Cardiovascular risk associated with social determinants of health at individual and area levels
1. In this cohort study, individual and area level social determinants of health (SDOH) were associated with an increased risk in atherosclerotic cardiovascular disease (ASCVD) events.
Evidence Rating Level: 1 (Excellent)
Social determinants of health (SDOH) are several conditions that affect people’s health, functioning, and quality of life. Cardiovascular health is often affected by an individual’s SDOH along with the area’s SDOH. Atherosclerotic cardiovascular disease (ASCVD) has previously been studied and found to have an association with both individual and area level socioeconomic status. However, the quantitative risk associated with poor SDOH is poorly characterized. In this cohort study, participants were excluded if they had a history of ASCVD at baseline (6841 individuals), missing SDOH (8453 individuals), missing covariates included in the pooled cohort equations (PCEs) (1472 individuals), or missing ASCVD follow-up incidents (297 individuals). Many of the patient characteristics such as employment status (unemployed, not employed including those who were retired), race and ethnicity (Chinese American, Hispanic, non-Hispanic Black, non-Hispanic White), education level (less than high school, high school, or higher education), and income (less than $35 000, $35 000 or higher), were self-reported by the participants. To understand the effects of SDOH on ASCVD, the time to first ASCVD event was measured as the main outcome. Cox proportional hazard models were used to understand the association between every SDOH and incident ASCVD event. Included in the final study were 26 316 participants (mean [SD] age at baseline, 61.0 [9.1] years). Of the participants, there was at least 1 adverse individual-level SDOH in 11 764 participants (44.7%) and at least 1 in adverse area-level SDOH in 10 908 (41.5%) participants. At the individual level and the area level, SDOH was associated with a greater risk of ASCVD for education (individual: hazard ratio [HR], 1.39 [95% CI, 1.25-1.55]; area: HR, 1.31 [95% CI, 1.20-1.42]) low income (individual: 1.35 [95% CI, 1.25-1.47]; area: HR, 1.28 [95% CI, 1.17-1.40]) and unemployment (individual: HR, 1.61 [95% CI, 1.24-2.10]; area: HR, 1.25 [95% CI, 1.14-137]). Overall, both individual and area level SDOH were associated with a higher risk of ASCVD events. Additionally, adding individual and area SDOH to the PCEs improved discrimination slightly while also improving calibration for estimating ASCVD risk in Black people.
Access to mental health and substance use treatment in comprehensive primary care plus
1. In a cohort of individuals, those diagnosed with an opioid use disorder (OUD), anxiety, or depression that were associated with a Comprehensive Primary Care Plus (CPC+) practice had increased utilization of mental health services and substance use treatment.
2. Although CPC+ practices had higher utilization, the costs were not significantly different from non-CPC+ practices.
Evidence Rating Level: 2 (Good)
Many individuals have been negatively affected by the COVID-19 pandemic, both those affected by the disease and the decline in mental health experienced secondary to lockdowns. Along with this increased struggle, there was a shortage of mental health professionals in the United States leading to more unmet therapy needs. The Comprehensive Primary Care Plus (CPC+), an advanced primary care model with behavioural integration, was used to improve the quality, access, and efficiency of primary care. To test the CPC+ model, 469 practices and a total of 102 733 patients (mean [SD] age, 49.5 [5.6] years, 57 531 women [56.4%] and 45 202 men [43.6%]) were placed into the 152 CPC+ practices, while 86 037 patients (mean [SD] age, 51.6 [6.6] years; 47 321 women [54.9%] and 38 716 men [45.1%] were attributed to 317 non-CPC+ practices. The CPC+ practices were greater in number overall while diagnosing fewer patients with chronic conditions. In patients diagnosed with an opioid use disorder (OUD), belonging to a CPC+ practice was associated with more prescriptions filled for buprenorphine (0.177 [95% CI, 0.037 to 0.196] prescriptions per patient per quarter) and anxiolytics (0.162 [95% CI, 0.005 to 0.319] prescriptions per patient per quarter). Similarly, in individuals diagnosed with anxiety or depression, those associated with a CPC+ clinic were associated with more prescriptions for buprenorphine (0.024 [95% CI, 0.006 to 0.041] prescriptions per patient per quarter). Although there were differences between health care usage in the CPC+ versus non-CPC+ clinics, there was no cost difference for patients between the practices. Overall, individuals diagnosed with an OUD that were associated with a CPC+ clinic filled more prescriptions for anxiolytics and buprenorphine compared to those at non-CPC+ clinics.
1. In a cohort study in South Korea, prenatal opioid use did not significantly increase the risk of neuropsychiatric disorders in infants.
2. The risk of a neuropsychiatric disorder was increased by long-term opioid use, greater doses, and use during the first trimester.
Evidence Rating Level: 2 (Good)
Prenatal opioid exposure is generally contraindicated in pregnancy, though chronic pain and addiction can still lead to exposure. Currently, the association between opioid exposure and subsequent neuropsychiatric disorders in infants is poorly characterized. To assess this, a nationwide cohort study was conducted using 98% of the South Korean population. To ensure confidentiality, all patient data was anonymized where possible. The participants included 3 251 594 children who were paired with 2 369 322 mothers according to their unique identification numbers. Mothers who received two or more opioid prescriptions each trimester were defined as having opioid exposure for the study classification. The extent of opioid use had three categories. The first was based on pregnancy trimester (first, second, third trimester, more than 1 trimester). The second based on total opioid intake which was calculated using morphine milligram equivalents. The third was classified based on number of opioid prescriptions received (0-1, 2, or ≥3) and exposure time (<30, 30-59, or ≥ 60 days) of opioids throughout their pregnancy. To understand the effects of opioid use on infants of prenatal use, the onset of neuropsychiatric disorders in children was studied as the primary outcome. Of the participants, 93.1% (n=2 912 559) of infants had no associated with prenatal opioid exposure (51.3% male, 48.7% female) while 6.9% (n=216 012) of infants were associated with prenatal opioid exposure (51.2% male, 48.8% female). Opioid exposure during pregnancy was associated with a greater risk of neuropsychiatric disorders in infants (fully adjusted hazard ratio 1.07 (95% CI 1.05 to 1.10). Specifically, opioid exposure in the first trimester was related to a higher risk of neuropsychiatric disorders in infants compared to infants in the non-exposed group (1.11 (1.07 to 1.15)). Interestingly, neuropsychiatric disorder risk increased in a dose-dependent manner (low dose 1.06 (1.03 to 1.09); high dose, 1.15 (1.09 to 1.21)). Overall, prenatal opioid use was not associated with a substantial increased risk of neuropsychiatric disorders in opioid-exposed infants. Even though there was a slightly higher risk of developing a neuropsychiatric disorder, these results were observational and thus not clinically significant. Opioid exposure during the first trimester, higher exposure doses, and long-term use were associated with a greater risk of neuropsychiatric disorders.
1. Compared with using only using a GLP-1 receptor agonist or an SGLT-2 inhibitor, combination therapy with both drug classes was associated with a reduced risk of major adverse cardiac events (MACEs) and serious renal events.
2. The risk of serious renal events occurring was lower among those treated with GLP-1 receptor agonist-SGLT-2 inhibitor combination therapy.
Evidence Rating Level: 2 (Good)
Individually, Glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotranspotor-2 (SGLT-2) inhibitors have had useful effects at decreasing the risk of cardiorenal events and mortality occurring in patients with type II diabetes. However, the combined effects have not been thoroughly understood. To further study the combined effects of the drugs, a population-based cohort study was conducted using the UK Clinical Practice Research Datalink (DPRD) GOLD along with other databases. The combination drugs were compared with either drug class alone or with other antihyperglycemic drugs through the use of a prevalent new-user design, which is able to mirror a randomized controlled trial. Two cohorts were created. The first cohort compared individuals previously using a GLP-1 receptor agonist and then adding on an AGLT-2 inhibitor to individuals with continued use of a GLP-1 receptor agonist. The other cohort compared patients with previous use of an SGLT-2 inhibitor and added a GLP-1 receptor agonist to patients with continued use of an SGLT-2 inhibitor. For the primary outcomes, cardiorenal events were split into cardiovascular events (including myocardial infarction, ischemic stroke, and cardiovascular mortality) and renal events (including chronic renal disease, unspecified kidney failure, and diabetes renal complications). Compared with only using a GLP-1 receptor agonist, combining a GLP-1 receptor agonist with an SGLT-2 inhibitor as a treatment was associated with a 30% lower risk of major adverse cardiovascular events (MACE) (7.0 v 10.3 per 1000 person years; hazard ratio 0.70, 95% confidence interval 0.49 to 0.99) and a 57% lower risk of serious renal events (2.0 v 4.6 events per 1000 person-years; hazard ratio 0.43, 0.23 to 0.80). After one year, the number needed to treat to prevent one MACE was 378 while after three years it was 131. Compared with solely using an SGLT-2 inhibitor, the combined use of GLP-1 receptor agonist-SGLT-2 inhibitor was associated with a 29% decreased risk of MACE (7.6 v 10.7 per 1000 person-years; hazard ratio 0.71, 0.52 to 0.98) and a wide confidence interval for serious renal events (1.4 v 2.0 events per 1000 person years; hazard ratio 0.67, 0.32 to 1.41). The number needed to treat one adverse cardiovascular event decreased from 221 after one year to 86 after three years. In all, using a GLP-1 receptor agonist combined with an SGLT-2 inhibitor was associated with decreased risk of major cardiovascular and renal events compared with using each drug alone in type II diabetic patients.
1. A randomized control trial found LMWH bridging therapy did not increase the outcome of perioperative acute MI, cardiac death, stroke, or major bleeding in elderly individuals that underwent surgery > 12 months after PCI compared to the non-bridging group.
Evidence Rating Level: 1 (Excellent)
Many patients with coronary stents on antiplatelet drugs do not need invasive treatments, and it is key to examine their perioperative management. To understand the efficacy and safety of low molecular weight heparin (LMWH) bridging therapy for antiplatelet drug discontinuation, a randomized controlled trial recruited 2490 patients (of which 14 did not participate) from the Chinese PLA General Hospital. The patients were randomized in a 1:1 ratio to either receive LMWH bridging therapy with dalteparin sodium (2500 IU administered subcutaneously twice daily) or no bridging therapy (a matching subcutaneous placebo). The LMWH was paused during the surgery period, with the last dose given 24 hours before surgery and resuming LMWH 24 hours after surgery for those with low-to-moderate bleeding risk, and 48-72 hours later for those with a high bleeding risk. The LMWH bridging therapy group was assigned 1242 patients, while the placebo group was assigned 1234 patients. Aspirin was used to treat 1975 (79.77%) of patients, while clopidogrel was used to treat 386 (15.59%) patients. A significantly higher proportion of patients in the placebo (non-bridging) group were treated for two-vessel disease (46.76% vs. 41.94%, p = 0.016), while a lower proportion of patients were treated for a single-vessel disease (39.14% vs. 45.00%, p = 0.003). No significant difference was observed between the type of stent used in the two groups (p = 0.471). The experimental group had a lower rate of the combined endpoint when compared to the placebo group (5.79% vs. 8.42%, p = 0.012) and a lower rate of MI incidence (3.14% vs. 5.19%, p = 0.011) during the thirty-day follow-up period. The non-bridging group had a higher frequency of deep vein thrombosis compared to the bridging group (1.21% vs. 0.4%, p = 0.024) and a trend showed that there were more pulmonary embolisms in the non-bridging group comparatively (0.32% vs. 0.08%, p = 0.177). Independent predictors of ischemic events included LMWH bridging, creatinine clearance <30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus. While independent predictors of minor bleeding events included LMWH bridging, and a preoperative platelet count of < 70 x 109 /L. Overall, perioperative LMWH bridging was safe and efficacious for elderly patients who received coronary stents > 12 months prior undergoing non-cardiac surgery.
Image: PD
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