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A veterans affairs study estimated costs associated with incorporating the FOURIER findings on PCSK9 inhibition into practice.
It found approximately one-fourth of U.S. veterans ages 40 to 85 with atherosclerotic cardiovascular disease met eligibility criteria of the cardiovascular outcomes trial with evolocumab (Repatha). If all 154,823 such patients were treated, the VA would be looking at a cost of $2.08 billion per year.
But focusing on boosting use of maximal oral therapies first would cut the numbers substantially. Up-titrating to high-intensity statins for the half of eligible patients not receiving them would cut eligibility for evolocumab by about 20%. Addition of ezetimibe would cut it to half. Trying to improve statin adherence would help too, the researchers wrote in Circulation.
"Restricting [evolocumab] to patients with LDL >70 mg/dL after accounting for cost associated with titration to high-intensity statin plus ezetimibe would be expected to result in an annual net cost savings of $1.13 billion," the group noted.
"Importantly, we show that healthcare systems have considerable opportunity to increase use of evidence-based high-intensity statins and ezetimibe which may reduce the need for additional costly therapies such as evolocumab."
Nonadherence Prediction
Blood and urine testing on patients referred to a specialty center for suspected antihypertensive nonadherence turned up some factors that might help predict true nonadherence, researchers said.
Biochemical testing confirmed nonadherence in 41.6% and 31.5% of such patients in U.K. and Czech populations, respectively, in the study reported in Hypertension. Predictive factors were younger age, being female, use of diuretics, and higher number of prescribed antihypertensives, which together had areas under the curve of 0.758 and 0.710 in the British and Czech populations, respectively.
The researchers highlighted the number and class of prescribed antihypertensives as modifiable risk factors, suggesting that using combination pills to address pill burden could help.
But there's no simple answer to antihypertensive medication nonadherence, an accompanying editorial argued.
BP Trajectories and Dementia
Persistently high blood pressure in mid- and late-life was associated with elevated dementia risk, in an analysis of Framingham Offspring Study data presented at the American Academy of Neurology meeting in Boston.
Blood pressure that remained at 140/90 mm Hg or greater after age 55 was associated with a hazard ratio of 1.96 for incident dementia (95% CI 1.25-3.06) compared with people whose blood pressure was and remained below that threshold. But dementia risk was also elevated in people who started with controlled blood pressure in middle age that then saw a steeper than average drop in their systolic blood pressure into late-life (HR 2.40, 95% CI 1.39-4.15)
As to the observational findings, AAN session moderator David Wolk, MD, of the University of Pennsylvania in Philadelphia, told MedPage Today, "I think that in some internal medicine practices, clinicians tend to get a little looser in controlling blood pressure later in life, with the idea that elevated blood pressure is an accumulated risk and in later life it may not matter as much. I think there often is more concern about hypotension and its consequences as well."
However, he concluded, "The bottom line here is that keeping your body healthy -- including blood pressure -- also tends to keep your brain healthy."
See the full MedPage Today story here.
Blood Pressure Targets In Acute Stroke
A post hoc analysis of the ATACH-2 trial that had been halted for futility turned up some suggestive -- but not significant -- findings favoring treatment to bring systolic pressure to between 110 and 139 mm Hg for acute cerebral hemorrhage.
Researchers at the annual meeting of the American Academy of Neurology reported that hematoma expansion was seen in about 18% of those assigned to the intensive blood pressure target compared with 24% among those maintained to 140 to 179 mm Hg.
There were also nonsignificant signals for advantages of intensive blood pressure control for substantial expansion, control of large hematomas, and disability measures.
"We have learned from the ATACH studies that these are hard things to do," commented Natalia Rost, MD, of the Massachusetts General Hospital in Boston. "Stroke is complicated and we keep missing the targets on both the cutoffs and on the use of markers. We use intermediate markers such as what we see on an image. But we don't have evidence that these markers are perfect. But I think we may be making some progress."
See the rest of the story on MedPage Today.
In Other News
Medevac for the neurointerventionalist rather than the patient may be a faster and less expensive route to endovascular stroke treatment than transferring to a hospital with capacity for the procedure, MedPage Today reports from a proof-of-concept case in the Journal of Neurointerventional Surgery.