Association of Statin Use With All-Cause and Cardiovascular Mortality in US Veterans 75 Years and Older
Association of Statin Use With All-Cause and Cardiovascular Mortality in US Veterans 75 Years and Older
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DOI：
10.1001/jama.2020.7848
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发表时间：
2020-07-07
影响因子：
120.7
通讯作者：
Djousse, Luc
中科院分区：
文献类型：
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作者：
Orkaby, Ariela R.;Driver, Jane A.;Djousse, Luc
在基线时无动脉粥样硬化性心血管疾病的75岁及以上的美国退伍军人中，他汀类药物的使用是否与死亡风险降低相关？在这项回顾性队列研究中，使用倾向评分重叠加权，包括326981名参与者，与未使用他汀类药物相比，使用他汀类药物与全因死亡率和心血管死亡率的风险降低显著相关（风险比分别为0.75和0.80）。在基线时无动脉粥样硬化性心血管疾病的美国老年退伍军人中，他汀类药物治疗与较低的死亡率风险显著相关。重要的是，关于他汀类药物治疗75岁及以上成人动脉粥样硬化性心血管疾病（ASCVD）一级预防的数据有限。目的评价他汀类药物在75岁及以上退伍军人ASCVD死亡率和一级预防中的作用。回顾性队列研究，使用退伍军人健康管理局（VHA）的数据，75岁及以上的成人，无ASCVD，2002-2012年进行临床随访。随访持续至2016年12月31日。所有数据都与医疗保险和医疗补助索赔以及药物数据有关。使用新用户设计，排除那些与任何先前他汀类药物使用。采用考克斯比例风险模型评估他汀类药物使用与预后的关系。使用倾向评分重叠加权进行分析，以平衡基线特征。任何新的他汀类药物处方。主要结局和指标主要结局为全因死亡率和心血管死亡率。次要结局包括ASCVD事件的复合终点（心肌梗死、缺血性卒中和冠状动脉旁路移植术或经皮冠状动脉介入治疗的血运重建）。结果在326981名合格的退伍军人中（平均[SD]年龄，81.1 [4.1]岁; 97%为男性; 91%为白色），57178名（17.5%）在研究期间新开始使用他汀类药物。在平均6.8次随访期间（SD，3.9）年，共发生206902例死亡，包括53296例心血管死亡，他汀类药物使用者和非使用者的总死亡数分别为78.7和98.2例/1000人-年（加权发病率差异[IRD]/1000人-年，-19.5 [95%CI，-20.4至-18.5]）。在他汀类药物使用者和非使用者中，每1000人-年分别有22.6和25.7例心血管死亡（加权IRD/1000人-年，-3.1 [95 CI，-3.6至-2.6]）。对于复合ASCVD结局，有123379起事件，他汀类药物使用者和非使用者中分别有66.3和70.4起事件/1000人-年（加权IRD/1000人-年，-4.1 [95% CI，-5.1至-3.0]）。应用倾向评分重叠加权后，比较他汀类药物使用者与非使用者时，全因死亡率的风险比为0.75（95% CI，0.74-0.76），心血管死亡率的风险比为0.80（95% CI，0.78-0.81），ASCVD复合事件的风险比为0.92（95% CI，0.91-0.94）。结论和相关性在基线时无ASCVD的75岁及以上的美国退伍军人中，新的他汀类药物的使用与全因和心血管死亡风险降低显著相关。需要进一步的研究，包括随机临床试验，以更明确地确定他汀类药物治疗在老年人ASCVD一级预防中的作用。这项回顾性队列研究使用退伍军人健康管理局关于无动脉粥样硬化性心血管疾病（ASCVD）的成年人的数据，以评估新的他汀类药物使用与全因和心血管死亡率之间的关系，以及ASCVD事件的复合事件（心肌梗死、缺血性卒中和CABG手术或PCI血运重建）。
Key PointsQuestionAmong US veterans 75 years and older and free of atherosclerotic cardiovascular disease at baseline, is statin use associated with lower risk of mortality? FindingsIn this retrospective cohort study that used propensity score overlap weighting and included 326981 participants, statin use, compared with no statin use, was significantly associated with a lower risk of all-cause and cardiovascular mortality (hazard ratios, 0.75 and 0.80, respectively). MeaningAmong older US veterans without atherosclerotic cardiovascular disease at baseline, statin therapy was significantly associated with a lower risk of mortality.ImportanceData are limited regarding statin therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in adults 75 years and older. ObjectiveTo evaluate the role of statin use for mortality and primary prevention of ASCVD in veterans 75 years and older. Design, Setting, and ParticipantsRetrospective cohort study that used Veterans Health Administration (VHA) data on adults 75 years and older, free of ASCVD, and with a clinical visit in 2002-2012. Follow-up continued through December 31, 2016. All data were linked to Medicare and Medicaid claims and pharmaceutical data. A new-user design was used, excluding those with any prior statin use. Cox proportional hazards models were fit to evaluate the association of statin use with outcomes. Analyses were conducted using propensity score overlap weighting to balance baseline characteristics. ExposuresAny new statin prescription. Main Outcomes and MeasuresThe primary outcomes were all-cause and cardiovascular mortality. Secondary outcomes included a composite of ASCVD events (myocardial infarction, ischemic stroke, and revascularization with coronary artery bypass graft surgery or percutaneous coronary intervention). ResultsOf 326981 eligible veterans (mean [SD] age, 81.1 [4.1] years; 97% men; 91% white), 57178 (17.5%) newly initiated statins during the study period. During a mean follow-up of 6.8 (SD, 3.9) years, a total 206902 deaths occurred including 53296 cardiovascular deaths, with 78.7 and 98.2 total deaths/1000 person-years among statin users and nonusers, respectively (weighted incidence rate difference [IRD]/1000 person-years, -19.5 [95% CI, -20.4 to -18.5]). There were 22.6 and 25.7 cardiovascular deaths per 1000 person-years among statin users and nonusers, respectively (weighted IRD/1000 person-years, -3.1 [95 CI, -3.6 to -2.6]). For the composite ASCVD outcome there were 123379 events, with 66.3 and 70.4 events/1000 person-years among statin users and nonusers, respectively (weighted IRD/1000 person-years, -4.1 [95% CI, -5.1 to -3.0]). After propensity score overlap weighting was applied, the hazard ratio was 0.75 (95% CI, 0.74-0.76) for all-cause mortality, 0.80 (95% CI, 0.78-0.81) for cardiovascular mortality, and 0.92 (95% CI, 0.91-0.94) for a composite of ASCVD events when comparing statin users with nonusers. Conclusions and RelevanceAmong US veterans 75 years and older and free of ASCVD at baseline, new statin use was significantly associated with a lower risk of all-cause and cardiovascular mortality. Further research, including from randomized clinical trials, is needed to more definitively determine the role of statin therapy in older adults for primary prevention of ASCVD.This retrospective cohort study uses Veterans Health Administration data on adults free of atherosclerotic cardiovascular disease (ASCVD) to evaluate the association between new statin use and all-cause and cardiovascular mortality, and a composite of ASCVD events (myocardial infarction, ischemic stroke, and revascularization with CABG surgery or PCI), in veterans 75 years and older.