Paul Muntner

University of Alabama at Birmingham, Birmingham, Alabama, United States

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Publications (459)2954.39 Total impact

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    ABSTRACT: Background—The use of statins increased among US adults with high coronary heart disease (CHD) risk following publication of the 2001 cholesterol treatment guidelines. Methods and Results—We analyzed the association between lipids and CHD among 9,578 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants and 346,595 Kaiser Permanente Southern California (KPSC) members with baseline lipid measurements in 2003-2007. We performed the same analyses among 14,590 Atherosclerosis Risk In Communities (ARIC) study participants with lipid measurements in 1987-1989. Analyses were restricted to blacks and whites 45-64 years of age, without CHD, who were not taking statins at baseline. Total cholesterol, high-density lipoprotein cholesterol (HDL-C) and triglycerides were measured at baseline. Low-density lipoprotein cholesterol (LDL-C), non-HDL-C, total-to-HDL-C and triglycerides-to-HDL-C ratios were calculated. The prevalence of diabetes, history of stroke and antihypertensive medication use increased at higher LDL-C in ARIC but not in REGARDS or KPSC. Over 8.9 years of follow-up, 225 CHD events occurred in REGARDS, 6,547 events in KPSC and 583 events in ARIC. After multivariable adjustment, less favorable lipid levels were associated with higher hazard ratios (HR) for CHD in ARIC. These associations were attenuated in REGARDS and KPSC. For example, the HR (95%CI) associated with the highest versus lowest quartile of LDL-C (≥146 mg/dL versus ≤102 mg/dL) was 1.89 (1.42-2.51) in ARIC, and 1.25 (0.81-1.92) in REGARDS and 1.49 (1.38-1.61) in KPSC. Conclusions—The association between lipids and CHD in contemporary studies may be attenuated due to preferential use of statins by high risk individuals.
    No preview · Article · Dec 2016 · Circulation
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    ABSTRACT: Background African Americans (AAs) have lower lung function, higher blood pressure variability (BPV) and increased risk for hypertension and cardiovascular disease (CVD) compared with whites. The mechanism through which reduced lung-function is associated with increased CVD risk is unclear. Methods We evaluated the association between percent predicted lung-function and 24-hour BPV in 1008 AAs enrolled in the Jackson Heart Study who underwent ambulatory blood pressure (BP) monitoring. Lung-function was assessed as forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and the ratio of FEV1-to-FVC during a pulmonary function test using a dry rolling sealed spirometer and grouped into gender-specific quartiles. The pairwise associations of these three lung-function measures with two measures of 24-hour BPV, (1) day-night standard deviation (SDdn) and (2) average real variability (ARV) were examined for systolic BP (SBP) and, separately, diastolic BP (DBP). Results SDdn of SBP was not associated with FEV1 (mean ± standard deviation from lowest-to-highest quartile: 9.5 ± 2.5, 9.4 ± 2.4, 9.1 ± 2.3, 9.3 ± 2.6; p-trend = 0.111). After age and sex adjustment, the difference in SDdn of SBP was 0.0 (95 % CI −0.4,0.4), −0.4 (95 % CI −0.8,0.1) and −0.3 (95 % CI −0.7,0.1) in the three progressively higher versus lowest quartiles of FEV1 (p-trend = 0.041). Differences in SDdn of SBP across FEV1 quartiles were not statistically significant after further multivariable adjustment. After multivariable adjustment, no association was present between FEV1 and ARV of SBP or SDdn and ARV of DBP or when evaluating the association of FVC and FEV1-to-FVC with 24-hour BPV. Conclusion Lung-function was not associated with increased 24-hour BPV.
    Full-text · Article · Dec 2016 · BMC Cardiovascular Disorders
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    ABSTRACT: Background: Medicare claims have been used to study lipid-lowering medication (LLM) use among US adults. Methods: We analyzed the agreement between Medicare claims for LLM and LLM use indicated by self-report during a telephone interview and, separately, by a medication inventory performed during an in-home study visit upon enrollment into the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. We included REGARDS participants ≥65 years enrolled in 2006-2007 with Medicare pharmacy benefits (Part D) from 120 days before their telephone interview through their medication inventory (n = 899). Results: Overall, 39.2% and 39.5% of participants had a Medicare claim for an LLM within 120 days prior to their interview and medication inventory, respectively. Also, 42.7% of participants self-reported using LLMs, and 41.8% had an LLM in their medication inventory. The Kappa statistic (95% confidence interval [CI]) for agreement of Medicare claims with self-report and medication inventory was 0.68 (0.63-0.73) and 0.72 (0.68-0.77), respectively. No Medicare claims for LLMs were present for 22.1% (95%CI: 18.1-26.6%) of participants who self-reported taking LLMs and 18.9% (15.1-23.3%) with LLMs in their medication inventory. Agreement between Medicare claims and self-report was lower among Black male individuals (Kappa = 0.34 [95%CI: 0.14-0.54]) compared with Black female individuals (0.70 [0.61-0.79]), White male individuals (0.65 [0.56-0.75]), and White female individuals (0.79 [0.72-0.86]). Agreement between Medicare claims and the medication inventory was also low among Black male individuals (Kappa = 0.48 [95%CI: 0.29-0.66]). Conclusions: Although substantial agreement exists, many Medicare beneficiaries who self-report LLM use or have LLMs in a medication inventory have no claims for these medications. Copyright © 2016 John Wiley & Sons, Ltd.
    No preview · Article · Jan 2016 · Pharmacoepidemiology and Drug Safety
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    Full-text · Article · Jan 2016 · Circulation
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    ABSTRACT: Objectives To compare the coronary heart disease risk among patients with rheumatoid arthritis (RA) initiating common biologic disease-modifying antirheumatic drugs of different mechanisms. Methods We conducted a retrospective cohort study of patients with RA enrolled in Medicare, a public health plan covering >90% of US residents 65 years or older, from 2006 to 2012 who (1) initiated a biologic, (2) had complete medical and pharmacy coverage for at least 12 months before biologic initiation and (3) were free of coronary heart disease at the time of initiation. We compared the incidence rates (IRs) of (1) acute myocardial infarction (AMI) and (2) a composite outcome of AMI or coronary revascularisation and used multivariable adjusted Cox regression models to examine the associations between the type of biologic and the two outcomes. Results We identified 47 193 eligible patients with RA with mean age 64 (SD 13) years; 85% were women. Crude IRs for AMI ranged from 5.7 to 8.8 cases per 1000 person-years (PYs). AMI risk was significantly elevated among antitumour necrosis factor (anti-TNF) initiators overall (adjusted HR (aHR) 1.3; 95% CI 1.0 to 1.6) and individually among etanercept (aHR 1.3; 95% CI 1.0 to 1.8) and infliximab (aHR 1.3; 95% CI 1.0 to 1.6) compared with abatacept initiators. Crude IRs for the composite outcome ranged from 7.6 to 14.5 per 1000 PYs. Tocilizumab initiators were at reduced risk of the composite outcome compared with abatacept initiators (aHR 0.64, 95% CI 0.41 to 0.99). Discussion Findings from this observational study of patients with RA suggested that anti-TNF biologics may be associated with higher AMI risk compared with abatacept.
    No preview · Article · Jan 2016 · Annals of the Rheumatic Diseases

  • No preview · Conference Paper · Jan 2016
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    ABSTRACT: Background: There are limited data on the use of healthy lifestyles among adults who are candidates for primary prevention of atherosclerotic cardiovascular disease (ASCVD) with statin therapy due to a 10-year predicted risk ≥ 7.5%. We determined the prevalence of healthy lifestyle factors and their association with incident ASCVD and all-cause mortality in the Reason for Geographic and Racial Differences in Stroke study participants (n = 5709). Methods: Lifestyle factors (non-obese waist circumference, physical activity ≥ 5 times-per-week, non-smoking, low saturated-fat-intake, highest Mediterranean diet score quartile) were assessed during an in-home examination and interviewer-administered questionnaires. Adjudicated incident ASCVD (nonfatal/fatal stroke, nonfatal myocardial infarction or coronary heart disease death) and all-cause mortality were identified through active participant follow-up. Results: Overall, 5.1%, 28.9%, 36.9%, 21.7% and 7.5% had 0, 1, 2, 3, and ≥ 4 of the 5 healthy lifestyle factors studied. There were 377 incident ASCVD events (203 CHD events and 174 strokes) and 471 deaths during 5.8 and 6.0 median years of follow-up, respectively. ASCVD incidence rates (95% CI) per 1000-person-years associated with 0, 1, 2, 3 and ≥ 4 healthy lifestyles were 13.4 (7.3–19.5), 12.8 (10.4–15.2), 11.0 (9.0–12.9), 11.0 (8.3–13.7), and 8.7 (4.9–12.4), respectively. Mortality rates associated with 0, 1, 2, 3 and ≥ 4 healthy lifestyles were 20.6 (13.3–27.8), 15.9 (13.3–18.5), 13.1 (10.9–15.2), 12.6 (9.9–15.2) and 9.2 (5.3–13.2) per 1000-person-years, respectively. The use of more healthy lifestyles was associated with lower risks for ASCVD and mortality after multivariable adjustment. Conclusion: Healthy lifestyles are underutilized among high-risk US adults and may substantially reduce their ASCVD risk.
    Full-text · Article · Jan 2016 · International journal of cardiology
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    Full-text · Article · Dec 2015 · Circulation
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    ABSTRACT: We aimed to assess the impact of L-carnitine on plasma Lp(a) concentrations through systematic review and meta-analysis of available RCTs. The literature search included selected databases up to 31st January 2015. Meta-analysis was performed using fixed-effects or random-effect model according to I2 statistic. Effect sizes were expressed as weighted mean difference (WMD) and 95% confidence interval (CI). The meta-analysis showed a significant reduction of Lp(a) levels following L-carnitine supplementation (WMD: -8.82 mg/dL, 95%CI: -10.09, -7.55, p<0.001). When the studies were categorized according to the route of administration, a significant reduction in plasma Lp(a) concentration was observed with oral (WMD: -9.00 mg/dL, 95%CI: -10.29, -7.72, p<0.001) but not intravenous L-carnitine (WMD: -2.91 mg/dL, 95%CI: -10.22, 4.41, p=0.436). The results of the meta-regression analysis showed that the pooled estimate is independent of L-carnitine dose (slope: -0.30; 95%CI: -4.19, 3.59; p=0.878) and duration of therapy (slope: 0.18; 95%CI: -0.22, 0.59; p=0.374). In conclusion, the meta-analysis suggests a significant Lp(a) lowering by oral L-carnitine supplementation. Taking into account the limited number of available Lp(a)-targeted drugs, L-carnitine might be an effective alternative to effectively reduce Lp(a). Prospective outcome trials will be required to fully elucidate the clinical value and safety of oral L-carnitine supplementation.
    Full-text · Article · Dec 2015 · Scientific Reports

  • No preview · Article · Dec 2015 · Journal of Hypertension
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    ABSTRACT: Ambulatory blood pressure monitoring (ABPM) is more commonly recommended for assessing out-of-clinic blood pressure than home blood pressure monitoring (HBPM). We conducted a systematic review to examine whether ABPM or HBPM is more strongly associated with cardiovascular disease events and/or mortality. Of 1,007 abstracts published through July 20, 2015, nine articles, reporting results from seven cohorts, were identified. After adjustment for blood pressure on HBPM, blood pressure on ABPM was associated with an increased risk of outcomes in two of four cohorts for systolic blood pressure and two of three cohorts for diastolic blood pressure. After adjustment for blood pressure on ABPM, systolic blood pressure on HBPM was associated with outcomes in zero of three cohorts; an association was present in one of two cohorts for diastolic blood pressure on HBPM. There is a lack of strong empiric evidence supporting ABPM or HBPM over the other approach for predicting cardiovascular events or mortality.
    No preview · Article · Dec 2015 · Journal of the American Society of Hypertension (JASH)
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    ABSTRACT: BACKGROUND: Several studies suggest differences between fibrates and statins in lowering plasma fibrinogen (Fib) concentrations, but the evidence is not definitive. Therefore, the aim of this meta-analysis of head-to-head randomized trials was to compare the efficacy of statins and fibrates on plasma Fib concentrations. METHODS: The literature search included Medline, Scopus, and Web of Science up to February 1st, 2015, to identify head-to-head comparative randomized trials investigating the efficacy of fibrates vs statins on plasma Fib concentrations. RESULTS: In total 22 trials with 2762 participants were included to the meta-analysis. Random-effect meta-analysis suggested a significantly greater effect of fibrates vs statins in lowering plasma Fib concentrations (weighted mean difference [WMD]: -40.7 mg/dL, 95% confidence interval [CI]: -55.2, -26.3, p<0.001). When the analysis was stratified according to the type of fibrate administered, there were significant Fib-lowering effects with both bezafibrate (n=8 treatment arms; WMD: -23.7 mg/dL, 95%CI: -41.8, -5.7, p=0.01) and fenofibrate (n=15 treatment arms; WMD: -43.7 mg/dL, 95%CI: -61.3, -26.2, p<0.001). Overall, there was a numerically greater effect in the subgroup of trials with ≥12 weeks duration (n=17 treatment arms; WMD: -42.7 mg/dL, 95%CI: -60.3, -25.1, p<0.001) compared with the subgroup of trials lasting <12 weeks (n=7 treatment arms; WMD: -36.7 mg/dL, 95%CI: -52.0, -21.4, p<0.001). CONCLUSIONS: Monotherapy with either fibrates or statins suggested a significantly greater effect of fibrates in lowering plasma Fib concentrations. According to these findings, mechanisms associated with fibrinogen metabolism might be responsible for the distinct effects of statins and fibrates in reducing cardiovascular endpoints.
    Full-text · Article · Dec 2015 · Pharmacological Research
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    ABSTRACT: Objective: To evaluate the impact of comorbid depressive symptoms and/or stress on adverse cardiovascular (CV) outcomes in individuals with diabetes compared with those without diabetes. Research design and methods: Investigators examined the relationship between baseline depressive symptoms and/or stress in adults with and without diabetes and physician-adjudicated incident CV outcomes including stroke, myocardial infarction/acute coronary heart disease, and CV death over a median follow-up of 5.95 years in the national REGARDS cohort study. Results: Subjects included 22,003 adults (4,090 with diabetes) (mean age 64 years, 58% female, 42% black, and 56% living in the southeastern "Stroke Belt"). Elevated stress and/or depressive symptoms were more common in subjects with diabetes (36.8% vs. 29.5%; P < 0.001). In fully adjusted models, reporting either elevated stress or depressive symptoms was associated with a significantly increased incidence of stroke (HR 1.57 [95% CI 1.05, 2.33] vs. 1.01 [0.79, 1.30]) and CV death (1.53 [1.08, 2.17] vs. 1.12 [0.90, 1.38]) in subjects with diabetes but not in those without diabetes. The combination of both elevated stress and depressive symptoms in subjects with diabetes was associated with a higher incidence of CV death (2.15 [1.33, 3.47]) than either behavioral comorbidity alone (1.53 [1.08, 2.17]) and higher than in those with both elevated stress and depressive symptoms but without diabetes (1.27 [0.86, 1.88]). Conclusions: Comorbid stress and/or depressive symptoms are common in individuals with diabetes and together are associated with progressively increased risks for adverse CV outcomes.
    No preview · Article · Nov 2015 · Diabetes care
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    ABSTRACT: Background: In the Systolic Blood Pressure Intervention Trial (SPRINT), a systolic blood pressure (SBP) goal of <120 mmHg resulted in lower cardiovascular disease (CVD) risk compared with a SBP goal of <140 mmHg. Objectives: To estimate the prevalence, number, and characteristics of US adults meeting SPRINT eligibility criteria and a broader population to whom SPRINT could be generalized. Methods: We conducted a cross-sectional, population-based study using data from the National Health and Nutrition Examination Survey 2007-2012. SPRINT eligibility included the following: inclusion criteria were age ≥ 50 years, SBP of 130 to 180 mmHg depending on the number of antihypertensive medication classes being taken, high CVD risk (history of coronary heart disease, estimated glomerular filtration rate of 20 to 59 ml/min/1.73 m(2), 10-year CVD risk ≥15%, or age ≥ 75 years); exclusion criteria were diabetes, history of stroke, >1 gram of proteinuria daily, heart failure, estimated glomerular filtration rate < 20 ml/min/1.73m(2) or receiving dialysis. Treated hypertension was defined by self-reported use of medication to lower blood pressure with one or more classes of antihypertensive medication identified through a pill bottle review. Results: Overall, 7.6% (95%CI 7.0%-8.3%) or 16.8 million (95%CI 15.7-17.8) of US adults, and 16.7% (95%CI 15.2%-18.3%) or 8.2 million (95%CI 7.6-8.8) of those with treated hypertension, met the SPRINT eligibility criteria. Among both the overall US population and adults with treated hypertension, the percentage meeting SPRINT eligibility criteria increased with older age, was higher among males than females, and was higher among non-Hispanic whites compared with non-Hispanic blacks or Hispanics. Of US adults eligible for SPRINT, 51.0% (95%CI 47.8%-54.1%) or 8.6 million (95%CI 8.0-9.1) were not treated for hypertension. Conclusions: A substantial percentage of US adults meet the eligibility criteria for SPRINT.
    No preview · Article · Nov 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Objective: We previously developed an 8-item self-assessment tool to identify individuals with a high probability of having albuminuria. This tool was developed and externally validated among non-Hispanic Whites and non-Hispanic Blacks. We sought to validate it in a multi-ethnic cohort that also included Hispanics and Chinese Americans.Design: This is a cross-sectional study.Setting: Data were collected using stan­dardized questionnaires and spot urine samples at a baseline examination in 2000- 2002. The 8 items in the self-assessment tool include age, race, gender, current ciga­rette smoking, history of diabetes, hyperten­sion, or stroke, and self-rated health.Participants: Of 6,814 community-dwelling adults aged 45-84 years participating in the Multi-Ethnic Study of Atherosclerosis (MESA), 6,542 were included in the primary analysis.Main Outcome Measures: Albuminuria was defined as urine albumin-to-creatinine ratio ≥30 mg/g at baseline.Results: Among non-Hispanic Whites, non- Hispanic Blacks, Hispanics, and Chinese Americans, the prevalence of albuminuria was 6.0%, 11.3%, 11.6%, and 10.8%, respectively. The c-statistic for discriminating participants with and without albuminuria was .731 (95% CI: .692, .771), .728 (95% CI: .687, .761), .747 (95% CI: .709, .784), and .761 (95% CI: .699, .814) for non-His­panic Whites, non-Hispanic Blacks, Hispan­ics, and Chinese Americans, respectively. The self-assessment tool over-estimated the probability of albuminuria for non-Hispanic Whites and Blacks, but was well-calibrated for Hispanics and Chinese Americans.Conclusions: The albuminuria self-assess­ment tool maintained good test charac­teristics in this large multi-ethnic cohort, suggesting it may be helpful for increasing awareness of albuminuria in an ethnically diverse population. Ethn Dis.2015;25(4):427- 434; doi:10.18865/ed.25.4.427
    No preview · Article · Nov 2015 · Ethnicity & disease
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    ABSTRACT: HIV+ individuals have an increased risk for cardiovascular disease (CVD), but the mechanisms behind this association are poorly understood. While hypertension is a well-established CVD risk factor, clinic-based blood pressure (BP) assessment by itself cannot identify several important BP patterns, including white coat hypertension, masked hypertension, nighttime hypertension, and nighttime BP dipping. These BP patterns can be identified over a 24-h period by ambulatory BP monitoring (ABPM). In this review, we provide an overview of the potential value of conducting ABPM in HIV+ individuals. ABPM phenotypes associated with increased CVD risk include masked hypertension (i.e., elevated out-of-clinic BP despite non-elevated clinic BP), nighttime hypertension, and a non-dipping BP pattern (i.e., a drop in BP of <10 % from daytime to nighttime). These adverse ABPM phenotypes may be highly relevant in the setting of HIV infection, given that increased levels of inflammatory biomarkers, high psychosocial burden, high prevalence of sleep disturbance, and autonomic dysfunction have been commonly reported in HIV+ persons. Additionally, although antiretroviral therapy (ART) is associated with lower AIDS-related morbidity and CVD risk, the mitochondrial toxicity, oxidative stress, lipodystrophy, and insulin resistance associated with long-term ART use potentially lead to adverse ABPM phenotypes. Existing data on ABPM phenotypes in the setting of HIV are limited, but suggest an increased prevalence of a non-dipping BP pattern. In conclusion, identifying ABPM phenotypes may provide crucial information regarding the mechanisms underlying the excess CVD risk in HIV+ individuals.
    No preview · Article · Nov 2015 · Current Hypertension Reports
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    ABSTRACT: Hypertension, a common risk factor for cardiovascular disease, is usually diagnosed and treated based on blood pressure readings obtained in the clinic setting. Blood pressure may differ considerably when measured inside versus outside of the clinic setting. Over the past several decades, evidence has accumulated on the following 2 approaches for measuring blood pressure outside of the clinic: ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). Both of these methods have a stronger association with cardiovascular disease outcomes than clinic blood pressure measurement. Controversy exists about whether ABPM or HBPM is superior for estimating risk for cardiovascular disease and under what circumstances these methods should be used in clinical practice for assessing blood pressure outside of the clinic. This review describes ABPM and HBPM procedures, the blood pressure phenotypic measurements that can be ascertained, and the evidence that supports the use of each approach to measuring blood pressure outside of the clinic. It also describes barriers to the successful implementation of ABPM and HBPM in clinical practice, proposes core competencies for the conduct of these procedures, and highlights important areas for future research.
    No preview · Article · Oct 2015 · Annals of internal medicine
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    ABSTRACT: We examined claims-based approaches for identifying a study population free of coronary heart disease (CHD) using data from 8,937 US blacks and whites enrolled during 2003–2007 in a prospective cohort study linked to Medicare claims. Our goal was to minimize the percentage of persons at study entry with self-reported CHD (previous myocardial infarction or coronary revascularization). We assembled 6 cohorts without CHD claims by requiring 6 months, 1 year, or 2 years of continuous Medicare fee-for-service insurance coverage prior to study entry and using either a fixed-window or all-available look-back period. We examined adding CHD-related claims to our “base algorithm,” which included claims for myocardial infarction and coronary revascularization. Using a 6-month fixed-window look-back period, 17.8% of participants without claims in the base algorithm reported having CHD. This was reduced to 3.6% using an all-available look-back period and adding other CHD claims to the base algorithm. Among cohorts using all-available look-back periods, increasing the length of continuous coverage from 6 months to 1 or 2 years reduced the sample size available without lowering the percentage of persons with self-reported CHD. This analysis demonstrates approaches for developing a CHD-free cohort using Medicare claims.
    No preview · Article · Oct 2015 · American journal of epidemiology
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    ABSTRACT: BACKGROUND Nonstatin lipid-lowering therapy is adjunctive therapy for high-risk individuals on statins or monotherapy among those who cannot tolerate statins. OBJECTIVES This study determined time trends between 2007 and 2011 for statin and nonstatin lipid-lowering therapy (niacin, fibrates, bile acid sequestrants, and ezetimibe) use among Medicare beneficiaries with coronary heart disease (CHD) in light of emerging clinical trial evidence. METHODS We conducted a retrospective cohort study using the national 5% random sample of Medicare beneficiaries (n = 310,091). We created 20 cohorts of individuals with CHD, representing calendar quarters from 2007 through 2011, to assess trends in use of statins and nonstatin lipid-lowering medications. RESULTS Statin use increased from 53.1% to 58.8% between 2007 and 2011. Ezetimibe use peaked at 12.1% and declined to 4.6% by the end of 2011, declining among both patients on statins (18.4% to 6.2%) and not on statins (5.0% to 2.4%). Fibrate use increased from 4.2% to 5.0%, bile acid sequestrants did not change significantly, and niacin use increased from 1.5% to 2.4% and then declined in late 2011. Use of nonstatin lipid-lowering therapy was less common at older age, among African Americans, patients with heart failure, and patients with a higher Charlson comorbidity score. Nonstatin lipid-lowering therapy use was more common among men and patients with diabetes, those who had cardiologist visits, and among those taking statins. CONCLUSIONS Declining ezetimibe and niacin use but not fibrate therapy among Medicare beneficiaries with CHD coincides with negative clinical trial results for these agents. (C) 2015 by the American College of Cardiology Foundation.
    No preview · Article · Oct 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Background/aims: Persons with occult-reduced estimated glomerular filtration rate (eGFR <60 ml/min/1.73 m2 detected by serum cystatin C but missed by creatinine) have high risk for complications. Among persons with preserved kidney function by creatinine-based eGFR (eGFRcreat >60 ml/min/1.73 m2), tools to guide cystatin C testing are needed. Methods: We developed a risk score to estimate an individual's probability of reduced eGFR by cystatin C (eGFRcys <60 ml/min/1.73 m2) in The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study and externally validated in the Third National Health and Nutrition Examination Survey (NHANES III). We used logistic regression with Bayesian model averaging and variables available in practice. We assessed performance characteristics using calibration and discrimination measures. Results: Among 24,877 adults with preserved kidney function by creatinine, 13.5% had reduced eGFRcys. Older and Black participants, current smokers and those with higher body mass index, lower eGFRcreat, diabetes, hypertension and history of cardiovascular disease were more likely to have occult-reduced eGFR (p < 0.001). The final risk function had a c-statistic of 0.87 in REGARDS and 0.84 in NHANES. By risk score, 72% of occult-reduced eGFR cases were detected by screening only 22% of participants. Conclusions: A risk score using characteristics readily accessible in clinical practice can identify the majority of persons with reduced eGFRcys, which is missed by creatinine.
    No preview · Article · Sep 2015 · American Journal of Nephrology

Publication Stats

20k Citations
2,954.39 Total Impact Points


  • 2009-2016
    • University of Alabama at Birmingham
      • Department of Epidemiology
      Birmingham, Alabama, United States
    • Sinai Hospital
      New York, New York, United States
  • 2015
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2007-2015
    • Icahn School of Medicine at Mount Sinai
      • Department of Medicine
      Borough of Manhattan, New York, United States
    • Ochsner
      • Center for Health Research
      New Orleans, Louisiana, United States
    • University of Alabama in Huntsville
      Huntsville, Alabama, United States
  • 2013
    • Columbia University
      • Department of Medicine
      New York, New York, United States
  • 2011
    • University of Alabama
      Tuscaloosa, Alabama, United States
  • 2008-2009
    • Mount Sinai Medical Center
      New York, New York, United States
  • 2007-2009
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2002-2009
    • Tulane University
      • • Department of Medicine
      • • Department of Epidemiology
      New Orleans, Louisiana, United States
    • Johns Hopkins Bloomberg School of Public Health
      • Department of Epidemiology
      Baltimore, Maryland, United States
  • 2005
    • Beijing Fuwai Hospital
      Peping, Beijing, China
  • 2004
    • University of North Carolina at Chapel Hill
      • Department of Epidemiology
      North Carolina, United States
  • 2000-2002
    • University of Geneva
      • Institute of Social and Preventive Medicine
      Genève, Geneva, Switzerland
    • University of Mississippi Medical Center
      • Department of Pediatrics
      Jackson, Mississippi, United States