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Title: Cardiovascular Events: Prevention and Management

Citation Type: Dissertation/Thesis

Publication Year: 2022

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Abstract: This dissertation was a compilation of three, distinct studies assessing effects of various exposures on ultimate cardiovascular outcomes. In Aim 1, we assessed the relative and absolute risk of statin-associated muscle symptoms (SAMS) by exposure to statins of varying intensity (none, moderate, or high) in RCTs with at least 1,000 enrolled patients with planned follow-up of at least 2 years (n=152,461 patients in 24 RCTs). Risk was significantly greater for high compared with moderate intensity statin therapy for any muscle problem (RR=1.04, 95% CI 1.00 to 1.07; I2=0%), myalgia (RR=1.04, 95% CI 1.00 to 1.08; I2=0%, number needed to harm (NNH)=173), attrition due to muscle problems (RR=1.37, 95% CI 1.09 to 1.73, I2=0%, NNH=218) and elevated CK (RR=4.69, 95% CI 2.50 to 8.80; I2=7%, NNH=527). Risk also was significantly higher for high intensity compared with placebo for any muscle problem (RR=1.05, 95% CI 1.01 to 1.09, I2=0%), myalgia (RR=1.13, 95% CI 1.05 to 1.23; I2=0%, NNH=182), attrition due to muscle problems (RR=1.55, 95% CI 1.15 to 2.08, I2=0%, NNH=187) and elevated CK (RR=5.37, 95% CI 2.48 to 11.61; I2=7%, NNH=589). Due to inconsistency of results across sensitivity analyses, estimates were inconclusive for rhabdomyolysis and CK. There were no significant differences in risk between moderate intensity therapy and placebo for all outcomes. In Aim 2, we assessed odds of VTE in a case-control study of women, free of VTE disease at baseline, aged 50-65 who had at least one year of continuous enrollment in the Optum database. Women were assessed for most recent exposure to hormone therapy (HT) – estrogen, progestogen, none, or both – and statin therapy (moderate intensity, high intensity, or none) after adjusting for confounders. Cases were matched, 1:10, by age +/- 2 years and index date of event (+/- 1 month). There were 20,359 cases matched 1:10 to 203,590 controls in the selected sample. Exposure to HT was defined as any prescription in the 60 days prior to index date after review of the literature and homogeneity estimates across exposure groups. Using the same methods, exposure to statins was defined as three or more prescriptions for statins in the last 90 days prior to index date. Odds of VTE were significantly higher for women taking any HT (OR=1.51, 95% CI: 1.43, 1.60) but lower for those exposed to any statins (OR=0.88, 95% CI: 0.84, 0.93). The effect of statin exposure increased in magnitude for those exposed to high intensity statins (OR=0.82, 95% CI: 0.74, 0.90; referent is no exposure) versus moderate intensity statins (OR=0.90, 95% CI: 0.86, 0.95). In Aim 3, we assessed feasibility and possible effectiveness of a novel disease management program implemented at the St. Vincent’s Free Clinic in Galveston. Post-hospitalization heart failure (HF) disease management represents an important area of focus in preventing morbidity, mortality, and excess healthcare costs. Uninsured patients were offered enrollment in the disease management clinic during or immediately following hospitalization for a primary HF diagnosis at University of Texas Medical Branch at Galveston from January 2021 - December 2021. The program included twice-weekly visits with multiple healthcare professionals, including nurses, physicians, occupational therapists, social workers, pharmacists, and counselors. Patients were scheduled for 16 visits (2 months of follow-up) post-hospitalization before returning to usual care. Patients who attended at least the introductory appointment and one follow-upappointment within 30 days of discharge were considered enrolled. Of 59 patients referred, 47 (80%) were enrolled. Just 4 patients (8.5%, 95% CI: 2.5%, 20.5%) were readmitted at 30 days, while 4 of 12 (33%, 95% CI: 13.6%, 61.2%) were readmitted at 30 days in those who did not enroll. Program participants were readmitted significantly less frequently than national readmission rate estimates (23%, p=0.02). Thus, each Aim represents a novel exploration of various interventions and associations with important, clinical outcomes. The methods and findings in this dissertation are foundational to my future career as a physician-scientist.

Url: https://utmb-ir.tdl.org/server/api/core/bitstreams/299b6f11-b5d0-42ba-a3ed-673d0eb2ff92/content

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Authors: Davis, John

Institution: University of Texas Medical Branch

Department: Medicine

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Pages: 1-275

Data Collections: IPUMS Health Surveys - MEPS

Topics: Health, Population Health and Health Systems

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