FOURIER study, evolocumab treatment would save an average of 0.34 (95% confidence interval [CI] 0.27-0.41) life-years at a cost of $101 899 (95% CI $97 325-$106 473), yielding a cost per YOLS of $299 482. We estimate that to have a 50% probability of achieving a cost per YOLS below $50 000 and $100 000 would require annual drug costs below $1200 and $2300, respectively. INTERPRETATION: At current pricing, the use of evolocumab for secondary prevention is unlikely to be cost-effective in Canada.

The Measurable Benefits of a Workplace Wellness Program in Canada: Results After One Year.

OBJECTIVE: The aim of this study was to evaluate the impact of an employee wellness program in Canada. METHODS: A comprehensive program including web-based lifestyle challenges was evaluated with annual health screenings. RESULTS: Among 730 eligible employees, 688 (94%) registered for the program, 571 (78%) completed a health screening at baseline, and 314 (43%) at 1 year. Most (66%) employees tracked their activity for more than 6 weeks. At 1-year follow-up, there were significant clinical improvements in systolic blood pressure -3.4 mm Hg, and reductions in poor sleep quality (33% to 28%), high emotional stress (21% to 15%), and fatigue (11% to 6%). A positive dose-response was noted where the greatest improvements were observed among those who participated the most. CONCLUSION: The program had high employee engagement. After 1 year, the benefits included clinically important improvements in physical and mental health.

Estimating the cost effectiveness of ramipril used for specific clinical indications: comparing the outcomes in four clinical trials with a common economic model.

BACKGROUND AND OBJECTIVES: Economic analyses of drug therapies are highly dependent on the clinical indications for treatment. The cost effectiveness of ramipril has been evaluated in numerous studies, usually based on the results of one specific clinical trial. We estimated the cost effectiveness of this drug across a range of currently accepted therapeutic indications, using a single health economic model and adjusted for quality of life, to compare the different outcomes observed in four clinical trials. METHODS: The cardiovascular life expectancy model, a validated Markov model, was calibrated to accurately forecast the results of four trials including AIRE, HOPE, Micro-HOPE, and REIN. We then extrapolated these results over the remaining life expectancy of the patients enrolled in each study and adjusted for the quality of life associated with the observed outcomes. The cost per quality-adjusted life-year (QALY) was then calculated from the perspective of the Canadian healthcare system incorporating the estimated direct healthcare costs associated with treatments and outcomes. RESULTS: After discounting all costs and outcomes 3% annually, the benefits associated with ramipril ranged from 0.74 QALYs in the AIRE study to 1.22 QALYs in Micro-HOPE. Treatment was estimated to be cost-saving for some patient groups, such as those in REIN. The highest cost-effectiveness ratio was observed among individuals enrolled in HOPE ($Can20 000 per QALY in 2002). CONCLUSION: Treatment with ramipril appears to be economically attractive across a wide range of patient groups, including those with increased coronary risk and/or diabetes mellitus (HOPE and Micro-HOPE), those with congestive heart failure (AIRE), and those with non-diabetic nephropathy (REIN).

Preventing cardiovascular disease among Canadians: what are the potential benefits of treating hypertension or dyslipidemia?

BACKGROUND: Treatments for hypertension and dyslipidemia to prevent the development of cardiovascular disease compete for the same finite number of health care dollars. Therefore, the potential benefits of treating Canadians without cardiovascular disease or diabetes who would currently be targeted by the national treatment guidelines were estimated and compared. STUDY DESIGN: Canadian Heart Health Surveys data were used to estimate the number of Canadians requiring intervention. The Cardiovascular Life Expectancy Model, a previously validated Markov model, was used to calculate the increased life expectancy and decreased morbidity associated with treating risk factors to target. RESULTS: Among 8.44 million adults 40 to 74 years of age without cardiovascular disease or diabetes, it was estimated that approximately 2.33 million would require treatment for dyslipidemia and 2.34 million for hypertension. The estimated Framingham 10-year coronary risk averaged 12.4% versus 9.6%, respectively. Treating dyslipidemia was associated with an average increased life expectancy of 1.67 years and 1.81 years of life free of cardiovascular disease. Treating hypertension was expected to increase life expectancy by 0.94 years and years of life free of cardiovascular disease by 1.29 years. The population benefits associated with treating dyslipidemia or hypertension would be 2.5 million and 1.4 million person years of life saved, respectively. Overall, the person years of treatment required to save one year of life was estimated to average 20 years for dyslipidemia therapy and 38 years for hypertension. CONCLUSIONS: The potential benefits associated with treating hypertension or dyslipidemia to prevent cardiovascular disease are substantial. However, compared with hypertension guidelines, dyslipidemia guidelines target higher-risk patients. Accordingly, given the relative efficacy of each treatment, the forecasted benefits associated with treating dyslipidemia are substantially greater than those associated with hypertension therapy.

The prevalence of erectile dysfunction in the primary care setting: importance of risk factors for diabetes and vascular disease.

BACKGROUND: The prevalence of erectile dysfunction (ED) and associated risk factors has been described in many clinical settings, but there is little information regarding men seen by primary care physicians. We sought to identify independent factors associated with ED in a primary care setting. METHODS: We surveyed a cross-sectional sample of 3921 Canadian men, aged 40 to 88 years, seen by primary care physicians. Participants completed a full medical history, physical examination, and measurement of fasting blood glucose and lipid levels. We used the International Index of Erectile Function to define ED as a score of less than 26 on the erectile function domain. RESULTS: The overall prevalence of ED was 49.4%. The presence of cardiovascular disease (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.16-1.81; P<.01) or diabetes (OR, 3.13; 95% CI, 2.35-4.16; P<.001) increased the probability of ED after adjustment for other confounders. Among those individuals without cardiovascular disease or diabetes, the calculated 10-year Framingham coronary risk (OR, 1.03 per 1% increase; 95% CI, 1.02-1.05; P<.001) and fasting blood glucose levels (OR, 1.14 per 18-mg/dL [1-mmol/L] increase; 95% CI, 1.04-1.24; P<.01) were independently associated with ED. Erectile dysfunction was also independently associated with undiagnosed hyperglycemia (OR, 1.46; 95% CI, 1.02-2.10; P = .04), impaired fasting glucose (OR, 1.26; 95% CI, 1.08-1.46; P = .004), and the metabolic syndrome (OR, 1.45; 95% CI, 1.24-1.69; P<.001). CONCLUSIONS: Cardiovascular disease, diabetes, future coronary risk, and increasing fasting glucose levels are independently associated with ED. It remains to be determined if ED precedes the development of these conditions.

Impact of modified glucose target and exercise interventions on vascular risk factors.

Potent glucose-lowering medications other than metformin may impede weight loss in type 2 diabetes (T2D). Supervised exercise programs improve glycemic control without significantly enhancing weight loss; their impact on fitness and blood pressure in T2D remains unclear. In this pilot study, 42 type 2 diabetes patients were randomized to (i) liberalized (10 mmol/l) OR strict (7 mol/l) preprandial glucose thresholds for adjustment of medication other than metformin and (ii) dietary counseling with OR without supervised exercise (2 x 2 factorial design). Weight (-1.2% versus -0.3%, p=0.38) and hemoglobin A1C changes (-0.8% versus 0%, p=0.37) were similar for glucose threshold-defined groups. Dietary counseling with supervised exercise participants had greater improvement in mean arterial pressure than those not randomized to an exercise program (-3.3% versus 1.1%, p=0.02). Overall weight (-1.5% versus 0%, p=0.06) and fitness changes (5.4% versus 1.5%, p=0.18) were not significantly different between these groups, but weight (-1.6% versus 0%, p=0.03) and fitness changes (21.3% versus 1.5%, p=0.03) were significantly greater among those who attended >or=75% of exercise classes. Liberalizing preprandial thresholds neither enhances weight loss nor compromises hemoglobin A1C. T2D patients who consistently participate in supervised exercise programs may experience modest weight loss and significant improvements in fitness and blood pressure.

Impact of dyslipidemia associated with Highly Active Antiretroviral Therapy (HAART) on cardiovascular risk and life expectancy.

We investigated the effect of dyslipidemia associated with highly active antiretroviral therapy on cardiovascular risk and life expectancy among patients who had the human immunodeficiency virus. Dyslipidemia estimates were based on results from a phase 2 randomized trial that compared lipid changes after 32 weeks of therapy with atazanavir with those with nelfinavir (each in combination with stavudine and lamivudine). The resultant increased coronary risk was estimated using Framingham risk equations, and change in life expectancy (after adjustment for mortality due to human immunodeficiency virus) was based on the cardiovascular life expectancy model, which is based on a published Markov's model. Levels of total cholesterol and low-density lipoprotein cholesterol increased significantly more among patients who used nelfinavir (+24% and +28%) than among those who used atazanavir (+4% and +1%). This dyslipidemia increased the risk of coronary disease by 50% over 10 years. The absence of dyslipidemia was estimated to preserve life expectancy 0.15 to 1.53 additional years depending on a patient's age, gender, and other risk factors. There are increasing reports of dyslipidemia and cardiovascular events associated with highly active antiretroviral therapy. Significant increases in blood lipid levels observed with some protease inhibitors are associated with an increase in calculated 10-year coronary risk. Accordingly, minimizing dyslipidemia associated with highly active antiretroviral therapy may preserve life expectancy among adults who have the human immunodeficiency virus.

Cost-effectiveness of lipid-lowering treatment according to lipid level.

BACKGROUND: Recent studies suggest that the benefit of lipid-lowering treatment for the primary and secondary prevention of cardiovascular disease (CVD) extends to individuals with average cholesterol levels, to women and to the elderly. However, the proportion of the general population for which treatment is cost-effective has not been evaluated. OBJECTIVES AND METHODS: Using data provided by the Canadian Heart Health Survey, the level of CVD risk was estimated for a random sample of the total population. A cost-effectiveness ratio for simvastatin was then calculated for each individual in the sample. Lastly, the proportion of the total population for which lipid-lowering therapy would be cost-effective for primary and secondary prevention of CVD was estimated according to total cholesterol (TC) levels. RESULTS: Among the surveyed individuals who were 30 to 74 years of age, 2212 had CVD and 12,982 did not. Among those with a TC level higher than 6.2 mmol/L, the proportions of individuals for which lipid-lowering therapy was cost-effective (at a level of less than 50,000 dollars per year of life saved) were 85.6% of men and 28.7% of women for primary prevention, and 99.8% of men and 86.1% of women for secondary prevention. The estimated cost of one year of lipid-lowering treatment for all individuals in the population with a TC level higher than 6.2 mmol/L and for all individuals regardless of TC levels for whom treatment would be cost-effective was $1 billion and 3.9 billion dollars, respectively. CONCLUSIONS: Lipid-lowering treatment for CVD prevention is cost-effective for a high proportion of the population, even for primary prevention. As a result, the cost of population-wide treatment for only one year is high even among individuals with a TC level higher than 6.2 mmol/L. Such costs should be considered in health care policy decisions.

The importance of indirect costs in primary cardiovascular disease prevention: can we save lives and money with statins?

BACKGROUND: The losses in productivity due to cardiovascular disease (CVD) are substantial but rarely considered in health economic analyses. We compared the cost-effectiveness of lipid level modification in the primary prevention of CVD with and without these indirect costs. METHODS: We used the Cardiovascular Life Expectancy Model to estimate the long-term benefits and cost-effectiveness of lipid level modification with atorvastatin calcium, including 28% and 38% reductions in total cholesterol and low-density lipoprotein cholesterol levels, respectively, and a 5.5% increase in high-density lipoprotein cholesterol level. The direct costs included all medical care costs associated with CVD. The indirect costs represented the loss of employment income and the decreased value of housekeeping services after different manifestations of CVD. All costs were expressed in 2000 Canadian dollars. RESULTS: When only direct medical care costs were considered, the incremental cost-effectiveness ratios for lifelong therapy with atorvastatin calcium, 10 mg/d, were generally positive, ranging from a few thousand to nearly $20 000 per year of life saved. When the societal point of view was adopted and indirect costs were included, the total costs were generally negative, representing substantial cost savings (up to $50 000) and increased life expectancy for most groups of individuals. CONCLUSIONS: Lipid therapy with statins can reduce CVD morbidity and mortality as demonstrated in a number of clinical trials. Adding the indirect CVD costs associated with productivity losses at work and home can result in forecasted cost savings to society as a whole such that lipid therapy could potentially save lives and money.

Years of life lost and healthy life-years lost from diabetes and cardiovascular disease in overweight and obese people: a modelling study.

BACKGROUND: Despite the increased risk of cardiovascular disease and type 2 diabetes associated with excess bodyweight, development of a clinically meaningful metric for health professionals remains a challenge. We estimated the years of life lost and the life-years lost from diabetes and cardiovascular disease associated with excess bodyweight. METHODS: We developed a disease-simulation model to estimate the annual risk of diabetes, cardiovascular disease, and mortality for people with BMI of 25-<30 kg/m(2) (overweight), 30-<35 kg/m(2) (obese), or 35 kg/m(2) and higher (very obese), compared with an ideal BMI of 18·5-<25 kg/m(2). We used data from 3992 non-Hispanic white participants in the National Nutrition and Examination Survey (2003-10) for whom complete risk factor data and fasting glucose concentrations were available. After validation of the model projections, we estimated the years of life lost and healthy life-years lost associated with each bodyweight category. FINDINGS: Excess bodyweight was positively associated with risk factors for cardiovascular disease and type 2 diabetes. The effect of excess weight on years of life lost was greatest for young individuals and decreased with increasing age. The years of life lost for obese men ranged from 0·8 years (95% CI 0·2-1·4) in those aged 60-79 years to 5·9 years (4·4-7·4) in those aged 20-39 years, and years lost for very obese men ranged from 0·9 (0-1·8) years in those aged 60-79 years to 8·4 (7·0-9·8) years in those aged 20-39 years, but losses were smaller and sometimes negligible for men who were only overweight. Similar results were noted for women (eg, 6·1 years [4·6-7·6] lost for very obese women aged 20-39 years; 0·9 years [0·1-1·7] lost for very obese women aged 60-79 years). Healthy life-years lost were two to four times higher than total years of life lost for all age groups and bodyweight categories. INTERPRETATION: Our estimations for both healthy life-years and total years of life lost show the effect of excess bodyweight on cardiovascular disease and diabetes, and might provide a useful health measure for discussions between health professionals and their patients. FUNDING: Canadian Institutes of Health Research.

Evaluating the benefits of treating dyslipidemia: the importance of diabetes as a risk factor.

PURPOSE: Diabetes mellitus is associated with an increased risk of cardiovascular disease. We compared the clinical effects of treating dyslipidemia in patients who had diabetes mellitus but no diagnosed cardiovascular disease with the effects of similar treatment in patients who had cardiovascular disease but no diabetes mellitus. METHODS: We estimated the number of adults (ages 30 to 74 years) requiring lipid therapy using data from the third National Health and Nutrition Examination Survey and current lipid treatment guidelines. Using the Cardiovascular Life Expectancy Model, we estimated the mean increase in life expectancy that would result from lowering low-density lipoprotein cholesterol levels by 35% and increasing high-density lipoprotein cholesterol levels by 8% based on results from the Scandinavian Simvastatin Survival Study. RESULTS: The mean number of years of life saved ranged from 3 to 3.4 years for men with diabetes versus 2.4 to 2.7 years for men with cardiovascular disease. In women, the estimated benefits were 1.6 to 2.4 years for those with diabetes versus 1.6 to 2.1 years for those with cardiovascular disease. Total population benefits were also substantial for patients with diabetes (25.4 million person-years of life saved) and those with cardiovascular disease (16.0 million person-years of life saved). CONCLUSION: The clinical benefits of treating dyslipidemia in patients with diabetes should be at least equivalent to, if not more substantial than, the benefits observed among those with cardiovascular disease.

Development and preliminary testing of a patient decision aid to assist pharmaceutical care in the prevention of cardiovascular disease.

STUDY OBJECTIVE: To develop and test a decision aid for patients with hypertension and/or dyslipidemia because a decision aid may assist in pharmaceutical care by providing relevant evidence-based information. DESIGN: Before and after use of a decision aid. SETTING: Hypertension clinic of a university hospital and a specialized coronary heart disease-prevention clinic. PATIENTS: A convenience sample of 16 patients receiving pharmacologic treatment for hypertension and/or dyslipidemia. INTERVENTION: A face-to-face interview was conducted before using the decision aid. This was followed by a telephone interview after the patient used the decision aid to assess the acceptability of the decision aid to the patient, as well as the patient's knowledge, risk perception, and decisional conflict. MEASUREMENTS AND MAIN RESULTS: The decision aid consists of a booklet containing general, evidence-based information and a personal worksheet. The worksheet provides information on patient risk factors, personal estimates of cardiovascular disease (CVD) risk, the benefits of treatment options, and values clarification exercise. It invites patients to specify an action plan and follow their own progress over time. Most patients (86-93%) rated the presentation of the information as excellent or very good, 80% judged the information about lifestyle changes and drug therapy to be balanced, 93% rated the amount of information "just right," and 100% found the decision aid useful. After using the decision aid, patients had higher knowledge scores for general risk factors (before, 91%; after, 100%, p=0.014), personal risk factors (73%, 92%, p=0.016), and treatment options (68%, 99%, p<0.001). More patients were able to estimate correctly their CVD risk category (50%, 93%, p=0.03) and their absolute 10-year CVD risk (0%, 93%, p<0.001), whereas the overall decisional conflict score decreased (p=0.007). CONCLUSION: The decision aid was acceptable to patients and improved their knowledge, risk perception, and decisional conflict. Therefore, the feasibility and impact of using the decision aid in community pharmacies and medical clinics should be assessed.