Search

Background and Aims: Telehealth plays an integral part in healthcare delivery. The impact of telehealth and the COVID-19 pandemic on medication prescribing and patient satisfaction with telehealth in cardiology clinics remains unknown., Methods: A retrospective study of cardiology clinic patients at an Australian tertiary hospital was conducted; 630 patients seen before the COVID-19 pandemic (0.6% telehealth) and 678 during the pandemic (91.2% telehealth) were included. Medication changes, new prescriptions and time to obtaining prescriptions after clinic were compared. To evaluate patients' experiences, cardiology clinic patients reviewed during the pandemic were prospectively invited to participate in an electronic survey sent to their mobile phones., Results: The overall rates of medication changes made in the clinic between the prepandemic and the pandemic periods did not differ significantly (26.9% vs 25.8%). Compared with prepandemic, new cardiac medication prescriptions during clinic were significantly less (9.3% vs 2.5%; P < 0.0001) and recommendations to general practitioners (GP) to initiate cardiac medications were significantly more (2.6% vs 9.1%; P < 0.0001). Time to obtaining new prescriptions was significantly longer in the pandemic cohort (median 0 days (range: 0-32) vs 10.5 days (range: 0-231); P < 0.0001). Two hundred forty-three (32.7%) patients participated in the survey; 50% reported that telehealth was at least as good as face-to-face consultations. Most patients (61.5%) were satisfied with telehealth and most (62.9%) wished to see telehealth continued postpandemic., Conclusion: Telehealth during the COVID-19 pandemic was associated with greater reliance on GP to prescribe cardiac medications and delays in obtaining prescriptions among cardiology clinic patients. Although most patients were satisfied with telehealth services, nearly half of the cardiac patients expressed preference towards traditional face-to-face consultations., (© 2024 The Authors. Internal Medicine Journal published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Physicians.)

Objective: To describe changes in atherosclerotic cardiovascular disease (ASCVD) risk over time among people living with HIV (PLHIV)., Methods: We used data from the TREAT Asia HIV Observational Database (TAHOD) and the Australian HIV Observational Database (AHOD). Five-year ASCVD risk was calculated using the D:A:D equation. Individuals were eligible for inclusion if they were aged ≥18 years, had started ART, had no previous history of ASCVD and had complete ASCVD risk factor data available within the first 5 years of ART initiation., Results: A total of 3368 adults contributed data, 3221 were from TAHOD and 147 were from AHOD. The median age at ART initiation was 36 [IQR 31-43] years for TAHOD participants, and 42 [IQR 35-50] years for AHOD participants. Most TAHOD (70.4%) and AHOD (91.8%) participants were male. Overall, ASCVD risk increased from 0.84% (95% CI 0.81%-0.87%) at ART initiation to 1.34% (95% CI 1.29%-1.39%) after 5 years on ART. After adjusting for traditional and HIV-associated ASCVD risk factors, ASCVD risk increased at a similar rate among sub-populations defined by HIV exposure (heterosexuals, men who have sex with men, people who inject drugs), race/ethnicity (Caucasian and Asian) and nadir CD4 at ART initiation (<200 and ≥200 cells/mm3)., Conclusions: These findings emphasize the growing burden of ASCVD risk among PLHIV and the need to develop interventions that are effective across a broad range of HIV sub-populations., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To investigate trends in SGLT2i and GLP-1RA use in Australia in the era of increased evidence of their cardiovascular benefits., Methods: We used national dispensing claims for a 10% random sample of Australians to estimate the number of prevalent and new users (no dispensing in the prior year) of SGLT2i or GLP-1RA per month from January 2014 to July 2022. We assessed prescriber specialty and prior use of other antidiabetic and cardiovascular medicines as a proxy for evidence of type 2 diabetes (T2D) and cardiovascular conditions, respectively., Results: We found a large increase in the number of prevalent users (216-fold for SGLT2i; 11-fold for GLP-1RA); in July 2022 approximately 250,000 Australians were dispensed SGLT2i and 120,000 GLP-1RA. Most new users of SGLT2i or GLP-1RA had evidence of both T2D and cardiovascular conditions, although from 2022 onwards, approximately one in five new users of SGLT2i did not have T2D. The proportion of new users initiating SGLT2i by cardiologists increased after 2021, reaching 10.0% of initiations in July 2022. Among new users with evidence of cardiovascular conditions, empagliflozin was the most commonly prescribed SGLT2i, while dulaglutide or semaglutide was the most common GLP-1RA., Conclusion: SGLT2i and GLP-1RA use is increasing in Australia, particularly in populations with higher cardiovascular risk. The increased use of SGLT2i among people without evidence of T2D suggests that best-evidence medicines are adopted in Australia across specialties, aligning with new evidence and expanding indications., (© 2023. The Author(s).)

Background The burden of cardiovascular disease is increasing, with many people treated for multiple cardiovascular conditions. We examined persistence and adherence to medicines for cardiovascular disease treatment or prevention in Australia. Methods and Results Using national dispensing claims for a 10% random sample of people, we identified adults (≥18 years) initiating antihypertensives, statins, oral anticoagulants, or antiplatelets in 2018. We measured persistence to therapy using a 60-day permissible gap, and adherence using the proportion of days covered up to 3 years from initiation, and from first to last dispensing. We reported outcomes by age, sex, and cardiovascular multimedicine use. We identified 83 687 people initiating antihypertensives (n=37 941), statins (n=34 582), oral anticoagulants (n=15 435), or antiplatelets (n=7726). Around one-fifth of people discontinued therapy within 90 days, with 50% discontinuing within the first year. Although many people achieved high adherence (proportion of days covered ≥80%) within the first year, these rates were higher when measured from first to last dispensing (40.5% and 53.2% for statins; 55.6% and 80.5% for antiplatelets, respectively). Persistence was low at 3 years (17.5% antiplatelets to 37.3% anticoagulants). Persistence and adherence increased with age, with minor differences by sex. Over one-third of people had cardiovascular multimedicine use (reaching 92% among antiplatelet users): they had higher persistence and adherence than people using medicines from only 1 cardiovascular group. Conclusions Persistence to cardiovascular medicines decreases substantially following initiation, but adherence remains high while people are using therapy. Cardiovascular multimedicine use is common, and people using multiple cardiovascular medicines have higher rates of persistence and adherence.

Aims/hypothesis: Whether sodium-glucose co-transporter 2 inhibitors (SGLT2is) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are cost-effective based solely on their cardiovascular and kidney benefits is unknown. We projected the health and economic outcomes due to myocardial infarction (MI), stroke, heart failure (HF) and end-stage kidney disease (ESKD) among people with type 2 diabetes, with and without CVD, under scenarios of widespread use of these drugs., Methods: We designed a microsimulation model using real-world data that captured CVD and ESKD morbidity and mortality from 2020 to 2040. The populations and transition probabilities were derived by linking the Australian Diabetes Registry (1.1 million people with type 2 diabetes) to hospital admissions databases, the National Death Index and the ESKD Registry using data from 2010 to 2019. We modelled four interventions: increase in use of SGLT2is or GLP-1 RAs to 75% of the total population with type 2 diabetes, and increase in use of SGLT2is or GLP-1 RAs to 75% of the secondary prevention population (i.e. people with type 2 diabetes and prior CVD). All interventions were compared with current use of SGLT2is (20% of the total population) and GLP-1 RAs (5% of the total population). Outcomes of interest included quality-adjusted life years (QALYs), total costs (from the Australian public healthcare perspective) and the incremental cost-effectiveness ratio (ICER). We applied 5% annual discounting for health economic outcomes. The willingness-to-pay threshold was set at AU$28,000 per QALY gained., Results: The numbers of QALYs gained from 2020 to 2040 with increased SGLT2i and GLP-1 RA use in the total population (n=1.1 million in 2020; n=1.5 million in 2040) were 176,446 and 200,932, respectively, compared with current use. Net cost differences were AU$4.2 billion for SGLT2is and AU$20.2 billion for GLP-1 RAs, and the ICERs were AU$23,717 and AU$100,705 per QALY gained, respectively. In the secondary prevention population, the ICERs were AU$8878 for SGLT2is and AU$79,742 for GLP-1 RAs., Conclusions/interpretation: At current prices, use of SGLT2is, but not GLP-1 RAs, would be cost-effective when considering only their cardiovascular and kidney disease benefits for people with type 2 diabetes., (© 2022. The Author(s).)

Purpose: Surgery for epithelial ovarian cancer (EOC) may activate stress-inflammatory responses that stimulate tumor growth and increase metastatic growth. Animal and in vitro studies have shown that inhibition of the catecholamine-induced inflammatory response via beta-adrenergic receptor blockade has antitumor potential in EOC. However, observational studies have reported mixed results. We assessed whether beta-blocker (BB) use at the time of primary ovarian cancer surgery was associated with improved survival in a large population-based study., Materials and Methods: Using linked administrative data, a population-based cohort of 3,844 Australian women age 50 years or older with a history of cardiovascular conditions who underwent surgery for EOC was followed for survival outcomes. The average treatment effect of selective BB (SBB) and nonselective BB (NSBB) supply at the time of surgery on survival was estimated from a causal inference perspective using covariate-balanced inverse probability of treatment weights with flexible parametric survival models that allowed for time-varying survival effects., Results: Around the time of surgery, 560 (14.5%) women were supplied a SBB and 67 (1.7%) were supplied a NSBB. At 2 years postsurgery, the survival proportion was 80% (95% CI, 68 to 88) for women dispensed NSBBs at surgery compared with 69% (95% CI, 67 to 70) for women not supplied NSBBs. The survival advantage appeared to extend to at least 8 years postsurgery. No association was observed for women dispensed a SBB around the time of surgery., Conclusion: Perioperative supply of NSBBs appeared to confer a survival advantage for women age over 50 years with a history of cardiovascular conditions. Long-term clinical trials are required to confirm these findings.

Study Objective: Multimorbidity and multimedicine use are common in people with cardiovascular disease and can lead to harms, such as prescribing errors and drug interactions. We quantified multimedicine use in people treated with cardiovascular medicines in a national sample of Australians., Design: Cross-sectional study., Data Source: Pharmaceutical dispensing claims for a 10% random sample of Australians., Patients: Australian adults dispensed any cardiovascular medicine between June and August 2019., Intervention: None., Measurements: We quantified the number and type of cardiovascular and non-cardiovascular medicines dispensed during the study period, and the number of unique prescribers, by age and sex., Main Results: We identified 493,081 people dispensed any cardiovascular medicine (median age = 67 years, 50.2% women). The population prevalence of cardiovascular medicine dispensing increased from 1.7% (n = 10,503) in people 18-34 years to 80.1% (n = 99,271) in people 75-84 years. Cardiovascular medicine dispensing varied by sex; women 18-34 years were more likely to be dispensed any cardiovascular medicine than men (male:female prevalence ratio [PR] = 0.84, 95% confidence interval [CI] = 0.81-0.87), whereas the prevalence of cardiovascular medicine dispensing was higher in men 35-44 years (PR = 1.27, 95% CI 1.24-1.30) and 45-54 years (PR = 1.24, 95% CI 1.22-1.26) and was similar between sexes in people ≥65 years. Overall, both women and men were dispensed a median of 2.0 (interquartile range [IQR] = 1.0-3.0) cardiovascular medicines. Two-thirds of people ≥65 years (73.5%; n = 208,524) were dispensed ≥2 cardiovascular medicines, with 16.6% (n = 6736) of people ≥85 years dispensed five or more. Women and men were dispensed a median of 2.0 (IQR = 1.0-5.0) and 2.0 (IQR = 0.0-4.0) non-cardiovascular medicines, respectively, to treat comorbid conditions, commonly gastroesophageal reflux disease medicines (32.2% of women and 26.6% of men), antibiotics (28.7% of women and 22.4% of men), and antidepressants (26.3% of women and 15.9% of men). One quarter of both sexes had multiple prescribers for their cardiovascular medicines alone, whereas 54.5% (n = 134,939) of women and 49.9% (n = 122,706) of men had multiple prescribers for all medicines., Conclusion: Multimedicine use is common in people treated with cardiovascular medicines and presents a risk for inappropriate prescribing. Understanding the comorbid conditions commonly treated concurrently with cardiovascular disease can help improve co-prescribing guidelines and develop a person-centered approach to multimorbidity treatment., (© 2022 The Authors. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy published by Wiley Periodicals LLC on behalf of Pharmacotherapy Publications, Inc.)

Background and Objectives: Statins have been extensively utilised in atherosclerotic cardiovascular disease (ASCVD) prevention and can inhibit inflammation. However, the association between statin therapy, subclinical inflammation and associated health outcomes is poorly understood in the primary care setting. Materials and Methods: Primary care electronic health record (EHR) data from the electronic Practice-Based Research Network (ePBRN) from 2012−2019 was used to assess statin usage and adherence in South-Western Sydney (SWS), Australia. Independent determinants of elevated C-reactive protein (CRP) were determined. The relationship between baseline CRP levels and hospitalisation rates at 12 months was investigated. Results: The prevalence of lipid-lowering medications was 14.0% in all adults and 44.6% in the elderly (≥65 years). The prevalence increased from 2012 to 2019 despite a drop in statin use between 2013−2015. A total of 55% of individuals had good adherence (>80%). Hydrophilic statin use and higher intensity statin therapy were associated with elevated CRP levels. However, elevated CRP levels were not associated with all-cause or ASCVD hospitalisations after adjusting for confounders. Conclusions: The prevalence and adherence patterns associated with lipid-lowering medications highlighted the elevated ASCVD-related burden in the SWS population, especially when compared with the Australian general population. Patients in SWS may benefit from enhanced screening protocols, targeted health literacy and promotion campaigns, and timely incorporation of evidence into ASCVD clinical guidelines. This study, which used EHR data, did not support the use of CRP as an independent marker of future short-term hospitalisations.

Lipid-lowering medications comprise standard of care in the prevention of cardiovascular disease. This study examined the trends in the utilization of statin and non-statin medications in the Australian general population between 2013 and 2019. Pharmacoepidemiological analyses were performed using pharmacy dispensing data from Australian Pharmaceutical Benefits Scheme. One-year prevalence and incidence of statin and non-statin prescribing patterns were reported, and relative variations in prescribing examined via Poisson regression modelling. The one-year prevalence of statins' prescriptions decreased between 2013-2019 by 5.5% (from 25.0%-19.5%). Females were less likely than males to be prescribed statins (rate ratio [RR]=0.90, 95% confidence interval [CI] 0.89-0.91). The one-year prevalence of ezetimibe alone, and in combination with statins, increased consistently from 2013-2019 from 1.5%-3.6% (P<0.01) and 0.1%-1.1% (P<0.01), respectively. The prevalence was higher among those aged 61-80 years (RR=1.20, 95%CI 1.10-1.21) and those aged older than 80 years (RR=1.34, 95%CI 1.22-1.47), when compared to people aged <60 years. The incidence of ezetimibe prescriptions was highest in people aged 61-80 years (RR=1.36, 95%CI 1.31-1.41) compared to those aged <60 years. The one-year prevalence of proprotein convertase subtilisin/kexin type 9 inhibitor prescriptions was highest among those aged 46-60 years (RR=1.24, 95%CI 0.97-4.97) compared to people aged <46 and >60 years. Females were less likely than males to be prescribed a proprotein convertase subtilisin/kexin type 9 inhibitor (RR=0.87, 95%CI 0.75-0.98). Statins remain the most prevalent lipid-lowering medication prescribed in Australia. The prescribing of non-statin medications remains low, but is increasing., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The effect of supplementing unscreened adults with vitamin D 3 on mortality is unclear. We aimed to determine whether monthly doses of vitamin D 3 influenced mortality in older Australians., Methods: We did a randomised, double-blind, placebo-controlled trial of oral vitamin D 3 supplementation (60 000 IU per month) in Australians 60 years or older who were recruited across the country via the Commonwealth electoral roll. Participants were randomly assigned (1:1), using automated computer-generated permuted block randomisation, to receive one oral gel capsule of either 60 000 IU vitamin D 3 or placebo once a month for 5 years. Participants, staff, and investigators were blinded to study group allocation. The primary endpoint was all-cause mortality assessed in all participants who were randomly assigned. We also analysed mortality from cancer, cardiovascular disease, and other causes. Hazard ratios (HRs) and 95% CIs were generated using flexible parametric survival models. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613000743763., Findings: Between Feb 14, 2014, and June 17, 2015, we randomly assigned 21 315 participants, including 10 662 to the vitamin D group and 10 653 to the placebo group. In 4441 blood samples collected from randomly sampled participants (N=3943) during follow-up, mean serum 25-hydroxy-vitamin D concentrations were 77 (SD 25) in the placebo group and 115 (SD 30) nmol/L in the vitamin D group. Following 5 years of intervention (median follow-up 5·7 years [IQR 5·4-6·7]), 1100 deaths were recorded (placebo 538 [5·1%]; vitamin D 562 [5·3%]). 10 661 participants in the vitamin D group and 10 649 participants in the placebo group were included in the primary analysis. Five participants (one in the vitamin D group and four in the placebo group) were not included as they requested to be withdrawn and their data to be destroyed. The HR of vitamin D 3 effect on all-cause mortality was 1.04 [95% CI 0·93 to 1·18]; p=0·47)and the HR of vitamin D 3 effect on cardiovascular disease mortality was 0·96 (95% CI 0·72 to 1·28; p=0·77). The HR for cancer mortality was 1·15 (95% CI 0·96 to 1·39; p=0·13) and for mortality from other causes it was 0·83 (95% CI 0·65 to 1·07; p=0·15). The odds ratio for the per-protocol analysis was OR 1·18 (95% CI 1·00 to 1·40; p=0·06). In exploratory analyses excluding the first 2 years of follow-up, those randomly assigned to receive vitamin D had a numerically higher hazard of cancer mortality than those in the placebo group (HR 1·24 [95% CI 1·01-1·54]; p=0·05)., Interpretation: Administering vitamin D 3 monthly to unscreened older people did not reduce all-cause mortality. Point estimates and exploratory analyses excluding the early follow-up period were consistent with an increased risk of death from cancer. Pending further evidence, the precautionary principle would suggest that this dosing regimen might not be appropriate in people who are vitamin D-replete., Funding: The D-Health Trial is funded by National Health and Medical Research Council., Competing Interests: Declaration of interests PMW has funding from AstraZeneca for an unrelated study of ovarian cancer. PRE reports grants and honoraria from Amgen, honoraria from Sanofi, grants from Novartis, grants from Eli-Lilly, and grants from Alexion. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Cardiovascular disease (CVD) events are highly preventable through appropriate treatment and disproportionally affect socioeconomically disadvantaged individuals. This study quantified the relationship of socioeconomic factors to dispensing and persistent use of lipid- and blood pressure-lowering medication following hospital admission for a major CVD event (myocardial infarction, ischaemic stroke/transient ischaemic attack). Data from 8285 people with such events aged ≥45 years from the Australian 45 and Up Study with linked medication data were used to estimate relative risks (RRs) for combined lipid- and blood pressure-lowering dispensing at three-months following hospital discharge and for 12-month persistent use, in relation to education, income, and level of medication subsidisation. Overall, 56% were dispensed guideline-recommended medications at three months and 37% persistently used them across 12 months. After adjusting for demographic factors, type of CVD and history of CVD hospitalisation, RRs for lowest (no educational qualifications) compared to highest education level (university degree) were 1.14 (95% CI: 1.06, 1.22) for medication dispensing and 1.15 (1.02, 1.29) for persistent medication use; 1.14 (1.06, 1.22) and 1.17 (1.04, 1.32) respectively for lowest (<$20,000) versus highest (≥$70,000) household pre-tax income; and 1.25 (1.17, 1.33) and 1.28 (1.15, 1.43) respectively for those receiving highest versus lowest subsidisation. There was little to no evidence of a relationship of income and education to medication use after adjustment for medication subsidisation. While preventive medication use is sub-optimal, subsidisation is substantially associated with increased use and accounts for most of the relationship with socioeconomic position, suggesting subsidy schemes are working in the intended direction., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Cardiovascular disease (CVD) and risk factors remains a major burden in terms of disease, disability, and death in the Australian population and mental health is considered as an important risk factor affecting cardiovascular disease. A multidisciplinary collaborative approach in primary care is required to ensure an optimal outcome for managing cardiovascular patients with mental health issues. Medicare introduced numerous primary care health services and medications that are subsidised by the Australian government in order to provide a more structured approach to reduce and manage CVD. However, the utilisation of these services nor gender comparison for CVD management in primary care has been explored. Therefore, the aim is to compare the provision of subsidised chronic disease management plans (CDMPs), mental health care and prescription of guideline-indicated medications to men and women with CVD in primary care practices for secondary prevention., Methods: De-identified data for all active patients with CVD were extracted from 50 Australian primary care practices. Outcomes included the frequency of receipt of CDMPs, mental health care and prescription of evidence-based medications. Analyses adjusted for demography and clinical characteristics, stratified by gender, were performed using logistic regression and accounted for clustering effects by practices., Results: Data for 14,601 patients with CVD (39.4% women) were collected. The odds of receiving the CDMPs was significantly greater amongst women than men (preparation of general practice management plan [GPMP]: (46% vs 43%; adjusted OR [95% CI]: 1.22 [1.12, 1.34]). Women were more likely to have diagnosed with mental health issues (32% vs 20%, p<0.0001), however, the adjusted odds of men and women receiving any government-subsidised mental health care were similar. Women were less often prescribed blood pressure, lipid-lowering and antiplatelet medications. After adjustment, only an antiplatelet medication or agent was less likely to be prescribed to women than men (44% vs 51%; adjusted OR [95% CI]: 0.84 [0.76, 0.94])., Conclusion: Women were more likely to receive CDMPs but less likely to receive antiplatelet medications than men, no gender difference was observed in the receipt of mental health care. However, the receipt of the CDMPs and the mental health treatment consultations were suboptimal and better use of these existing services could improve ongoing CVD management., (Copyright © 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Introduction: Estimating the mortality risk of persons with diabetes can be challenging. Associated conditions such as cardiovascular disease can become the primary cause of mortality and the underlying contribution of diabetes not recorded. Alternative methods to assess mortality risk in people with diabetes would be useful., Objective: To evaluate an Australian pharmaceutical database to identify multi-morbidity cohorts associated with diabetes and determine mortality rates in these groups using prescription exchange cessation as a proxy event for death., Methods: Australian Pharmaceutical Benefits Scheme data covering the period 2003-14 were used. Persons with diabetes, cardiovascular diseases and dyslipidemia were identified using Anatomic Therapeutic Chemical codes allocated to their recorded dispensed treatments. People with combinations of these conditions were followed and the last recorded prescription exchange used as a proxy event for mortality. Age and gender specific mortality rates and mortality rate ratios for the multi-morbidity cohorts were then calculated from the number of deaths occurring within 10 years., Results: 346,201 individuals were identified as taking treatments for diabetes, dyslipidemia and cardiovascular conditions in 2004, 86,165 deaths occurred within 10 years of follow up. Overall crude mortality was 26.2/1,000 person years. Age specific mortality rates and rate ratios were calculated for various multi-morbidity groupings. Statin treatments improved the mortality rates associated with diabetes and cardiovascular disease in persons age >54 (Log-Rank <.001)., Conclusions: Administrative pharmaceutical data can be used to identify persons with diabetes and associated multi-morbidities. Proxy mortality events defined by the cessation of treatment can generate mortality rates, providing an alternative perspective for the assessment of mortality risk., Competing Interests: Statements of conflicts of interest: The authors have no conflicts of interest to declare.

Objectives: To describe (1) absolute cardiovascular disease risk (ACVDR) scores in patients presenting to hospital with acute coronary syndrome (ACS) and (2) proportions of these patients on guideline-recommended pharmacotherapy according to their ACVDR score., Design: Cross-sectional study., Setting: Single-site tertiary centre hospital, Queensland, Australia over a 12-month period., Participants: Patients >18 years of age presenting to hospital with ACS due to coronary artery disease (CAD) confirmed by angiography., Primary and Secondary Outcome Measures: Proportion of patients without prior history of CVD with a high ACVDR score, and of patients with a prior history of CVD, who are on guideline-recommended pharmacotherapy., Results: 527 ACS patients were included of whom the mean age was 63 years and 75% were male. Overall, 66% (350) had no prior CVD and 34% (177) patients had prior CVD.In patients with no prior CVD, the proportions of patients with low, intermediate and high CVD risk scores were 41%, 24% and 36%. In the no prior CVD, high-risk patient group, 48% were on no preventative pharmacotherapy, 32% on single pharmacotherapy and 20% patients on complete guideline-recommended pharmacotherapy. In the prior CVD group, 7% patients were on no pharmacotherapy, 40% on incomplete pharmacotherapy and 53% were on complete guideline-recommended pharmacotherapy., Conclusion: This study adds to the evidence on implementation gaps in guideline-recommended management of ACVDR, showing that a large proportion of patients presenting with ACS due to CAD were at high risk of developing CVD prior to the event and most were not on guideline-recommended treatment. A significant proportion of these events are likely to have been preventable, and therefore, increased assessment and appropriate treatment of ACVDR in primary care is needed to reduce the incidence of CVD events in the population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Following cardiovascular events, individuals often make choices about their working life that pose fiscal costs for the government in relation to lost tax revenue, increasing disability or early retirement. We evaluate the fiscal consequences for the Australian Government in atherosclerotic cardiovascular disease (ASCVD) patients with low-density lipoprotein >3.3 mmol/L after the maximum tolerated doses of a statin or when contraindicated or intolerant to statins, compared to evolocumab added to the standard of care., Methods: The natural history of patients with ASCVD was evaluated using a multi-state Markov cohort model comparing evolocumab with current treatment practices. Published rates for the likelihood of being disabled and retiring prematurely in patients experiencing stroke or myocardial infarction were modeled. Reported government costs for annual disability payments and lost tax revenues from the nationally representative STINMOD + data set were used to estimate the fiscal consequences associated with attributable ASCVD events., Results: The incremental tax gain associated with evolocumab in someone aged 40, 50 or 60 results in additional tax revenues of Aus$15,716, Aus$9,810 and Aus$4,217, respectively. Cost-savings attributed to disability payments of Aus$3,483, Aus$2,495 and Aus$4,619 were observed in those aged 40, 50 and 60, respectively. The ratio of evolocumab to fiscal benefits indicates that up to 52% of evolocumab costs are offset by future lifetime taxes paid and reduced social benefits payments in those treated aged 40. The ratio of fiscal benefits to costs in treating those aged 50 and 60 were 37% and 31%, respectively., Conclusions: Applying a cross-sectorial government perspective budget impact assessment improves our understanding of fiscal changes attributed to ASCVD based on changes in premature mortality and work activity and how this influences lifetime tax contributions and public benefits. The main cost driver observed was associated with reduced ASCVD events that enabled people to remain productive and paying taxes.

Objective: To quantify postinjury cardiovascular-related health service use experienced by mid to older aged adults hospitalised for injury, compared with uninjured adults. Additionally, to explore the effect of beta-blocker medications on postinjury cardiovascular hospitalisations among injury patients, given the potential cardioprotective effects of beta blockers., Design: A retrospective cohort study using linked administrative and survey data., Participants: Records of 35 026 injured and 60 823 uninjured matched adults aged over 45 from New South Wales, Australia, who completed the 45 and up survey., Primary and Secondary Outcome Measures: Admission rates and cumulative lengths of stay for cardiovascular hospitalisations, and prescription rates for cardiovascular medications. Negative binomial and Cox proportional hazards regression modelling were used to generate incident rate ratios (IRRs) and HR., Results: Compared with the uninjured, those with injury had a 19% higher adjusted rate of postinjury cardiovascular admissions (IRR 1.19, 95% CI 1.14 to 1.25), spent 40% longer in hospital for ardiovascular disease (IRR 1.40, 95% CI 1.26 to 1.57) and had slightly higher cardiovascular prescription rates (IRR 1.04, 95% CI 1.02 to 1.06), during study follow-up. Those in the injury cohort that used beta blockers both prior to and after injury (continuous) appeared to have reduced need for post-injury cardiovascular hospitalisation (IRR 1.09, 95% CI 1.17 to 1.42) compared with those commencing on beta blockers after injury (after 30 days: IRR 1.69, 95% CI 1.37 to 2.08)., Conclusions: Apparent increased postinjury hospitalisation rates and prolonged length of stay related to cardiovascular disease suggest that injury patients may require clinical support for an extended period after injury. Additionally, injury patients who were on continuous beta blocker treatment appeared to have lower need for post-injury cardiovascular hospitalisations. However, the data do not allow us to draw clear conclusions and further clinical research is required., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Recent cardiovascular safety trials on sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists have demonstrated the significant cardiovascular and renal benefits of these medications. Diabetes organisations have revised their medication guidelines to include a focus on disease outcomes for cardiovascular disease, heart failure and renal disease. This article summarises latest evidence, guideline recommendations and current Australian Pharmaceutical Benefits Scheme requirements., (© 2020 Royal Australasian College of Physicians.)

Purpose: To describe Australians' prescribed medicine use on a typical day (September 25, 2018)., Methods: We conducted a cross-sectional study using nationally representative dispensing claims data using the Australian Government Department of Human Services random 10% sample of all Australians eligible for prescription medicines subsidised through the Australian Pharmaceutical Benefits Scheme (PBS). Our main outcome measures were the number and proportion of people using at least one prescribed medicine and the specific medicine groups and classes on the day. We estimated the proportion of Australians using these medicines using the mid-year Australian population as the denominator. We quantified multiple medicine use by calculating the number and proportion of people experiencing polypharmacy (the use of 5 or more unique medicines) and hyper-polypharmacy (the use of 10 or more unique medicines)., Results: We found that 9.0 million Australians used at least one PBS medicine on September 25, 2018; equating to 27.5 million medicines in use across Australia. "Cardiovascular system", "nervous system" and "alimentary tract and metabolism" medicines comprised the top three medicine groups. Over 1.8 million people experienced polypharmacy on the day, accounting for 13.6 million dispensed medicines. 1 022 590 (45%) people aged ≥70 years old experienced polypharmacy and 188 930 (8%) experienced hyper-polypharmacy., Conclusions: Rates of polypharmacy were high, particularly in the people most susceptible to polypharmacy-related harm. Strategies to optimise the risk-benefit ratio of medicines and to reduce polypharmacy through "choosing wisely" and "de-prescribing" in this age group are needed. Australia's national data provides a benchmark to inform global medicine utilisation practices., (© 2020 John Wiley & Sons Ltd.)

Aboriginal and Torres Strait Islander people have high rates of cardiovascular disease (CVD). The National Vascular Disease Prevention Alliance (NVDPA) CVD risk assessment algorithm is used for all Australians. The Central Australian Rural Practitioners Association (CARPA) algorithm used in the Northern Territory adds five percentage points to all NVDPA risk scores for Indigenous Australians. Information was extracted from an Aboriginal Community-Controlled Health Service for all Aboriginal and Torres Strait Islander regular clients aged 35-74 years without known CVD (n=1057). CVD risk scores were calculated using both algorithms. Prescription of lipid-lowering medications was assessed. Clients with high-risk scores were reviewed and recalled if required. CVD risk scores were calculated for 362 (34.4%) clients. Clients with high CVD risk comprised 17.7% (NVDPA) or 23.8% (CARPA), with most determined clinically. Clients with low CVD risk comprised 73.7% (NVDPA) or 47.2% (CARPA). More than 30% of those with high risk were not on lipid-lowering medications. Significant health and social issues affected treatment uptake. It is unclear which algorithm is most applicable; however, this service has decided to continue to use the NVDPA algorithm. Use of CVD risk assessment and management of high-risk clients could be increased in primary care.

Adherence to cardiac medications makes a significant contribution to avoidance of morbidity and premature mortality in patients with cardiovascular disease. This quantitative study used cross-sectional survey design to evaluate medication adherence and contributing factors among patients with cardiovascular disease, comparing patients who were admitted to a cardiac ward (n = 89) and those attending outpatient cardiac rehabilitation (n = 31) in Australia. Data collection was completed between October 2016 and December 2017. Descriptive and regression analyses were conducted to identify medication adherence and determine factors independently predictive of medication adherence. Participants from cardiac rehabilitation had significantly lower adherence to cardiac medications than those recruited from the cardiac ward (58.1 vs 64.0%, respectively). Self-efficacy was significantly associated with participants' medication adherence in both groups. The ability to refill medications and beliefs about cardiac medications were independently significantly predictive of cardiac medication adherence. These findings indicate areas where clinical nurses could expand their role to improve cardiac patients' medication self-management., (© 2020 John Wiley & Sons Australia, Ltd.)

Background and Objectives: Pharmaceutical industry interactions with professional medical associations have come under scrutiny, yet industry ties among the leadership of these associations are often overlooked. The aim of this study was to investigate pharmaceutical industry payments to leaders of Australian diabetes or cardiovascular associations, and general associations serving doctors who manage these conditions., Method: Payments were identified using publicly available industry transparency reports (October 2015 to April 2018)., Results: Overall, 48/197 (24.4%) leaders received payments, predominantly for speaker (51.4%) and advisory board (25.3%) engagements. The proportion of paid leaders was higher for diabetes- and cardiovascular-specific associations (72.7% and 41.2%, respectively) than for general associations (7.6%)., Discussion: These findings raise concerns about industry influence on clinical practice and policy.

Background and Objectives: Data are sparse on how well the absolute risk approach is implemented in primary healthcare. The aim of this study was to quantify absolute cardiovascular disease (CVD) risk, appropriate use of blood pressure (BP)-lowering and lipid-lowering therapy, and clinical target responses in the Busselton baby boomer population., Method: This was a cross-sectional study of 5107 people aged 45-69 years (54.6% female) who participated in the 2010-2015 Busselton Healthy Ageing Study., Results: Overall, 16.1% of participants had prior CVD (5.8%) or a high primary CVD risk (10.3%). The frequency of use of a guideline-recommended combination of BP-lowering and lipid-lowering therapy was 46.2% in participants with prior CVD, compared with only 16.8% in those with high primary CVD risk (P <0.001). Among the high-risk participants who were receiving recommended combination therapy, only 42.7% achieved target systolic BP levels and 42.1% achieved target total cholesterol levels., Discussion: These data confirm substantial under treatment of Australian adults who are at high CVD risk. Enhanced implementation of absolute CVD risk assessment and evidence-based treatment in high-risk adults has potential for substantial health gains.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies (mAb) have progressed from showing marked low density lipoprotein cholesterol lowering in early phase trials through to reducing cardiovascular events in large clinical outcome trials. Recently in Australia, the indication for evolocumab has been expanded to include both heterozygous and homozygous familial hypercholesterolaemia under the Pharmaceutical Benefits Scheme (PBS). With prices remaining high currently their use in non-familial hypercholesterolaemia in Australia remains by private prescription only at this stage. This manuscript summarises the major outcomes trials of the PCSK9 mAbs and the secondary analyses that have assessed their benefits in high risk patient groups, and describes the consensus of authors on which patients would most likely benefit from PCSK9 mAb therapy., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objective: In light of the Cardiovascular Outcomes for People using Anticoagulation Strategies (COMPASS) trial, our objective was to assess the cost-effectiveness, from the Australian healthcare perspective, of rivaroxaban in combination with aspirin versus aspirin alone for the prevention of recurrent cardiovascular disease among patients with stable atherosclerotic vascular disease., Methods: A Markov model was developed using input data from the COMPASS trial to predict the clinical course and costs of patients over a 20-year time-horizon. The model comprised of three health states: 'Alive without recurrent CVD', 'Alive after recurrent CVD' and 'Dead'. Costs were from the Australian public healthcare system perspective, and estimated from published sources, as were utility data. The costs of rivaroxaban were based on current acquisition prices on the Australian Pharmaceutical Benefits Schedule (PBS) and assumed as AUD$3.09/day. The main outcome of interest was the incremental cost-effectiveness ratio (ICER) in terms of cost per quality adjusted life year (QALY) gained, and cost per year of life saved (YoLS). Costs and benefits were discounted by 5.0% per year., Results: Compared to aspirin alone, rivaroxaban plus aspirin was estimated to cost an additional AUD$12,156 (discounted) per person, but lead to 0.516 YoLS (discounted) and 0.386 QALYs gained (discounted), over 20 years. These equated to ICERs of AUD$23,560/YoLS and AUD$31,436/QALY gained. We have assumed a threshold of AUD$50,000/QALY gained to signify cost-effectiveness., Conclusion: Compared to aspirin, rivaroxaban in combination with aspirin is likely to be cost-effective in preventing recurrent cardiovascular events in patients with stable atherosclerotic vascular disease., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Purpose: Clinical guidelines specify who should receive high-intensity statins; however, it is unclear how high-intensity statins are used in Australia. Our objective was to determine the demographic, clinical, and lifestyle factors associated with high-intensity statin therapy in Australia., Methods: Data from the Australian Diabetes, Obesity and Lifestyle study collected in 2011-2012 were analyzed. High-, moderate-, and low-intensity statins were defined as use of statins at doses demonstrated to reduce low-density lipoprotein cholesterol levels by > 50, 30-50, and < 30%, respectively. Logistic regression was used to estimate adjusted odd ratios (ORs) and 95% confidence intervals (CIs) for factors associated with high- versus low-to-moderate-intensity statin therapy., Results: Overall, 1108 (24%) study participants used a statin. Data on statin intensity were available for 1072 participants. The proportions of high-, moderate-, and low-intensity statin therapy were 32 (n = 341), 65 (n = 696), and 3% (n = 35), respectively. Overall, 51% of people with prior cardiovascular disease (CVD) used a high-intensity statin. In addition to prior CVD (OR = 3.34, 95% CI = 1.95-5.73), no (OR = 1.84, 95%CI 1.02-3.31) or insufficient physical activity (OR = 1.51, 95% CI = 1.01-2.25), obesity (OR = 1.87, 95% CI = 1.13-3.10), and consuming > 2 alcoholic drinks daily (OR = 1.66, 95% CI = 1.08-2.55) were associated with high versus low-to-moderate-intensity statin therapy. Conversely, age 65-74 vs. < 65 years was inversely associated with high-intensity statin therapy (OR = 0.62, 95% CI = 0.41-0.94)., Conclusions: Prior CVD was the strongest factor associated with high-intensity statin therapy. Although the prevalence of CVD increases with age, older people were less likely to be treated with high-intensity statins.

Cardiovascular disease (CVD), preventable through appropriate management of absolute CVD risk, disproportionately affects socioeconomically disadvantaged individuals. The aim of this study was to estimate absolute and relative socioeconomic inequalities in absolute CVD risk and treatment in the Australian population using cross-sectional representative data on 4751 people aged 45-74 from the 2011-12 Australian Health Survey. Poisson regression was used to calculate prevalence differences (PD) and ratios (PR) for prior CVD, high 5-year absolute risk of a primary CVD event and guideline-recommended medication use, in relation to socioeconomic position (SEP, measured by education). After adjusting for age and sex, the prevalence of high absolute risk of a primary CVD event among those of low, intermediate and high SEP was 12.6%, 10.9% and 7.7% (PD, low vs. high = 5.0 [95% CI: 2.3, 7.7], PR = 1.6 [1.2, 2.2]) and for prior CVD was 10.7%, 9.1% and 6.7% (PD = 4.0 [1.4, 6.6], PR = 1.6 [1.1, 2.2]). The proportions using preventive medication use among those with high primary risk were 21.3%, 19.5% and 29.4% for low, intermediate and high SEP and for prior CVD, were 37.8%, 35.7% and 17.7% (PD = 20.1 [9.7, 30.5], PR = 2.1 [1.3, 3.5]). Proportions at high primary risk and not using medications among those of low, intermediate and high SEP were 10.6%, 8.8% and 4.7% and with prior CVD and not using medications were 8.5%, 6.3% and 4.1%. Findings indicate substantial potential to prevent CVD and reduce inequalities through appropriate management of high absolute risk in the population., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To quantify absolute cardiovascular disease (CVD) risk in Aboriginal and Torres Strait Islander people and their use of lipid-lowering therapies., Design, Participants: Cross-sectional analysis of nationally representative data from 2820 participants aged 18-74 years who provided biomedical data for the National Aboriginal and Torres Strait Islander Health Measures Survey component of the 2012-13 Australian Aboriginal and Torres Strait Islander Health Survey., Main Outcome Measures: Prior CVD and use of lipid-lowering medications were ascertained at interview. 5-year absolute risk of a primary CVD event was calculated with the Australian National Vascular Disease Prevention Alliance algorithm, with categories low (< 10%), moderate (10-15%) and high risk (> 15%)., Results: Among participants aged 35-74 years, 9.6% (95% CI, 7.2-12.0%) had prior CVD; 15.7% (95% CI, 13.0-18.3%) were at high, 4.9% (95% CI, 3.3-6.6%) at moderate, and 69.8% (95% CI, 66.8-72.8%) at low absolute primary CVD risk. 82.6% of those at high primary risk were identified on the basis of clinical criteria. High primary absolute risk affected 1.1% (95% CI, 0.0-2.5%) of 18-24-year-olds, 4.7% (95% CI, 2.0-7.5%) of 25-34-year-olds, and 44.2% (95% CI, 33.1-55.3%) of 65-74-year-olds. Lipid-lowering therapy was being used by 52.9% (95% CI, 38.2-67.6%) of people aged 35-74 years with prior CVD and by 42.2% (95% CI, 30.5-53.8%) of those at high primary CVD risk., Conclusion: Absolute CVD risk is high among Aboriginal and Torres Strait Islander people, and most of those at high risk are undertreated. Substantial proportions of people under 35 years of age are at high risk, but are not targeted by current guidelines for absolute CVD risk assessment, compromising CVD prevention in this population.

Background: Regional differences in risk of diabetes mellitus and cardiovascular outcomes in people with impaired glucose tolerance are poorly characterized. Our objective was to evaluate regional variation in risk of new-onset diabetes mellitus, cardiovascular outcomes, and treatment effects in participants from the NAVIGATOR (Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research) trial., Methods and Results: NAVIGATOR randomized people with impaired glucose tolerance and cardiovascular risk factors or with established cardiovascular disease to valsartan (or placebo) and to nateglinide (or placebo) with a median 5-year follow-up. Data from the 9306 participants were categorized by 5 regions: Asia (n=552); Europe (n=4909); Latin America (n=1406); North America (n=2146); and Australia, New Zealand, and South Africa (n=293). Analyzed outcomes included new-onset diabetes mellitus; cardiovascular death; a composite cardiovascular outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke; and treatment effects of valsartan and nateglinide. Respective unadjusted 5-year risks for new-onset diabetes mellitus, cardiovascular death, and the composite cardiovascular outcome were 33%, 0.4%, and 4% for Asia; 34%, 2%, and 6% for Europe; 37%, 4%, and 8% for Latin America; 38%, 2%, and 6% for North America; and 32%, 4%, and 8% for Australia, New Zealand, and South Africa. After adjustment, compared with North America, European participants had a lower risk of new-onset diabetes mellitus (hazard ratio 0.86, 95% CI 0.78-0.94; P=0.001), whereas Latin American participants had a higher risk of cardiovascular death (hazard ratio 2.68, 95% CI 1.82-3.96; P<0.0001) and the composite cardiovascular outcome (hazard ratio 1.48, 95% CI 1.15-1.92; P=0.003). No differential interactions between treatment and geographic location were identified., Conclusions: Major regional differences regarding the risk of new-onset diabetes mellitus and cardiovascular outcomes in NAVIGATOR participants were identified. These differences should be taken into account when planning global trials., Clinical Trial Registration: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00097786., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Objective: To identify facilitators and barriers to clinical trial implementation in Aboriginal health services., Design: Indepth interview study with thematic analysis., Setting: Six Aboriginal community-controlled health services and one government-run service involved in the Kanyini Guidelines Adherence with the Polypill (KGAP) study, a pragmatic randomised controlled trial that aimed to improve adherence to indicated drug treatments for people at high risk of cardiovascular disease., Participants: 32 health care providers and 21 Aboriginal and Torres Strait Islander patients., Results: A fundamental enabler was that participants considered the research to be governed and endorsed by the local health service. That the research was perceived to address a health priority for communities was also highly motivating for both providers and patients. Enlisting the support of Aboriginal and Torres Strait Islander staff champions who were visible to the community as the main source of information about the trial was particularly important. The major implementation barrier for staff was balancing their service delivery roles with adherence to often highly demanding trial-related procedures. This was partially alleviated by the research team's provision of onsite support and attempts to make trial processes more streamlined. Although more intensive support was highly desired, there were usually insufficient resources to provide this., Conclusion: Despite strong community and health service support, major investments in time and resources are needed to ensure successful implementation and minimal disruption to already overstretched, routine services. Trial budgets will necessarily be inflated as a result. Funding agencies need to consider these additional resource demands when supporting trials of a similar nature.

Objective: To measure the costs of a polypill strategy and compare them with those of usual care in people with established cardiovascular disease (CVD) or at similarly high cardiovascular risk., Design: A within-trial cost analysis of polypill-based care versus usual care with separate medications, using data from the Kanyini Guidelines Adherence with the Polypill (GAP) trial and linked health service and medication administrative claims data., Participants: Kanyini GAP participants who consented to Australian Medicare record access., Main Outcome Measures: Mean health service and pharmaceutical expenditure per patient per year, estimated with generalised linear models. Costs during the trial (randomisation January 2010 - May 2012, median follow-up 19 months, maximum follow-up 36 months) were inflated to 2012 costs., Results: Our analysis showed a statistically significantly lower mean pharmaceutical expenditure of $989 (95% CI, $648-$1331) per patient per year in the polypill arm compared with usual care (P < 0.001; adjusted, excluding polypill cost). No significant difference was shown in health service expenditure., Conclusions: This study provides evidence of significant cost savings to the taxpayer and Australian Government through the introduction of a CVD polypill strategy. The savings will be less now than during the trial due to subsequent reductions in the costs of usual care. Nonetheless, given the prevalence of CVD in Australia, the introduction of this polypill could increase considerably the efficiency of health care expenditure in Australia., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN126080005833347.

Objectives: To determine the impact of four NPS MedicineWise programs targeting quality use of medicines in cardiovascular management in primary care., Design: Interrupted time-series analysis using the Department of Veterans' Affairs (DVA) claims dataset from 1 January 2002 to 31 August 2010. We examined the use of antithrombotics in people with atrial fibrillation and in those who had had a stroke, and the use of echocardiography and spironolactone in the population with heart failure., Participants: All veterans and their dependants in Australia who had received cardiovascular medicines or health services related to the targeted intervention., Intervention: NPS MedicineWise national programs to improve cardiovascular management in primary care, which included prescriber feedback, academic detailing, case studies and audits as well as printed educational materials., Main Outcome Measures: Changes in medication and health service use before and after the interventions., Results: All national programs were positively associated with significant improvements in related prescribing or test request practice. The interventions to improve the use of antithrombotics resulted in a 1.27% (95% CI, 1.26%-1.28%) and 0.63% (95% CI, 0.62%-0.64%) relative increase in the use of aspirin or warfarin in the population with atrial fibrillation 6 and 12 months after the program, respectively, and in a 1.51% (95% CI, 1.49%-1.53%) relative increase in the use of aspirin as monotherapy for secondary stroke prevention 12 months after the intervention. The heart failure programs resulted in a 3.69% (95% CI, 3.67%-3.71%) relative increase in the use of low-dose spironolactone and a 4.31% (95% CI, 4.27%-4.35%) relative increase in the use of echocardiogram tests 12 months after the intervention., Conclusions: NPS MedicineWise programs were effective in achieving positive changes in medicine and health service use for patients with cardiovascular diseases.

Background: Measures of blood pressure variation have been associated with cardiovascular disease and related outcomes. The regular consumption of black tea can lower blood pressure, but its effects on blood pressure variation have yet to be investigated., Objective: We aimed to assess the effects of black tea consumption on the rate of ambulatory blood pressure variation., Design: Men and women (n = 111) with systolic blood pressure between 115 and 150 mm Hg at screening were recruited in a randomized, controlled, double-blind, 6-mo parallel-designed trial designed primarily to assess effects on blood pressure. Participants consumed 3 cups/d of either powdered black tea solids (tea) or a flavonoid-free caffeine-matched beverage (control). The 24-h ambulatory blood pressure level and rate of measurement-to-measurement blood pressure variation were assessed at baseline, day 1, and 3 and 6 mo., Results: Across the 3 time points, tea, compared with the control, resulted in lower rates of systolic (P = 0.0045) and diastolic (P = 0.016) blood pressure variation by ~10% during nighttime (2200-0600). These effects, which were immediate at day 1 and sustained over 6 mo, were independent of the level of blood pressure and heart rate. The rate of blood pressure variation was not significantly altered during daytime (0800-2000)., Conclusions: These findings indicate that a component of black tea solids, other than caffeine, can influence the rate of blood pressure variation during nighttime. Thus, small dietary changes have the potential to significantly influence the rate of blood pressure variation. This trial was registered at the Australian New Zealand Clinical Trials Registry as ACTR12607000543482.

Objective: To determine whether regular aspirin use is associated with a higher risk for developing age-related macular degeneration (AMD) by using analyzed data from a 15-year prospective cohort., Methods: A prospective analysis was conducted of data from an Australian population-based cohort with 4 examinations during a 15-year period (1992-1994 to 2007-2009). Participants completed a detailed questionnaire at baseline assessing aspirin use, cardiovascular disease status, and AMD risk factors. Age-related macular degeneration was graded side-by-side from retinal photographs taken at each study visit to assess the incidence of neovascular (wet) AMD and geographic atrophy (dry AMD) according to the international AMD classification., Results: Of 2389 baseline participants with follow-up data available, 257 individuals (10.8%) were regular aspirin users and 63 of the 2389 developed neovascular AMD. Persons who were regular aspirin users were more likely to have incident neovascular AMD: the 15-year cumulative incidence was 9.3% in users and 3.7% in nonusers. After adjustment for age, sex, smoking, history of cardiovascular disease, systolic blood pressure, and body mass index, persons who were regular aspirin users had a higher risk of developing neovascular AMD (odds ratio [OR], 2.46; 95% CI, 1.25-4.83). The association showed a dose-response effect (multivariate-adjusted P = .01 for trend). Aspirin use was not associated with the incidence of geographic atrophy (multivariate-adjusted OR, 0.99; 95% CI, 0.59-1.65)., Conclusion: Regular aspirin use is associated with increased risk of incident neovascular AMD, independent of a history of cardiovascular disease and smoking.

Background: Cardiovascular disease is the leading cause of death worldwide. Like many countries, Australia is currently changing its guidelines for cardiovascular disease prevention from drug treatment for everyone with 'high blood pressure' or 'high cholesterol', to prevention based on a patient's absolute risk. In this research, we model cost-effectiveness of cardiovascular disease prevention with blood pressure and lipid drugs in Australia under three different scenarios: (1) the true current practice in Australia; (2) prevention as intended under the current guidelines; and (3) prevention according to proposed absolute risk levels. We consider the implications of changing to absolute risk-based cardiovascular disease prevention, for the health of the Australian people and for Government health sector expenditure over the long term., Methods: We evaluate cost-effectiveness of statins, diuretics, ACE inhibitors, calcium channel blockers and beta-blockers, for Australian men and women, aged 35 to 84 years, who have never experienced a heart disease or stroke event. Epidemiological changes and health care costs are simulated by age and sex in a discrete time Markov model, to determine total impacts on population health and health sector costs over the lifetime, from which we derive cost-effectiveness ratios in 2008 Australian dollars per quality-adjusted life year., Results: Cardiovascular disease prevention based on absolute risk is more cost-effective than prevention under the current guidelines based on single risk factor thresholds, and is more cost-effective than the current practice, which does not follow current clinical guidelines. Recommending blood pressure-lowering drugs to everyone with at least 5% absolute risk and statin drugs to everyone with at least 10% absolute risk, can achieve current levels of population health, while saving $5.4 billion for the Australian Government over the lifetime of the population. But savings could be as high as $7.1 billion if Australia could match the cheaper price of statin drugs in New Zealand., Conclusions: Changing to absolute risk-based cardiovascular disease prevention is highly recommended for reducing health sector spending, but the Australian Government must also consider measures to reduce the cost of statin drugs, over and above the legislated price cuts of November 2010.

Objective: To examine the association between co-morbidities and the use of antidiabetic medications or adjunctive cardiovascular medicines among Australian veterans with diabetes., Methods: data were sourced from the Australian Department of Veterans' Affairs Health Claims database. All veterans aged 65 years and over who were dispensed medicines for diabetes from July to December 2006 were included. Dispensings of antidiabetic and adjunctive cardiovascular medicines over the first six months of 2007 were examined. Log binominal regression models were used to calculate the relative risks of the dispensing of medications for various co-morbidities, taking into account potential confounders., Results: among the 14,802 veterans who were dispensed medicines for diabetes, 70% had five or more co-morbidities. Patients who had diabetes-related co-morbidities had significantly less dispensing of metformin monotherapy and more dispensing of insulin than those without these conditions. Patients who had cardiovascular disease were more likely to have three or more oral antidiabetics dispensed (RR=1.16, 95% CI: 1.04-1.30), particularly those who had heart failure (RR=1.24, 95% CI: 1.05-1.47). Patients with renal disease were more likely to have glitazones dispensed (RR=1.46, 95% CI: 1.24-1.72). Adjunctive cardiovascular medicines were significantly less likely to be dispensed to those with established heart conditions and non-related co-morbidities, particularly dementia., Conclusions: consistent with guideline recommendations, in this cohort more intensive antidiabetic and cardiovascular therapy is used in those with more severe disease as measured by related co-morbidities. Cardiovascular medicines however may be underutilised in those with un-related co-morbidities., (2010 Elsevier Ireland Ltd. All rights reserved.)

Objectives: This study uses data from a prospective randomized controlled trial to estimate predictors of pharmaceutical expenditure in diabetes (DM) or cardiovascular disease (CVD) patients. Identifying drivers of pharmaceutical use and the extent to which they are modifiable may inform cost-effective policy-making., Methods: The trial followed 260 patients aged >18 years (mean 68) from three general practices for 12 months. Patients had type 2 diabetes (90 patients) or cardiovascular disease (170 patients). Costs for pharmaceuticals prescribed on the Pharmaceutical Benefits Scheme (PBS) were obtained retrospectively at 12 months. Sociodemographic data and health-related quality-of-life (QoL) were recorded from questionnaires. Clinical measures (including body mass index (BMI), blood pressure, high and low density lipoprotein (LDL), and HbA1c) were also collected., Results: Mean pharmaceutical costs for DM patients (AU$4119) was greater than CVD patients (AU$2424). The largest contributor to costs in both groups was pharmaceuticals used for management of conditions other than CVD or DM. QoL (EQ5D) and BMI were significant predictors of costs in both groups. A history of cardiac events, HbA1c, age, and unemployment were significant predictors of costs in the DM group. A diagnosis of heart failure, frequency of hospital admissions, and LDL levels were significant predictors of costs in the CVD group. Roughly one third of total variation of costs can be explained by the regressors in both models., Limitations: Generalizability will be limited as data was derived from a trial and the study was not powered for this post-hoc analysis. Missing data imputation and self-reporting bias may also impact on results., Conclusions: Factors such as QoL BMI, HbA1c levels, and a history of cardiac events are significant predictors of costs. The results suggest there may be a place for interventions that improve quality-of-life and concurrently reduce pharmaceutical costs in patients with CVD or DM.

Background: Cardiovascular disease (CVD) is the leading cause of death globally. Community pharmacist intervention studies have demonstrated clinical effectiveness for improving several leading individual CVD risk factors. Primary prevention strategies increasingly emphasise the need for consideration of overall cardiovascular risk and concurrent management of multiple risk factors. It is therefore important to demonstrate the feasibility of multiple risk factor management by community pharmacists to ensure continued currency of their role., Methods/design: This study will be a longitudinal pre- and post-test pilot study with a single cohort of up to 100 patients in ten pharmacies. Patients aged 50-74 years with no history of heart disease or diabetes, and taking antihypertensive or lipid-lowering medicines, will be approached for participation. Assessment of cardiovascular risk, medicines use and health behaviours will be undertaken by a research assistant at baseline and following the intervention (6 months). Validated interview scales will be used where available. Baseline data will be used by accredited medicines management pharmacists to generate a report for the treating community pharmacist. This report will highlight individual patients' overall CVD risk and individual risk factors, as well as identifying modifiable health behaviours for risk improvement and suggesting treatment and behavioural goals. The treating community pharmacist will use this information to finalise and implement a treatment plan in conjunction with the patient and their doctor. Community pharmacists will facilitate patient improvements in lifestyle, medicines adherence, and medicines management over the course of five counselling sessions with monthly intervals. The primary outcome will be the change to average overall cardiovascular risk, assessed using the Framingham risk equation., Discussion: This study will assess the feasibility of implementing holistic primary CVD prevention programs into community pharmacy, one of the most accessible health services in most developed countries., Trial Registration: Australia and New Zealand Clinical Trial Registry Number: ACTRN12609000677202.

Objectives: the study aimed to examine the prevalence of comorbidity, the prescribing of potentially inappropriate medications and treatment conflicts in a large sample of older people who have been dispensed an antidepressant medicine., Methods: a cross-sectional study of administrative claims data from the Department of Veterans' Affairs, Australia, 1 April-31 July 2007, of veterans aged > or =65 years was conducted. Comorbidities determined using the pharmaceutical-based comorbidity index, Rx-Risk-V. Concomitant medicines that may be potentially inappropriate for patients with depression and areas of treatment conflicts were determined from Australian clinical guidelines or reference compendia., Results: a total of 39,695 subjects were included, with a median of 5 comorbid conditions (inter-quartile range 3-6). Ninety percent of medicine use was attributed to the treatment of comorbid conditions. Eighty-seven percent of the study cohort was identified as having at least one comorbid condition that may cause a potential treatment conflict when an antidepressant is used. Those conditions of most concern included cardiovascular diseases, anxiety disorders, arthritis or pain management and osteoporosis., Conclusion: we observed a high level of potentially inappropriate prescribing and treatment conflicts that may arise when caring for older patients dispensed an antidepressant with comorbidity. These have the potential to place a large number of older people with depression at increased risk for adverse events.

Background: Cardiovascular disease (CVD) remains a leading cause of death across the world and poses a significant economic burden. Research regarding per-person use and cost of cardiovascular pharmaceuticals in Australia, as well as potential predictors of pharmaceutical costs in populations using the 'bottom up' costing approach, is limited. Previous studies have adopted 'top down' costing approaches and have been based largely on hypothetical examples and considered only inpatient settings., Objective: To determine the distribution of pharmaceutical costs (from a governmental perspective) related to each cardiovascular risk factor for individuals with, or at high risk of, CVD by analysing data for Australian participants enrolled in the Reduction of Atherothrombosis for Continued Health (REACH) Registry., Methods: 2873 participants were recruited for the REACH Registry through 273 general (primary care) practices in Australia. Included among data collected at baseline was a cardiovascular medicines review. Average weighted costs per person were estimated using Government-reimbursed prices (2007). Annual costs were stratified by sex, age, disease group and other co-morbidities. A multivariate linear regression model was utilized to reveal the predictors of the pharmaceutical costs., Results: The average annual median cost of cardiovascular pharmaceuticals per person was Australian dollars ($A)1310. Use of lipid-lowering agents, non-aspirin (acetylsalicylic acid) antiplatelet agents and thiazolidinediones (glitazones) added significantly to the average annual per-person costs. The multivariate regression model showed that the predictors of annual pharmaceutical costs were dyslipidemia (beta coefficient value [marginal annual cost associated with a condition] $A691; p < 0.001), hypertension ($A346; p < 0.001), vascular disease ($A340; p < 0.001), diabetes mellitus ($A298; p < 0.001), and obesity ($A52; p = 0.03). The same predictors, together with sex, were shown to have an impact on the number of medicines used., Conclusions: Among community-based Australians with, or at risk of, CVD, independent drivers of annual cardiovascular pharmaceutical costs are dyslipidemia (which accounts for half of per-person costs), followed by hypertension, established CVD, and diabetes. Obesity also independently adds to the cost of cardiovascular pharmaceuticals in community-based Australians with, or at risk of, CVD.

Australia's Pharmaceutical Benefits Scheme supports the use of effective drugs for the prevention and control of cardiovascular risk factors. However, there are little data available describing per person costs of medication in primary prevention and secondary prevention in the community. We aim to understand annual expenditure on cardiovascular medicines according to the level and extent of cardiovascular disease, using participants enrolled in the Reduction of Atherothrombosis for Continued Health (REACH) registry. 2873 participants were recruited into the REACH registry through 273 Australian general practices. Cardiovascular medicines review was undertaken at baseline. Average weighted costs of medications were estimated using government-reimbursed prices. Annual costs were stratified by disease extent and location. The annual mean cost of pharmaceuticals per person was 1307 AU dollars. The average reported medicine use per person across all states and participants groups varied significantly. Participants with cerebrovascular or peripheral arterial disease were prescribed less cardiovascular medication than those with coronary artery disease (CAD) (mean number of drugs 3.5 vs. 4.5, P < 0.0001) and (3.6 vs. 4.5, P < 0.0001), while those with risk factor alone had the same medication use as those with CAD (mean number 4.5). Medication use was lower in Western Australia in comparison to eastern States. Participants with existing cerebrovascular disease and peripheral vascular disease receive less preventive therapy than those with CAD or even risk factors alone. This observation is consistent across all mainland states. Given the evidence of the effectiveness and cost-effectiveness of treating all types of vascular diseases, the present study suggests that there is scope to improve the treatment of these high-risk participants in Australia.

Aims and Objectives: Community awareness of the importance of hypercholesterolemia and the need for appropriate therapy is an important part of global efforts to reduce the population burden of cardiovascular disease. The aim of this study was to assess the knowledge and attitudes about cholesterol and to determine adherence to taking cholesterol-lowering medication among patients at high risk for cardiovascular events., Background: In spite of the availability of lifestyle and medical treatments for lipid management, an estimated 50% of adult Australians (6.4 million) remain at risk for a cardiovascular-related event because they have total blood cholesterol levels which exceed recommended limits. It is within this context that a significant gap remains in meeting cholesterol goals, despite easy to meet targets with readily available therapeutic options., Design: A two-page national self-report postal survey was conducted from August-October 2006., Methods: A total of 508 Australian adults previously treated for hypercholesterolemia were surveyed to determine their understanding about cholesterol and their adherence to treatment. The mean age of participants was 67 (SD 10) years (72% male). Many participants (72%) were at risk of a cardiovascular event based on a prior history and 18% had type II diabetes., Results: Participants had been prescribed lipid-lowering therapy (94% statin therapy) for an average of 10 years and visited their general practitioner on average three times per year. For those who knew their most recent cholesterol reading (67%), the total cholesterol was on average 4.5 (SD 1.1) mmol/l. This level was above the recommended limits for 40% of participants. Overall, 85% of participants reported knowing that there was high- and low-density lipoprotein forms of cholesterol, but only 56% and 38%, respectively, said that they understood or showed signs of clearly understanding the different types of cholesterol when their knowledge was assessed further. On the whole, therefore, participants had a limited understanding about cholesterol and its potential impact on cardiovascular events. Moreover, 25% of participants admitted to being non-compliant in taking their medication and only 51% correctly identified modifiable risk factors as most important for heart disease. Encouragingly, despite 85% of participants finding lifestyle changes challenging, most still identified their potential benefits., Conclusions: This study highlights that there are many unresolved issues in relation to educating high-risk patients who regularly visit their general practitioner to learn about and optimise their cholesterol levels via appropriate treatment and monitoring., Relevance to Clinical Practice: There is a need for urgent public education and management by individuals and the health community. Strategies to address 'cholesterol complacency', in the sense of a willingness to accept sub-optimal standards of cholesterol control at both the patient and healthcare system levels (general practitioners in particular), are urgently needed to truncate an anticipated rising tide of cardiovascular disease in Australia.

Background: The provincial formulary review processes in Canada lead to the slow and inequitable availability of new products. In 2004, the exploration of a national pharmaceuticals strategy (NPS) was announced. The pricing policies of New Zealand and Australia have been suggested as possible models for the NPS., Objective: To compare health care indexes and health care use information from Canada, Australia and New Zealand., Methods: The 2006 Organisation for Economic Co-operation and Development health data were used to compare health and health care indexes from Canada, Australia and New Zealand between 1994 and 2002 to 2004. The principal focus of the evaluation was cardiovascular and respiratory disorders., Results: Although the mortality rate from acute myocardial infarction decreased in each country from 1994, it levelled off in New Zealand in 1997, 1998 and 1999. Between 1994 and 2003, the average length of hospital stay for any cause and for cardiovascular disorders was stable in Australia and Canada, but increased in New Zealand, while the rate of hospital discharges for cardiovascular diseases decreased in Canada and Australia, but strongly increased in New Zealand. Over the same period, sales of cardiovascular drugs decreased in New Zealand, while sharply increasing in Canada and Australia., Conclusions: Although only circumstantial, our results suggest an association between decreasing cardiovascular drug sales and markers of declining cardiovascular health in New Zealand. Careful consideration must be given to the potential consequences of any model for an NPS in Canada, as well as to opportunities provided for discussion and input from health care professionals and patients.

Objective: The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) Study is examining the effects of long-term fibrate therapy on coronary heart disease (CHD) event rates in patients with diabetes mellitus. This article describes the trial's run-in phase and patients' baseline characteristics., Research Design and Methods: FIELD is a double-blind, placebo-controlled trial in 63 centres in 3 countries evaluating the effects of fenofibrate versus placebo on CHD morbidity and mortality in 9795 patients with type 2 diabetes mellitus. Patients were to have no indication for lipid-lowering therapy on randomization, but could start these or other drugs at any time after randomization. Follow-up in the study was to be for a median duration of not less than 5 years and until 500 major coronary events (fatal coronary heart disease plus nonfatal myocardial infarction) had occurred., Results: About 2100 patients (22%) had some manifestation of cardiovascular disease (CVD) at baseline and thus high risk status. Less than 25% of patients without CVD had a (UKPDS determined) calculated 5-year CHD risk of <5%, but nearly all had a 5-year stroke risk of <10%. Despite this, half of the cohort were obese (BMI > 30), most were men, two-thirds were aged over 60 years, and substantial proportions had NCEP ATP III features of the metabolic syndrome independent of their diabetes, including low HDL (60%), high blood pressure measurement (41%), high waist measurement (65%), and raised triglycerides (52%). After a 6-week run-in period before randomisation with all participants receiving 200 mg comicronized fenofibrate, there were declines in total and LDL cholesterol (10%) and triglycerides (26%) and an increase in HDL cholesterol (6.5%)., Conclusion: The study will show the effect of PPAR-alpha agonist action on CHD and other vascular outcomes in patients with type 2 diabetes including substantial numbers with low to moderate CVD risk but with the various components of the metabolic syndrome. The main results of the study will be reported in late 2005.

Background: Little information is available about patients' perspectives on self- or nurse-related administration of medication., Aim: The aim of the study was to determine patients' perspectives about self-medication in the acute care setting., Methods: A qualitative approach, using in-depth semi-structured interviews, was taken. Ten patients with a chronic medical illness who had experienced multiple hospital admissions for treatment were interviewed about their experiences of medication administration in the acute care setting. Participants were recruited from two cardiovascular wards in a private, not-for-profit hospital in Melbourne, Australia. Data collection occurred between August and September 2002., Findings: Four major themes were identified from the interviews: benefits of self-administration, barriers to self-administration, assessing appropriateness of self-administration and timing of medication administration. Seven participants had previously experienced self-administration of medications and six were in favour of this practice in the clinical setting. Nine managed their own medications at home, and one self-administered with some assistance from his family. Participants were very concerned about how nurses' heavily regulated routines affected delivery of medications in hospital and disrupted individualized plans of care maintained in the home setting., Conclusions: In planning and implementing self-administration programmes, it is important to consider patients' views. Medication regimes should be simple and flexible enough to adapt to patients' lifestyles and usual routines. Nurses should also take advantage of opportunities to support and facilitate patient autonomy, to enable more effective management of health care needs when patients return home.

Unlabelled: This population-based study documented beta-blocker use in 59/569 cases with incident fracture and 112/775 controls. OR for fracture associated with beta-blocker use was 0.68 (95%CI, 0.49-0.96). Beta-blockers were associated with higher BMD at the total hip (2.5%) and UD forearm (3.6%) after adjusting for age, anthropometry, and thiazide use. Beta-blocker use is associated with reduced fracture risk and higher BMD., Introduction: Animal data suggests that bone formation is under beta-adrenergic control and that beta-blockers stimulate bone formation and/or inhibit bone resorption., Materials and Methods: We evaluated the association between beta-blocker use, bone mineral density (BMD), and fracture risk in a population-based study in Geelong, a southeastern Australian city with a single teaching hospital and two radiological centers providing complete fracture ascertainment for the region. Beta-blocker use was documented for 569 women with radiologically confirmed incident fractures and 775 controls without incident fracture. Medication use and lifestyle factors were documented by questionnaire., Results: Odds ratio for fracture associated with beta-blocker use was 0.68 (95% CI, 0.49-0.96) for any fracture. Adjusting for age, weight, medications, and lifestyle factors had little effect on the odds ratio. Beta-blocker use was associated with a higher BMD at the total hip (2.5%, p = 0.03) and ultradistal forearm (3.6%, p = 0.04) after adjustment for age, anthropometry, and thiazide use., Conclusion: Beta-blockers are associated with a reduction in fracture risk and higher BMD.

Background: The Heart Outcomes Prevention Evaluation (HOPE) study has demonstrated that ramipril 10 mg/day for 5 years in an at-risk population results in clinically and statistically significant reductions in the occurrence of cardiovascular death, myocardial infarction (MI), stroke and revascularization procedures. The likely impact of the intervention in Australia, in terms of the number of potential events avoided and the cost per life-year saved, has previously not been determined., Aims: To assess the clinical and economic impacts of the use of daily ramipril in the Australian at-risk population from the perspective of the public health-care budget., Methods: The clinical benefits were calculated from endpoints used in the trial, which were converted to the 'number needed to treat'. These were then applied to the at-risk population, which was determined nationally from the relevant Australian statistics. The result of this calculation is the potential number of events avoided in Australia. The economic benefits were established by undertaking an incremental cost-effectiveness analysis. The economic model considered the clinical benefits and the costs (and cost offsets) arising from ramipril 10 mg/day therapy for 5 years. Life-years saved was determined by calculating the difference in total years survived between the ramipril and control arms of the study. Net costs divided by life-years saved is the cost per life-year saved, and this is reported in Australian dollars as the incremental cost effectiveness., Results: The clinical benefits over a 5-year period were expressed as the number of potential events avoided and comprised approximately: 9188 strokes; 14 658 MI; 14 317 revascularization procedures; and 12,534 cardiovascular-related deaths, nationally. The incremental cost-effectiveness analysis showed the estimated cost per life-year saved to be 17,214 Australia dollars., Conclusion: The use of ramipril 10 mg/day over a 5-year period in the at-risk Australian population could prevent many thousands of cardiovascular events, including 12,534 cardiovascular-related deaths. The cost per life-year saved compares favourably to other health care interventions.