This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (108)  • Contact me when this article is cited  Related Content  • Related letters  • Similar articles in JAMA  Topic Collections  • Aging/ Geriatrics  • Nutritional and Metabolic Disorders  • Lipids and Lipid Disorders  • Cardiovascular System  • Cardiovascular Disease/ Myocardial Infarction  • Alert me on articles by topic  Social Bookmarking   What's this?

The Treatment-Risk Paradox

Dennis T. Ko, MD; Muhammad Mamdani, PharmD, MPH; David A. Alter, MD, PhD

JAMA. 2004;291:1864-1870.

Context  The benefits of cardiovascular therapies such as statins for secondary prevention have been well documented, although they may not be optimally used in patients most likely to benefit. Ideally, aggressiveness in the use of these beneficial therapies should correlate with baseline cardiovascular risk.

Objective  To examine the association between physicians' treatment aggressiveness and baseline cardiovascular risk.

Design, Setting, and Patients  Retrospective cohort study incorporating the use of multiple linked health care administrative databases covering more than 1.4 million elderly residents of Ontario. We included 396 077 patients aged 66 years or older who had a history of cardiovascular disease or diabetes while undergoing medical treatment and who were alive on April 1, 1998. Baseline cardiovascular risk was derived using a risk-adjustment index in which we modeled probability of death after 3 years of follow-up.

Main Outcome Measure  Likelihood of statin use, stratified by baseline cardiovascular risk, after adjusting for age, sex, socioeconomic status, and rural or urban residence.

Results  Only 75 617 patients (19.1%) in this secondary prevention cohort were prescribed statins. In patients 66 to 74 years old, the adjusted probabilities of statin prescription were 37.7%, 26.7%, and 23.4% in the categories of low, intermediate, and high baseline risk, respectively. The likelihood of statin prescription was 6.4% lower (adjusted odds ratio, 0.94; 95% confidence interval, 0.93-0.95) for each year of increase in age and each 1% increase in predicted 3-year mortality risk. The influence of age also interacted synergistically with baseline risk on the prescription of statins (P<.001).

Conclusions  We found that prescription of statins diminished progressively as baseline cardiovascular risk and future probability of death increased. Since the benefits of a therapy are dependent on the baseline risk, the maximum benefits of statins may not be fully realized until implementation of therapy includes patients at highest risk.

Author Affiliations: Division of Cardiology, Schulich Heart Centre, and Department of Medicine, Sunnybrook and Women's College Health Sciences Centre (Drs Ko and Alter), and Institute for Clinical Evaluative Sciences (Drs Ko, Mamdani, and Alter), Toronto, Ontario.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

RELATED LETTERS

Risk-Treatment Paradox in Use of Statins
Carlos O. Weiss and Ravi Varadhan
JAMA. 2004;292(2):169.
EXTRACT | FULL TEXT  

Risk-Treatment Paradox in Use of Statins—Reply
Dennis T. Ko and David A. Alter
JAMA. 2004;292(2):169.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Nebivolol in older adults with heart failure reduced rates for seniors?
Armstrong and Alexander
J Am Coll Cardiol 2009;53:2159-2161.
FULL TEXT  

Medication errors: what they are, how they happen, and how to avoid them
Aronson
QJM 2009;0:hcp052v1-hcp052.
ABSTRACT | FULL TEXT  

Management of Hyperlipidemia in Older Adults
Alexander et al.
J CARDIOVASC PHARMACOL THER 2009;14:49-58.
ABSTRACT  

Statins: Not just for the young or the faint of heart
Coull and Johnston
Neurology 2009;72:684-685.
FULL TEXT  

Effect of atorvastatin in elderly patients with a recent stroke or transient ischemic attack
Chaturvedi et al.
Neurology 2009;72:688-694.
ABSTRACT | FULL TEXT  

Beyond the Randomized Clinical Trial: The Role of Effectiveness Studies in Evaluating Cardiovascular Therapies
Nallamothu et al.
Circulation 2008;118:1294-1303.
FULL TEXT  

Discontinuation of statin therapy following an acute myocardial infarction: a population-based study
Daskalopoulou et al.
Eur Heart J 2008;29:2083-2091.
ABSTRACT | FULL TEXT  

Prevalence, Predictors, and Impact of Conservative Medical Management for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Who Have Angiographically Documented Significant Coronary Disease
Chan et al.
J Am Coll Cardiol Intv 2008;1:369-378.
ABSTRACT | FULL TEXT  

Reducing Post-Myocardial Infarction Mortality in the Elderly: The Power and Promise of Secondary Prevention
Boden and Maron
J Am Coll Cardiol 2008;51:1255-1257.
FULL TEXT  

Regional Variation in Cardiac Catheterization Appropriateness and Baseline Risk After Acute Myocardial Infarction.
Ko et al.
J Am Coll Cardiol 2008;51:716-723.
ABSTRACT | FULL TEXT  

Use of statins and beta-blockers after acute myocardial infarction according to income and education
Rasmussen et al.
J. Epidemiol. Community Health 2007;61:1091-1097.
ABSTRACT | FULL TEXT  

Compliance with National Guidelines for the Management of Drug Drug Interactions in Dutch Community Pharmacies
Buurma et al.
The Annals of Pharmacotherapy 2007;41:2024-2031.
ABSTRACT | FULL TEXT  

Patterns and predictors of statin use after coronary artery bypass graft surgery.
Kulik et al.
J. Thorac. Cardiovasc. Surg. 2007;134:932-938.
ABSTRACT | FULL TEXT  

Statins prescribing for the secondary prevention of ischaemic heart disease in Torino, Italy. A case of ageism and social inequalities
Gnavi et al.
Eur J Public Health 2007;17:492-496.
ABSTRACT | FULL TEXT  

Review: Statin plus thiazolidinedione use in patients with diabetes at high cardiovascular risk
Erdmann
British Journal of Diabetes & Vascular Disease 2007;7:211-216.
ABSTRACT  

Missed opportunities for secondary prevention of cerebrovascular disease in elderly British men from 1999 to 2005: a population-based study
Ramsay et al.
J Public Health (Oxf) 2007;29:251-257.
ABSTRACT | FULL TEXT  

Cholesterol Fractions and Apolipoproteins as Risk Factors for Heart Disease Mortality in Older Men
Clarke et al.
Arch Intern Med 2007;167:1373-1378.
ABSTRACT | FULL TEXT  

Effect of long-term ACE-inhibitor therapy in elderly vascular disease patients
Gianni et al.
Eur Heart J 2007;28:1382-1388.
ABSTRACT | FULL TEXT  

Cardiovascular disease and the elderly: can the evidence base avoid irrelevance?
Peterson and Masoudi
Eur Heart J 2007;28:1277-1278.
FULL TEXT  

Translating Evidence Into Practice: Are We Neglecting the Neediest?
Spertus and Furman
Arch Intern Med 2007;167:987-988.
FULL TEXT  

Management Patterns in Relation to Risk Stratification Among Patients With Non-ST Elevation Acute Coronary Syndromes
Yan et al.
Arch Intern Med 2007;167:1009-1016.
ABSTRACT | FULL TEXT  

Exploring the Treatment-Risk Paradox in Coronary Disease
McAlister et al.
Arch Intern Med 2007;167:1019-1025.
ABSTRACT | FULL TEXT  

Statin Therapy and the Elderly: SAGE Advice?
Gotto
Circulation 2007;115:681-683.
FULL TEXT  

Diabetes Is Not Treated as a Coronary Artery Disease Risk Equivalent
Shah et al.
Diabetes Care 2007;30:381-383.
FULL TEXT  

Analysis of Observational Studies in the Presence of Treatment Selection Bias: Effects of Invasive Cardiac Management on AMI Survival Using Propensity Score and Instrumental Variable Methods
Stukel et al.
JAMA 2007;297:278-285.
ABSTRACT | FULL TEXT  

Regional Differences in Process of Care and Outcomes for Older Acute Myocardial Infarction Patients in the United States and Ontario, Canada
Ko et al.
Circulation 2007;115:196-203.
ABSTRACT | FULL TEXT  

Relationship Between Adherence to Evidence-Based Pharmacotherapy and Long-term Mortality After Acute Myocardial Infarction
Rasmussen et al.
JAMA 2007;297:177-186.
ABSTRACT | FULL TEXT  

Benefits of achieving the NCEP optional LDL-C goal among elderly patients with ACS
Ray et al.
Eur Heart J 2006;27:2310-2316.
ABSTRACT | FULL TEXT  

Reanalysis of two studies with contrasting results on the association between statin use and fracture risk: the General Practice Research Database.
de Vries et al.
Int J Epidemiol 2006;35:1301-1308.
ABSTRACT | FULL TEXT  

Are Broad-Spectrum Fluoroquinolones More Likely To Cause Clostridium difficile-Associated Disease?
Dhalla et al.
Antimicrob. Agents Chemother. 2006;50:3216-3219.
ABSTRACT | FULL TEXT  

A 39-year-old woman with hypercholesterolemia.
Mittleman
JAMA 2006;296:319-326.
ABSTRACT | FULL TEXT  

Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction
Alter et al.
Eur Heart J 2006;27:1539-1549.
ABSTRACT | FULL TEXT  

Efficacy of lipid lowering drug treatment for diabetic and non-diabetic patients: meta-analysis of randomised controlled trials
Costa et al.
BMJ 2006;332:1115-1124.
ABSTRACT | FULL TEXT  

Association Between Hospital Process Performance and Outcomes Among Patients With Acute Coronary Syndromes
Peterson et al.
JAMA 2006;295:1912-1920.
ABSTRACT | FULL TEXT  

Management of Dyslipidemia in Special Populations
Tovar and Schering
Journal of Pharmacy Practice 2006;19:63-78.
ABSTRACT  

Antihypertensive Medication Prescribing in 27,822 Elderly Canadians With Diabetes Over the Past Decade
McAlister et al.
Diabetes Care 2006;29:836-841.
ABSTRACT | FULL TEXT  

Proliferation of Cardiac Technology in Canada: A Challenge to the Sustainability of Medicare
Alter et al.
Circulation 2006;113:380-387.
ABSTRACT | FULL TEXT  

Recent Trends in Cardiovascular Complications Among Men and Women With and Without Diabetes
Booth et al.
Diabetes Care 2006;29:32-37.
ABSTRACT | FULL TEXT  

Lipid Testing and Lipid-Lowering Therapy in Hospitalized Ischemic Stroke and Transient Ischemic Attack Patients: Results From a Statewide Stroke Registry
Mullard et al.
Stroke 2006;37:44-49.
ABSTRACT | FULL TEXT  

Secondary prevention of coronary heart disease in older British men: extent of inequalities before and after implementation of the National Service Framework
Ramsay et al.
J Public Health (Oxf) 2005;27:338-343.
ABSTRACT | FULL TEXT  

Survival Bias Associated with Time-to-Treatment Initiation in Drug Effectiveness Evaluation: A Comparison of Methods
Zhou et al.
Am J Epidemiol 2005;162:1016-1023.
ABSTRACT | FULL TEXT  

Risk-Treatment Mismatch in the Pharmacotherapy of Heart Failure
Lee et al.
JAMA 2005;294:1240-1247.
ABSTRACT | FULL TEXT  

The Effectiveness of {beta}-Blockers After Myocardial Infarction in Patients With Type 2 Diabetes
McDonald et al.
Diabetes Care 2005;28:2113-2117.
ABSTRACT | FULL TEXT  

Vulnerable Populations in the United States
Fiscella
JAMA 2005;293:1924-1925.
FULL TEXT  

The 2003 Canadian recommendations for dyslipidemia management: Revisions are needed
Manuel et al.
CMAJ 2005;172:1027-1031.
FULL TEXT  

Long-term Outcomes of Regional Variations in Intensity of Invasive vs Medical Management of Medicare Patients With Acute Myocardial Infarction
Stukel et al.
JAMA 2005;293:1329-1337.
ABSTRACT | FULL TEXT  

National Trends in Cyclooxygenase-2 Inhibitor Use Since Market Release: Nonselective Diffusion of a Selectively Cost-effective Innovation
Dai et al.
Arch Intern Med 2005;165:171-177.
ABSTRACT | FULL TEXT  

Are Neurologists More Likely to Prescribe Antithrombotic Therapy After Stroke? * Response
Ellul et al.
Stroke 2004;35:2241-2242.
FULL TEXT  

Risk-Treatment Paradox in Use of Statins
Weiss and Varadhan
JAMA 2004;292:169-169.
FULL TEXT  

Are Risk Levels Being Used to Guide Statin Therapy in Elders?
Journal Watch Cardiology 2004;2004:4-4.
FULL TEXT