Anum Saeed, MD, Cardiologist, Postdoctoral Researcher and Clinical instructor, University of Pittsburgh, talks about a new type of medicine and how it’s different between two races
So talk to me about your research. Why did you and your colleagues want to look at this particular topic?
SAEED: Yeah. I think of racial disparities in the way we treat, you know, people in medicine are very existent. We’ve always known that there’s been a higher risk among Black individuals of having heart attacks and strokes compared to their White counterparts. What we have not really looked at in the real world is how are we doing in terms of giving them the medicines that they need and, in this case, statin, which is a basic preventive medicine in terms of preventing cardiovascular disease events, meaning a stroke and a heart attack, essentially. We wanted to see how we in a large health care system, are doing in prescribing statins in individuals who are at higher risk of having a cardiovascular disease event but have not yet have any events, which has not been done before in a non-governmental large healthcare system level in the USA before. So these are individuals, you know, who are in their 50s and 60s who have come to our health care system with a network of over 40 hospitals. And based on their risk, how have we treated them and how many of them have had a statin given to them based on their guideline-directed risk.
I want to ask you, for our viewers who have heard the term statin but – and know it’s got something to do with heart, what is a statin designed to do?
SAEED: So essentially a statin is a very commonly prescribed medicine used for cholesterol lowering. Now it’s been in the market for over three decades at this time. It works in our body in the cycle where it inhibits an enzyme, essentially, that stops the production of. By doing that, it lowers a certain amount of cholesterol production in our body. Statins come in various forms and various strengths. There’s typically low intensity, moderate intensity and high intensity statins, which are all based on the percentage of how much cholesterol they reduce in our body. We know, from very many studies at this point that statins are directly linked to reduction in your risk of having a future cardiovascular event, which is stroke, heart attack or having peripheral arterial disease.
Talk to me about what you found. How you went about gathering new data…
SAEED: We are very fortunate here at the UPMC system to have a clinical analytics team under Dr. Suresh Mulukutla and Dr. Oscar Marroquin, which uses the data gathered within the electronic medical system across our 40-plus hospital sites and several clinics, really. What we were able to do with the help of our clinical analytics team, we looked at the data from the electronic medical records. As you know, all our hospitals and outpatient sites, clinic sites do use EMR, or electronic medical records. We were able to compute the American College of Cardiology (ACC) and American Heart Association (AHA) 10-year ACVD risk for all our patients who entered in our system between 2013 to 2020. This is what is a percentage of a person having a heart attack or a stroke event over the next 10 years. We looked this is over amongst about half a million patients. Based on that, we categorized these patients in – you know, they had a low risk, intermediate risk in high risk. That is directed by the guidelines that are nationally applicable at this time. Essentially what we found is, in about 249,000 white individuals in our system and over 25,000 black individuals in our patients, we were able to find their risk of having a heart attack or stroke. Also, we found how we’ve done since the moment they came into our system in terms of prescribing them the medicine, which is the statin here, and what it impacted over the next six and a half years off their risk of arthroscopic cardiovascular diseases.
And tell me what you found, and I want to talk a little bit about the disparities in what you found.
SAEED: In about approximately 250,000 patients – we had approximately 25,000 Black patient records for the purpose of this study – again, the proportions are a little bit lower where we are demographically. We found that, in both groups of Black and White patients, in high risk individuals as deemed by the ACC/AHA 10-year risk, statin the prescription was lower than optimal. A lower proportion of Blacks received statin therapy in intermediate risk group – 22.4% vs 32% White patients. Even in the high risk, 40% Black patients received statins vs 44% Whites groups. Again, the proportion of Black individuals being prescribed this medicine was slightly lower than the White individuals in our population – although overall the statin prescription was less than ideal across both groups!
Did you and your colleagues follow that out in terms of cardiac events and how they did?
SAEED: Yeah, absolutely. So essentially what we found and with our electronic medical record, we have each time that the patients came into the hospital, each time they meet any other further interactions with any of our clinical sites. We looked at these data over the next 6.5 years since 2013 and followed their outcomes from cardiovascular perspective. Essentially we took two to three or three years from 2013 to 2016 to enroll these patients, their first visit and then, over 2020, we found out how many of them had had any kind of events, which are cardiovascular disease events stroke, heart attack, or any peripheral vascular disease intervention. What we found is, when you don’t get the statin you need or you are eligible for based on your risk, both parties, Blacks and white individuals, did poorly. They had people who were not given the statin therapy based on their risk, had a lower intensity statin prescribed to them, they had increased events in terms of heart attacks and strokes both.
Is there any indication why these patients were not getting the statins as they should have been prescribed?
SAEED: Yeah. So I think we have a hunch about it. I think, again, this is pretty remarkable. What we have really tried to do right now is find out how we’re doing and find out what we are doing and how that’s impacting our patients in the real world, right? We know we have all the data we need for stain therapies and how they prevent heart attacks and stroke. We know that statins are good for you. We know that, once you are at a certain risk, you should be given a statin so you can reduce the future risk of having a cardiovascular disease event. But in a large real-world population, these data are fairly missing. The only people who have been able to do this in patients without having heart attacks and stroke this is what we call a primary prevention population is the V.A. system. That has come most of the data have come out from the Michael E. DeBakey Houston VA Medical Center and as far as we know, we are the first people in a non-government-owned hospital system to provide these data for discussion and also just to understand that this is happening. We have enough inclination at this point that, nationally, the data would be comparable because in the V.A. system, the data is pretty comparable. That we are, as a nation, as physicians, we are prescribing less statins than we need to.
So I guess, knowing that, what are some information? What are some next steps then from getting this information?
SAEED: Right. I think what’s important is that, like you alluded to, what do we know why this is happening? The take home points really for us are that we are not optimally giving the statin therapy to both Blacks and white population. A little bit more in Black individuals we’re not giving enough statin therapy based on their 10-year risk and I think the next steps really are finding out why this is happening. I think the big question is that what part of us interacting with our patients are we failing to do the best we can? Is it lack of, you know, follow-up from the patients? Is it lack of us prescribing them based on their prescription or on their care? Or is it some systemic issues that we need to address? I think much remains to be seen, but I’m pretty confident that we have the analytics and the team behind us here to really answer some of these very key questions.
Do you know, doctor is there any indication why the disparity between the prescriptions of statins for white patients and Black patients?
SAEED: I think these are pretty comparable to national, what’s happening throughout the country. I think there’s more here we need to delve into. Is it lack of access of care? Is it just a lack of, like, knowledge in terms of that Black individuals are indeed a little bit higher at risk? Or it’s simply some more patient and physician discussion that needs to happen to explain the use of statins. Is there some disparity or is there some gap in the knowledge that we are unable to fill when we’re caring for our patients in terms of what are the benefits of the statin. Have we explained that?
What are some of the things that are known about statins also are that statins cause muscle aches? There’s all sorts of, if you Google search about statins, the first three or four papers are or first three or four, like, hits you get in Google are about the side effects of statins, which are fairly minimal. So is it just this knowledge or this lack of, you know, information that the patients don’t have access to and they are hesitant? Why we have a higher proportion of Black individuals who don’t get the statin as compared to the white patients in our population here? I think we have some questions to answer and some data that we need to look at.
And you had mentioned is there some patient reluctance? Is that part of it? I mean, maybe perhaps are you finding that physicians are talking about statins, you know, wanting to prescribe and there’s patient reluctance oh, no, maybe I don’t need that, doctor, or maybe I can’t afford that. You know, is it on the patient end too or is there not part of what you and your colleagues looked at?
SAEED: Yeah. This is not what we have looked at, so I can’t give you a strategic answer based on the numbers I’ve seen. I do know that, again, having been in the field for several years, I do know that, anecdotally and there’s data behind nationally we can find, internationally really. Statins have been plagued with some of these misinformation, and therefore when our patients read this information that is out there, they show much reluctance and it really takes a lot of convincing on our parts for them to get statin therapy. In fact, I have patients who have had heart attacks, who’ve had strokes, are reluctant to be on statins because it’s statins, remember statins do cause some muscle aches. Statins have been linked with rhabdomyolysis that is, the extreme break down of our muscles, but it’s a very low percentage. Which is less than 1% of people who have those problems. There’s other stories in the news articles and whatnot so our patients do read them and, unfortunately, sometimes do believe them and are hesitant to really listen to what the data the physicians can show them. So absolutely, there is patient reluctance, I just don’t know what it’s going to translate into in our data because we have not looked at it as yet.
Is there anything I didn’t ask you, doctor, that you think it would be important for our viewers to know?
SAEED: I think it’s important for our viewers to know that, when you are at a certain risk of having a heart attack and a stroke, A, you should always talk to your doctor and, B, your doctor as physicians, we should be calculating these scores these 10-year risks for our patients, and then really asking ourselves that have I prescribed the statin that these patients need? This should build on to the first steps which are improving our diets and lifestyle to be heart healthy. All of these steps taken together will certainly prove beneficial for them in terms of reducing their future risk of heart attack and strokes. And ask our patients, have that patient-physician discussion. Because while Blacks have a higher proportion that remain less than optimally prescribed statins based on their risk, the result of not being on the optimal statin dosing here and optimally treated is illustrated with the fact that they have higher risk of heart attacks and stroke in both White and Black populations in our data – equally. So racial disparities do exist. At the same time, we need to make sure that we’re counting for all our patients.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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