Acute kidney injury, renal impairment and renal failure associated with sodium glucose co-transporter-2 inhibitors in at-risk groups: A systematic review.

Randomized controlled trials (RCTs) show a reduction in acute kidney injury, renal impairment and acute renal failure after initiation of a sodium glucose cotransporter-2 inhibitor. Observational literature on the association is conflicting, but important to understand for populations with a higher risk of medication-related adverse renal events. We aimed to systematically review the literature to summarize the association between sodium glucose cotransporter-2 inhibitor use and acute kidney injury, renal impairment and acute renal failure in three at-risk groups: older people aged >65 years, people with heart failure and people with reduced renal function. A systematic search of Embase (1974 until 23 February 2024) and PubMed (1946 until 23 February 2024) was performed. RCTs were included if they reported numbers of acute kidney injury or acute renal failure in people using sodium glucose cotransporter-2 inhibitors compared to other diabetic therapies. Studies needed to report results by level of renal function, heart failure status or age. Of 922 results, eight studies were included. The absolute risk of acute kidney injury or acute renal failure was higher in people >65 years compared to those <65 years, higher in people with heart failure (vs without) and higher in people with reduced kidney function (vs preserved kidney function), but insufficient evidence to determine if the relative effect of sodium glucose cotransporter-2 inhibitors on this risk was similar for each group. At-risk cohorts are associated with a higher incidence of acute kidney problems in users of sodium glucose cotransporter-2 inhibitors.

Use of secondary prevention medications in metropolitan and non-metropolitan areas: an analysis of 41 925 myocardial infarctions in Australia.

AIMS: People in remote areas may have more difficulty accessing healthcare following myocardial infarction (MI) than people in metropolitan areas. We determined whether remoteness was associated with initial and 12-month use of secondary prevention medications following MI in Victoria, Australia. METHODS AND RESULTS: We included all people alive at least 90 days after discharge following MI between July 2012 and June 2017 in Victoria, Australia (n = 41 925). We investigated dispensing of P2Y12 inhibitors (P2Y12i), statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs), and beta-blockers within 90 days after discharge. We estimated 12-month medication use using proportion of days covered (PDC). Remoteness was determined using the Accessibility/Remoteness Index of Australia (ARIA). Data were analysed using adjusted parametric regression models stratified by ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). There were 10 819 STEMI admissions and 31 106 NSTEMI admissions. Following adjustment across NSTEMI and STEMI, there were no medication classes dispensed in the 90-day post-discharge that differed in a clinically significant way from the least remote (ARIA = 0) to the most remote (ARIA = 4.8) areas. The largest difference for NSTEMI was ACEI/ARB, with 71% (95% confidence interval 70-72%) vs. 80% (76-83%). For STEMI, it was statins with 89% (88-90%) vs. 95% (91-97%). Predicted PDC for STEMI and NSTEMI was not clinically significant across remoteness, with the largest difference in NSTEMI being P2Y12i with 48% (47-50%) vs. 55% (51-59%), and in STEMI, it was ACEI/ARB with 68% (67-69%) vs. 76% (70-80%). CONCLUSION: Remoteness does not appear to be a clinically significant driver for medication use following MI. Possible differences in cardiovascular outcomes in metropolitan and non-metropolitan areas are not likely to be explained by access to secondary prevention medications.

We investigated how where a person lives may affect the use of medications required following a heart attack. Our research used dispensing information and hospital admission information for a population of 41 925 heart attack admissions. Our main findings were as follows: There were no clinically significant differences in initial dispensing or 12-month use of secondary prevention medications with respect to how remote a person may live in Victoria, Australia.Our research suggests that there is equal access to medications with respect to remoteness, and any differences in quality of life or life expectancy following a heart attack are unlikely to be driven by differences in access to medications.

No effect of remoteness on clinical outcomes following myocardial infarction: An analysis of 43,729 myocardial infarctions in Victoria, Australia.

BACKGROUND: Remoteness has been shown to predict poor clinical outcomes following myocardial infarction (MI). This study investigated 1-year clinical outcomes following MI by remoteness in Victoria, Australia. METHODS: We included all admissions for people discharged from hospital following MI between July 2012 and June 2017 (n = 43,729). Remoteness was determined using the Accessibility/Remoteness Index of Australia (ARIA). The relationship between remoteness and major adverse cardiovascular events (MACE) and all-cause mortality over 1-year was evaluated using adjusted Poisson regression, stratified by type STEMI and NSTEMI. RESULTS: For NSTEMI, adjusted rates of MACE were 77.5[95% confidence interval 65.1-92.1] for the most remote area versus 83.4[65.5-106.3] for the least remote area per 1000 person-years. For STEMI, rates of MACE were 28.5[18.3-44.6] for the most versus 33.5[18.9-59.4] for the least remote areas per 1000 person-years. With respect to all-cause mortality, NSTEMI mortality rates were 82.2[67.0-100.9] for the most versus 100.8[75.2-135.1] for the least remote areas per 1000 person-years. For STEMI, mortality rates were 24.7[13.7-44.7] for the most versus 22.3[9.8-50.8] for the least remote per 1000 person-years. CONCLUSIONS: Rates of MACE and all-cause mortality were similar in regardless of degree of remoteness, suggesting that initiatives to increase access to cardiology care in more remote areas succeeded in reducing previous disparities.

Optimising adherence to secondary prevention medications following acute coronary syndrome utilising telehealth cardiology pharmacist clinics: a matched cohort study.

BACKGROUND: Adherence to secondary prevention medications following acute coronary syndromes (ACS) is a predictor of future major adverse cardiovascular events. Underutilisation of these medications is associated with higher risk of major adverse cardiovascular events globally. AIM: To explore the effects of a telehealth cardiology pharmacist clinic on patient adherence to secondary prevention medications in the 12 months following ACS. METHOD: Retrospective matched cohort study within a large regional health service comparing patient populations before and after implementation of pharmacist clinic with 12-month follow up. Patients who received percutaneous coronary intervention for ACS were consulted by the pharmacist at 1, 3- and 12-months. Matching criteria included age, sex, presence of left ventricular dysfunction and ACS type. Primary outcome was difference in adherence in adherence at 12 months post ACS. Secondary outcomes included major adverse cardiovascular events at 12 months and validation of self-reported adherence using medication possession ratios from pharmacy dispensing records. RESULTS: There were 156 patients in this study (78 matched pairs). Analysis of adherence at 12 months demonstrated an absolute increase in adherence by 13% (31 vs. 44%, p = 0.038). Furthermore, sub-optimal medical therapy (less than 3 ACS medication groups at 12 months) reduced by 23% (31 vs. 8%, p = 0.004). CONCLUSION: This novel intervention significantly improved adherence to secondary prevention medications at 12 months, a demonstrated contributor to clinical outcomes. Primary and secondary outcomes in the intervention group were both statistically significant. Pharmacist-led follow up improves adherence and patient outcomes.

Did Australia's COVID-19 Restrictions Impact Statin Incidence, Prevalence or Adherence?

COVID-19 restrictions may have an unintended consequence of limiting access to cardiovascular care. Australia implemented adaptive interventions (eg, telehealth consultations, digital image prescriptions, continued dispensing, medication delivery) to maintain medication access. This study investigated whether COVID-19 restrictions in different jurisdictions coincided with changes in statin incidence, prevalence and adherence. Analysis of a 10% random sample of national medication claims data from January 2018 to December 2020 was conducted across 3 Australian jurisdictions. Weekly incidence and prevalence were estimated by dividing the number statin initiations and any statin dispensing by the Australian population aged 18-99 years. Statin adherence was analyzed across the jurisdictions and years, with adherence categorized as <40%, 40%-79% and ≥80% based on dispensing per calendar year. Overall, 309,123, 315,703 and 324,906 people were dispensed and 39,029, 39,816, and 44,979 initiated statins in 2018, 2019, and 2020 respectively. Two waves of COVID-19 restrictions in 2020 coincided with no meaningful change in statin incidence or prevalence per week when compared to 2018 and 2019. Incidence increased 0.3% from 23.7 to 26.2 per 1000 people across jurisdictions in 2020 compared to 2019. Prevalence increased 0.14% from 158.5 to 159.9 per 1000 people across jurisdictions in 2020 compared to 2019. The proportion of adults with ≥80% adherence increased by 3.3% in Victoria, 1.4% in NSW and 1.8% in other states and territories between 2019 and 2020. COVID-19 restrictions did not coincide with meaningful changes in the incidence, prevalence or adherence to statins suggesting adaptive interventions succeeded in maintaining access to cardiovascular medications.

Clinical outcome measures in the assessment of impact of pharmacists in cardiology ambulatory care: A systematic review.

AIMS: Pharmacists are involved in the care of patients with cardiac disease within the ambulatory setting across multiple modes of delivery and practice settings. There is a lack of consensus surrounding the assessments used to measure the impact of pharmacist care. This heterogeneity may undermine confidence and limit utilisation of pharmacists in cardiology ambulatory care. A systematic review was conducted to understand how pharmacist interventions in cardiology ambulatory care were assessed and the impacts of these interventions on patient-centred outcomes. METHODS AND RESULTS: A comprehensive search was conducted of MEDLINE, CINAHL Plus, Cochrane Register of Randomised Controlled Trials and EMBASE from 2000 to 2020 with search terms involving pharmacist interventions among cardiology patients in the ambulatory care setting; with studies restricted to randomised controlled trials. Search results were independently screened by two reviewers. The Cochrane Risk of Bias in Randomised Trials tool was used for quality assessment of the included studies. Assessments of pharmacist impact were analysed and compared to established quality indicators of cardiology care. The search produced 3380 individual studies, following screening, 26 studies involving 9013 participants met inclusion criteria. Across the 26 included studies, eleven different intervention types were identified. Four main outcome measures assessing the impact of these interventions were identified: direct measure of cardiovascular disease risk factor, major adverse cardiovascular events, medication adherence, validated risk score for cardiovascular events. There was a high degree of variance in both the way these interventions influenced the outcome as well the outcome measures selected to assess the impact of the intervention. Of the 26 studies, sixteen listed positive impacts on primary outcomes and the remaining 10 listed neutral effects. CONCLUSION: Several outcome measures have been used to assess the impact of pharmacist intervention in cardiology ambulatory care. Aligning outcome measures with known indicators of cardiology care quality, as well as more detailed descriptions of intervention, will provide clinicians vital information in designing effective and measurable interventions in cardiology ambulatory care.

Towards OPtimising Care of Regionally-Based Cardiac Patients With a Telehealth Cardiology Pharmacist Clinic (TOPCare Cardiology).

INTRODUCTION: Cardiovascular disease is a major burden on the health of Australians, and cardiac health disparities exist for those who live outside of metropolitan areas. Poor patient medication literacy was identified by cardiologists at a regional Victorian health service as a barrier to medication optimisation and a factor in inefficiency in their service. Studies in Australia and overseas have shown pharmacists involved in multi-disciplinary and pre-admission models result in more accurate medication histories, increased patient medication knowledge and lower medication related adverse events. This study introduced a telehealth cardiology pharmacist clinic, with the primary aim of reducing cardiologist time gathering medication information and secondary aims of investigating the patient and cardiologist experience. METHODS: A cardiology pharmacist clinic was introduced where a pharmacist undertook a consultation with a patient in the days preceding their appointment with their cardiologist. The primary outcome of this study was to determine whether a cardiology pharmacist consultation undertaken prior to a cardiologist consultation reduces the time spent by the cardiologist gathering medication information. This was measured via direct observation of cardiologist consultations with and without a prior cardiology pharmacist clinic consultation. Descriptive and inferential statistics were performed to assess differences in time spent gathering the patient's medication information by the cardiologist. The secondary outcomes included differences between: the total length of cardiologist consultations, the number of cardiologist appointments with a medication uncertainty, and attendance rates for cardiologist consultations with and without a prior cardiology pharmacist clinic consultation. Other secondary outcomes included a quantitative survey assessing patient satisfaction with the pharmacist consultation, satisfaction with telehealth, confidence in medication management. Finally, clinician perceptions of the value of the pharmacist consultation were explored via semi-structured interviews. RESULTS: The time spent gathering medication information immediately before, and during, the cardiologist appointment reduced from 4.66 minutes without a prior cardiology pharmacist clinic consultation to 0.66 minutes with a prior cardiology pharmacist clinic consultation (difference 4 min, 95% CI: 3.27-4.77 p≤001). There was a 4.1-minute reduction in the mean consultation length of the cardiologist appointment if a cardiology pharmacist clinic consultation occurred prior (95% CI: 1.9-6.3, p<0.001). There were zero medication uncertainties (0/44) in the cardiologist appointment when the patient had a cardiology pharmacist clinic consultation compared to 51% (22/43) when no cardiology pharmacist clinic consultation had occurred. Patients with a cardiology pharmacist clinic consultation had a 5% (17/340) 'did not attend' (DNA) rate for their next cardiologist appointment. Patients who did not have a cardiology pharmacist clinic consultation had a 24% (202/855) DNA rate to their next cardiologist appointment. There was 100% patient satisfaction with the consultation provided by the cardiology pharmacist (100/100) and telehealth was considered an acceptable mode of delivery by 99% (95/96) of patients. Patients expressed an increase in their confidence to discuss their medications with their cardiologist (84% [81/96]). Benefits described by the clinicians whose patients received the service were greater confidence and ability to make treatment decisions within consultations, as well as improved patient health literacy. CONCLUSION: A cardiology pharmacist consultation undertaken prior to a cardiologist consultation reduced the time spent by the cardiologist gathering medication information. Importantly, it reduced medication uncertainty in cardiologist consultations which clinicians indicated provided them with greater confidence and ability to make treatment decisions within consultations. Patients who undertook a cardiology pharmacist clinic consultation were more likely to attend their cardiologist consultation, reducing wasted appointments. Patients were highly satisfied with the cardiology pharmacist consultation and considered telehealth an acceptable mode of delivery.