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Abstract: Background: Although few cardiovascular registries report the costs of illness or cost-effectiveness of health interventions, such information is critical to inform the effective and cost-effective management of cardiovascular disease, particularly if drawn from population-based registries, which more accurately reflect clinical practice and follow up patients for much longer than clinical trials. Objective: The goal of this study was to estimate the cost-effectiveness of closing the statin “treatment gap” in the secondary prevention of coronary artery disease (CAD) in Australia. Methods: A decision analysis Markov model was developed with yearly cycles and the health states of alive or dead. Using data from the Australian Reduction of Atherothrombosis for Continued Health Registry, the model compared current statin coverage (82%) in the secondary prevention of CAD (the current group) with a hypothetical situation of 100% coverage (the improved group). The 18% gap was filled with use of generic statins. Data from a recent meta-analysis were used to estimate the benefits of statin use in terms of reducing recurrent cardiovascular events and death. Government reimbursement data from 2011 were used to calculate direct health care costs. The cost of the intervention to improve statin coverage was assumed to be $250 per person. Years of life lived and costs were discounted at 5% annually. All values are given in Australian dollars. Results: Among the 2058 subjects in the current group, the model estimated that there would be 106 nonfatal myocardial infractions, 68 nonfatal strokes, and 275 deaths over 5 years. In the improved group, all of whom took statins, the corresponding numbers were 101, 65, and 259, equating to numbers needed to treat of 426, 639, and 127, respectively. Over the 5 years, there would be 0.018 life-years gained (discounted) at a net cost of $546 (discounted) per person. These equated to an incremental cost-effectiveness ratio of $29,717 per life-year gained. Conclusion: The results suggest that for patients with CAD, maximizing coverage with statins, in line with evidence-based recommendations, represents a cost-effective means of secondary prevention. [Copyright &y& Elsevier]

Aim: To determine the current prevalence and control of major cardiovascular risk factors in stable CAD outpatients worldwide., Methods: We analysed variations in cardiovascular risk factors in stable CAD outpatients from CLARIFY, a 5-year observational longitudinal cohort study, in seven geographical zones (Western/Central Europe; Canada/South Africa/Australia/UK; Eastern Europe; Central/South America; Middle East; East Asia; and India)., Results: Patient presentation (N=32,954, mean age 64.2 years, 78% male) varied between zones, as did prevalence of risk factors (all p < 0.0001). Obesity ranged from 20% (East Asia) to 42% (Middle East), raised blood pressure from 28% (Central/South America and East Asia) to 48% (Eastern Europe), raised LDL cholesterol from 24% (Canada/South Africa/Australia/UK) to 65% (Eastern Europe), elevated heart rate (≥70 bpm) from 38% (Western/Central Europe) to 78% (India), diabetes from 17% (Eastern Europe) to 60% (Middle East), and smoking from 6% (Central/South America) to 19% (Eastern Europe). Aspirin and lipid-lowering drugs were widely used everywhere (≥84% and ≥88%, respectively). Rates of risk factor control varied geographically (all p < 0.0001). Rate of controlled blood pressure in hypertension varied from 47% (Eastern Europe) to 66% (Central/South America), glucose control in diabetes from 23% (India) to 51% (Western/Central Europe and East Asia), controlled LDL cholesterol and dyslipidaemia from 32% (Eastern Europe) to 75% (Canada/South Africa/Australia/UK), heart rate <70 bpm from 22% (India) to 62% (Western/Central Europe), and heart rate ≤60 bpm in angina patients from 2% (India) to 29% (Canada/South Africa/Australia/UK and Central/South America)., Conclusion: Prevalence and control of major cardiovascular risk factors in stable CAD vary markedly worldwide. Many stable CAD outpatients are being treated suboptimally., (© The European Society of Cardiology 2014.)

Objective: The aim of the study is to determine the extent of lost therapeutic benefit (LTB) in the hypertensive patients, and to determine the relationship between the presence of LTB and clinical outcomes., Methods: Prospective-cohort study of n = 2856 patients with or at high risk of atherothrombosis. LTB was calculated as the proportion of patients receiving blood pressure medication who were not attaining guideline blood pressure (BP) control targets (<140/90 mmHg). Logistic regression analysis was performed to identify predictors of LTB at baseline, and propensity score matching (PSM) was undertaken to estimate the treatment effects by matching case LTB and control non-LTB cohorts based on the nearest neighbor matching., Results: Of the total sample of 2856, 45.6% had uncontrolled BP, and LTB was present in 46.7% patients. The likelihood of LTB was less in males (OR = 0.78 [95% CI; 0.64-0.97]), and those with a previous myocardial infarction (OR = 0.66 [0.53-0.81]) or heart failure (OR = 0.58 [0.42-0.82]). LTB was more common in those with diabetes (OR = 1.44 [1.16-1.79]), aged >65 years (OR = 1.36 [1.06-1.75]) and having an ABI < 0.09 in either leg at rest (OR = 1.30 [1.02-1.75]). Following PSM, the combination of ischemic events (55-64 age category) was more likely to occur in the LTB compared with non-LTB group (4.38% and 0.68%, respectively [P = 0.046])., Conclusion: Presence of HF, previous MI and being male decreased the likelihood of LTB, while presence of diabetes, age > 65 and ABI < 0.09 increased the risk of LTB. Patients with LTB in age category 55-64 had higher incidence of vascular events compared with those with non-LTB., (© 2013 John Wiley & Sons Ltd.)

Aims: To describe aspirin use in primary and secondary prevention and to determine the incremental costs-effectiveness ratio (ICER) per life year gain (LYG) of aspirin use among subjects with, or at high risk of atherothrombotic disease., Design and Subjects: To project the cost-effectiveness of aspirin over 5 years of follow-up, a Markov state transition model was developed with yearly cycles and the following health states: "Alive" (post-CAD) and "Dead." The model compared current coverage observed among 2361 subjects using the prospective Australian subset of Reduction of Atherothrombosis for continued Health (REACH) registry, and hypothetical situation whereby all subjects assumed to be treated. Costs were calculated based on the Australian government reimbursed data for 2010., Main Outcome Measures: ICER per LYG for increased use of aspirin., Results: The use of aspirin in current group varied from 67% to 70%. The base-case analysis showed that increasing aspirin use among subjects with existing CAD in outpatient settings was cost saving, while increasing use of aspirin in primary prevention equated to an ICER of AUD 7126 per LYG., Conclusion: Among subjects with existing CAD aspirin use was shown to be a dominant choice of treatment. However, among patients without existing cardiovascular disease (primary prevention), increased uptake of aspirin was cost effective but with uncertain benefit, with two hemorrhagic bleeding events occurring for every life saved., (© 2011 Blackwell Publishing Ltd.)

Objective: To report on 1-year cardiovascular (CV) event rates in patients with established cardiovascular disease (CVD) or with multiple cardiovascular risk factors., Design, Patients and Setting: Prospective cohort study of 2873 patients at high risk of atherothrombosis based on the presence of multiple risk factors and overt coronary artery disease (CAD), cerebrovascular disease (CerVD) or peripheral arterial disease (PAD) presenting to 273 Australian general practitioners; this study was conducted as part of the international REACH Registry., Main Outcome Measures: One-year rates of cardiovascular death, myocardial infarction, stroke, and hospitalisation for cardiovascular procedures., Results: The cardiovascular death rate at 1 year was 1.4%. The combined cardiovascular death, non-fatal MI, stroke and hospitalisation rate for vascular disease affecting one location at 1 year was 11%. Even for patients with no overt disease, but with multiple risk factors, the 1-year combined event rate was 4.2%. The highest combined event rate was in patients with PAD (21.0%), and in patients with atherothrombotic disease identified in all three locations (coronary arteries, cerebrovascular system and peripheral arteries) at 39%., Conclusion: The rate of clinical events in community-based patients with stable atherothrombotic disease increases dramatically with the severity of disease and the number of vascular beds involved. Where disease was evident in all three locations, and for patients with PAD alone, the 1-year risk of cardiovascular events was substantially increased. Poor adherence to statin therapy in the secondary preventive setting is a major treatment gap that needs to be closed; the influences of obesity and diabetes warrant further investigation.

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.

Objectives: Our purpose was to evaluate long-term mortality and identify factors associated with 1-year mortality in patients who underwent elective percutaneous coronary intervention (PCI)., Background: While long-term outcomes in PCI patients have been reported previously, limited data are currently available regarding the comparative long-term outcomes in PCI patients who receive enoxaparin versus intravenous unfractionated heparin (UFH)., Methods: We conducted a follow-up analysis of clinical outcomes at 1 year in patients enrolled in the STEEPLE (SafeTy and Efficacy of Enoxaparin in Percutaneous coronary intervention patients, an internationaL randomized Evaluation) trial of 3,528 patients undergoing elective PCI. Patients were randomized to receive either intravenous 0.50-mg/kg or 0.75-mg/kg enoxaparin or intravenous UFH during elective PCI procedures. All-cause mortality at 1 year after index PCI was the main outcome measure., Results: Mortality rates were 1.4%, 2.0%, and 1.5% from 1 month to 1 year, and 2.3%, 2.2%, and 1.9% from randomization to 1 year, after index PCI in patients receiving 0.50 mg/kg enoxaparin, 0.75 mg/kg enoxaparin, and UFH, respectively. Multivariate analysis identified nonfatal myocardial infarction and/or urgent target vessel revascularization up to 30 days after index PCI (hazard ratio: 3.5, 95% confidence interval: 1.7 to 7.3; p < 0.001), and major bleeding within 48 h (hazard ratio: 3.0, 95% confidence interval: 1.1 to 8.5; p = 0.04) as the strongest independent risk factors for 1-year mortality., Conclusions: The 1-year mortality rates were low and comparable between patients receiving enoxaparin and UFH during elective PCI. Periprocedural ischemic or bleeding events were the strongest independent predictors of 1-year mortality. (The STEEPLE Trial; NCT00077844).