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IIR 16-072 – HSR&D Study

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IIR 16-072
Determining and targeting reasons for low statin use to improve guideline-concordant statin therapy in high-risk patients
Salim Virani MD
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: July 2017 - June 2022

BACKGROUND/RATIONALE:
Optimal statin therapy reduces cardiovascular events. We have shown that optimal statin therapy is underused in Veterans with CVD. This can be due to clinical inertia or statin associated side effects which providers usually document in text notes and may not be well captured in structured datasets.

OBJECTIVE(S):
Our objectives are to (Aim 1) identify reasons for suboptimal statin use using structured data and provider text notes using NLP; (Aim 2) understand provider and patient perspectives on statin intolerance and refine a communication aid targeting providers to improve guideline-concordant statin use; and (Aim 3) pilot test an intervention to improve optimal statin use in Veterans with CVD using the communication aid refined in Aim 2.

METHODS:
For Aim 1, we will randomly identify VA patients with CVD on optimal, suboptimal and no statins, and partition them into training and test sets. We will train our NLP system to achieve sensitivity and specificity of >90%, compared with manual chart review to identify reason for suboptimal stain use. In Aim 2, we will conduct interviews with providers and patients to elicit their perspectives on clinical inertia and statin intolerance. These interviews will help refine the communication aid for Aim 3. In Aim 3, we will conduct a pilot trial with Houston and Nashville VAMC PACTs serving as intervention sites. PACTs at intervention sites will receive the communication aid to assist them with statin initiation and/or titration in CVD patients on suboptimal statins. At usual care sites, PACT providers will only receive a quarterly report of the proportion of their CVD patients on suboptimal statins. Our primary outcome is change in the proportion of CVD patients receiving optimal statin therapy.

FINDINGS/RESULTS:
We developed an initial corpus of 465 patients for training/testing the NLP system. We selected notes with standard titles that were most likely to contain documentation of adverse events related to statin usage. We used an iterative process to develop an annotation schema consisting of concepts of interest within the documents. Two nurse annotators identified an initial group of concepts within a small batch of 10-20 documents. Upon completion, annotation was discussed among the research team for further refinement and finalization.
To create document sets for annotation, we used one document from each patient. Documents were stratified so that each set of documents contained approximately 25% African Americans and 75% Non-African Americans, 25% females and 75% males, and 50% were on no statins, 25% on low statin, and 25% on moderate statin. Currently, a total of 171 documents (3 groups of 57) from 171 patients were selected for annotation. Within the first 57 documents, we identified 8 patients with statin-related adverse events, which corresponds to a prevalence rate of 14%.

IMPACT:
Our results identify the vast majority of high-risk Veterans not on optimal statin therapy due to intolerance versus clinical inertia. Our communication aid will identify strategies to initiate or titrate statins in high-risk Veterans. These results will be important for the VA Health Care System to identify patients with "true statin intolerance" who will be future candidates for expensive new drugs recently approved by the FDA.

PUBLICATIONS:

Journal Articles

  1. Ullah W, Haq S, Zahid S, Gowda SN, Ottman P, Saleem S, Hamzeh I, Virani SS, Alam M, Fischman DL. Safety and Efficacy of Colchicine in Patients with Stable CAD and ACS: A Systematic Review and Meta-analysis. American Journal of Cardiovascular Drugs : Drugs, Devices, and Other Interventions. 2021 Jun 21.
  2. Saeed A, Kinoush S, Virani SS. Lipoprotein (a): Recent Updates on a Unique Lipoprotein. Current Atherosclerosis Reports. 2021 Jun 19; 23(8):41.
  3. Al Rifai M, Jia X, Pickett J, Hussain A, Navaneethan SD, Birtcher KK, Ballantyne C, Petersen LA, Virani SS. Social Determinants of Health and Comorbidities Among Individuals with Atherosclerotic Cardiovascular Disease: The Behavioral Risk Factor Surveillance System Survey. Population health management. 2021 Jun 14.
  4. Saleem S, Ullah W, Syed MA, Megaly M, Thalambedu N, Younas S, Zahid S, Alam M, Virani SS, Verma DR, Abdul-Waheed M, Fischman DL. Meta-analysis comparing valve-in-valve TAVR and redo-SAVR in patients with degenerated bioprosthetic aortic valve. Catheterization and Cardiovascular Interventions : Official Journal of The Society For Cardiac Angiography & Interventions. 2021 Jun 10.
  5. Valero-Elizondo J, Chouair F, Khera R, Grandhi G, Saxena A, Warraich HJ, Virani S. Atherosclerotic Cardiovascular Disease, Cancer and Financial Toxicity among Adults in the United States. JACC: CardioOncology. 2021 Jun 1; 3(2):236-246.
  6. Jain V, Rifai MA, Brinzevich D, Taj M, Saleh M, Krittanawong C, Patel J, Patel A, Lee MT, Mahtta D, Virani SS. Association of premature atherosclerotic cardiovascular disease with higher risk of cancer: a behavioral risk factor surveillance system study. European journal of preventive cardiology. 2021 May 31.
  7. Jia X, Gao F, Pickett JK, Al Rifai M, Birnbaum Y, Nambi V, Virani SS, Ballantyne CM. Association Between Omega-3 Fatty Acid Treatment and Atrial Fibrillation in Cardiovascular Outcome Trials: A Systematic Review and Meta-Analysis. Cardiovascular drugs and therapy. 2021 Aug 1; 35(4):793-800.
  8. Rajan SS, Akeroyd JM, Ahmed ST, Ramsey DJ, Ballantyne CM, Petersen LA, Virani SS. Health care costs associated with primary care physicians versus nurse practitioners and physician assistants. Journal of the American Association of Nurse Practitioners. 2021 May 31.
  9. Hess PL, Gosch KL, Jani SM, Varosy PD, Bradley SM, Maddox TM, Michael Ho P, Virani SS. Use of Oral Anticoagulants in Patients with Valvular Atrial Fibrillation: Findings From the NCDR PINNACLE Registry®. American heart journal. 2021 May 22.
  10. Lowenstern A, Li S, Navar AM, Virani SS, Roger VL, Robinson JG, Goldberg AC, Kampman W, Peterson ED, Wang TY. Patient perceptions and use of non-statin lipid lowering therapy among patients with or at risk for atherosclerotic cardiovascular disease: Insights from the PALM registry. Clinical Cardiology. 2021 Jun 1; 44(6):863-870.
  11. Satish P, Vela E, Bilal U, Cleries M, Kanaya AM, Kandula N, Virani SS, Islam N, Valero-Elizondo J, Yahya T, Comin-Colet J, Nasir K, Mauri J, Cainzos-Achirica M. Burden of cardiovascular risk factors and disease in five Asian groups in Catalonia: a disaggregated, population-based analysis of 121 000 first-generation Asian immigrants. European journal of preventive cardiology. 2021 May 10.
  12. Lee MT, Mahtta D, Ramsey DJ, Liu J, Misra A, Nasir K, Samad Z, Itchhaporia D, Khan SU, Schofield RS, Ballantyne CM, Petersen LA, Virani SS. Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease. JAMA cardiology. 2021 Apr 21.
  13. Kamran H, Jneid H, Kayani WT, Virani SS, Levine GN, Nambi V, Khalid U. Oral Antiplatelet Therapy After Acute Coronary Syndrome: A Review. JAMA. 2021 Apr 20; 325(15):1545-1555.
  14. Khan SU, Khan MZ, Khan MU, Khan MS, Mamas MA, Rashid M, Blankstein R, Virani SS, Johansen MC, Shapiro MD, Blaha MJ, Cainzos-Achirica M, Vahidy FS, Nasir K. Clinical and Economic Burden of Stroke Among Young, Midlife, and Older Adults in the United States, 2002-2017. Mayo Clinic proceedings. Innovations, quality & outcomes. 2021 Apr 1; 5(2):431-441.
  15. Lee MT, Mahtta D, Chen L, Hussain A, Al Rifai M, Sinh P, Khalid U, Nasir K, Ballantyne CM, Petersen LA, Virani SS. Premature Atherosclerotic Cardiovascular Disease Risk Among Patients with Inflammatory Bowel Disease. The American journal of medicine. 2021 Apr 1.
  16. Weintraug H, Bostrom J, Johnson HM, Hoppe K, Shapiro MD, German CA, Virani S, Hussain A, Ballentyne CM, Agha AM, Toth PP. Ten Things to Know About Ten Cardiovascular Disease Risk Factors. American journal of preventive cardiology. 2021 Mar 1; 5(100149):https://doi.org/10.1016/j.ajpc.2021.100149.
  17. Lee MT, Mahtta D, Alam M, Ullah W, Nasir K, Hanif B, Virani SS. Contemporary outcomes studies to identify and mitigate the risk in patients with premature cardiovascular disease. Expert review of pharmacoeconomics & outcomes research. 2021 Feb 17; 1-12.
  18. Mahtta D, Ramsey D, Krittanawong C, Al Rifai M, Khurram N, Samad Z, Jneid H, Ballantyne C, Petersen LA, Virani SS. Recreational substance use among patients with premature atherosclerotic cardiovascular disease. Heart (British Cardiac Society). 2021 Apr 1; 107(8):650-656.
  19. Patel J, Al Rifai M, Blaha MJ, Nasir K, McEvoy JW, Pandey A, Kanaya AM, Kandula NR, Virani S. Hypertension guidelines and coronary artery calcification among south asians: results from MASALA and MESA. American journal of preventive cardiology. 2021 Feb 12; 6(100158):https://doi.org/10.1016/j.ajpc.2021.100158.
  20. Hussain A, Sun W, Deswal A, de Lemos JA, McEvoy JW, Hoogeveen RC, Matsushita K, Aguilar D, Bozkurt B, Virani SS, Shah AM, Selvin E, Ndumule C, Ballantyne CM, Nambi V. Association of NT-ProBNP, Blood Pressure, and Cardiovascular Events: The ARIC Study. Journal of the American College of Cardiology. 2021 Feb 9; 77(5):559-571.
  21. Ullah W, Thalambedu N, Zahid S, Zia Khan M, Mir T, Roomi S, Fischman DL, Virani SS, Alam M. Percutaneous coronary intervention in patients with cardiac allograft vasculopathy: a Nationwide Inpatient Sample (NIS) database analysis. Expert Review of Cardiovascular Therapy. 2021 Mar 1; 19(3):269-276.
  22. Krittanawong C, Mahtta D, Narasimhan B, Wang Z, Bandyopadhyay D, Hanif B, Samad Z, Kitai T, Alam M, Sharma SK, Jneid H, Virani SS. Clinical characteristics and mortality after acute myocardial infarction-related hospitalization among Asians from a national population-based cohort study. Progress in Cardiovascular Diseases. 2021 Feb 3.
  23. Hussain A, Tang O, Sun C, Jia X, Selvin E, Nambi V, Folsom A, Heiss G, Zannad F, Mosley T, Virani SS, Coresh J, Boerwinkle E, Yu B, Cunningham JW, Shah AM, Solomon SD, de Lemos JA, Hoogeveen RC, Ballantyne CM. Soluble Angiotensin-Converting Enzyme 2, Cardiac Biomarkers, Structure, and Function, and Cardiovascular Events (from the Atherosclerosis Risk in Communities Study). The American journal of cardiology. 2021 May 1; 146:15-21.
  24. Jia X, Lee MT, Ramsey DJ, Al Rifai M, Mahtta D, Krittanawong C, Akeroyd JM, Matheny ME, Gobbel G, Stone NJ, Ballantyne CM, Petersen LA, Virani SS. Facility-Level Variation in Reported Statin-Associated Side Effects Among Patients with Atherosclerotic Cardiovascular Disease-Perspective from the Veterans Affair Healthcare System. Cardiovascular drugs and therapy. 2021 Feb 1.
  25. Haddadin F, Arevalo AB, Jabri A, Beydoun H, Fram F, Munoz Estrella A, Karim S, Virani S, Ali Y. The risk and severity of stroke in patients with atrial fibrillation and gout: A National Representative Database study. Journal of arrhythmia. 2021 Apr 1; 37(2):394-399.
  26. Al Rifai M, Khalid U, Misra A, Liu J, Nasir K, Cainzos-Achirica M, Mahtta D, Ballantyne CM, Petersen LA, Virani SS. Racial and geographic disparities in influenza vaccination in the U.S. among individuals with atherosclerotic cardiovascular disease: Renewed importance in the setting of COVID-19. American journal of preventive cardiology. 2021 Mar 1; 5:100150.
  27. Navar AM, Wang TY, Li S, Mi X, Li Z, Robinson JG, Virani SS, Peterson ED. Patient-Perceived Versus Actual Risk of Cardiovascular Disease and Associated Willingness to Consider and Use Prevention Therapy. Circulation. Cardiovascular quality and outcomes. 2021 Jan 13; 14(1):e006548.
  28. Saeed A, Virani SS, Mulukutla S, Chow CK. Dyslipidemia and Cardiovascular Disease Prevention in South Asians: A Review and Discussion of Causes, Challenges and Management Strategies. Current Diabetes Reviews. 2021 Jan 12.
  29. Gregg LP, Hedayati SS, Yang H, Van Buren PN, Banerjee S, Navaneethan SD, Virani SS, Winkelmayer WC, Alvarez CA. Association of Blood Pressure Variability and Diuretics With Cardiovascular Events in Patients With Chronic Kidney Disease Stages 1-5. Hypertension (Dallas, Tex. : 1979). 2021 Mar 3; 77(3):948-959.
  30. Krittanawong C, Isath A, Hahn J, Wang Z, Narasimhan B, Kaplin SL, Jneid H, Virani SS, Tang WHW. Fish Consumption and Cardiovascular Health: A Systematic Review. The American journal of medicine. 2021 Jun 1; 134(6):713-720.
  31. Narasimhan B, Kaplin SL, Narasimhan H, Wang Z, Bandyopadhyay D, Jneid H, Virani SS, Krittanawong C. Trends in pneumococcal vaccination in patients presenting with acute coronary syndrome in the United States. Progress in Cardiovascular Diseases. 2021 Jan 9.
  32. Gu K, Mahtta D, Kaneria A, Sharedalal P, Dennis B, Song Y, Wei X, Khalid U, Hess P, Cho SH, Virani SS. Racial disparities among Asian Americans with atrial fibrillation: An analysis from the NCDR® PINNACLE Registry. International Journal of Cardiology. 2021 Apr 15; 329:209-216.
  33. Mahtta D, Lee MT, Ramsey DJ, Akeroyd JM, Krittanawong C, Khan SU, Sinh P, Alam M, Garratt KN, Schofield RS, Ballantyne CM, Petersen LA, Virani SS. Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7. Cardiovascular drugs and therapy. 2021 Jan 5.
  34. Hussain A, Al Rifai M, Mahtta D, Liu J, Jain V, Virani SS. Highlights from Studies Presented at the American Heart Association Scientific Session 2020: Navigating New Roads in Prevention. Current Atherosclerosis Reports. 2021 Jan 3; 23(1):4.
  35. Brunner G, Virani SS, Sun W, Liu L, Dodge RC, Nambi V, Coresh J, Mosley TH, Sharrett AR, Boerwinkle E, Ballantyne CM, Wasserman BA. Associations Between Carotid Artery Plaque Burden, Plaque Characteristics, and Cardiovascular Events: The ARIC Carotid Magnetic Resonance Imaging Study. JAMA cardiology. 2021 Jan 1; 6(1):79-86.
  36. Ullah W, Zahid S, Hamzeh I, Birnbaum Y, Virani SS, Alam M. Trends and Predictors of Transcatheter Aortic Valve Implantation Related In-Hospital Mortality (From the National Inpatient Sample Database). The American journal of cardiology. 2021 Mar 15; 143:97-103.
  37. Jain V, Rifai MA, Naderi S, Barolia R, Iqbal S, Taj M, Jia X, Merchant AT, Aronow WS, Virani SS. State-Level Temporal Trends in Smokeless Tobacco and Cigarette Use Among U.S. Adults. The American journal of cardiology. 2021 Mar 1; 142:145-147.
  38. Al Rifai M, Mirbolouk M, Jia X, Nasir K, Pickett JK, Nambi V, Ballantyne CM, Merchant AT, Blaha MJ, Virani SS. E-cigarette Use and Risk Behaviors among Lesbian, Gay, Bisexual, and Transgender Adults: The Behavioral Risk Factor Surveillance System (BRFSS) Survey. Kansas journal of medicine. 2020 Dec 11; 13:318-321.
  39. Krittanawong C, Isath A, Hahn J, Wang Z, Fogg SE, Bandyopadhyay D, Jneid H, Virani SS, Tang WHW. Mushroom Consumption and Cardiovascular Health: A Systematic Review. The American journal of medicine. 2021 May 1; 134(5):637-642.e2.
  40. Al Rifai M, Kanaya AM, Kandula NR, Cainzos-Achirica M, Patel J, Budoff M, Criqui MH, Blaha MJ, Virani SS. Distribution of calcium volume, density, number, and type of coronary vessel with calcified plaque in South Asians in the US and other race/ethnic groups: The MASALA and MESA studies. Atherosclerosis. 2021 Jan 1; 317:16-21.
  41. Feldman DI, Michos ED, Stone NJ, Gluckman TJ, Cainzos-Achirica M, Virani S, Blumenthal RS. Same Evidence, Varying Viewpoints: Three Questions Illustrating Important Differences between United States and European Cholesterol Guideline Recommendations. American journal of preventive cardiology. 2020 Nov 13; 4(100117):https://doi.org/10.1016/j.ajpc.2020.100117.
  42. Gupta MD, Miglani M, Bansal A, Jain V, Arora S, Kumar S, Virani SS, Kalra A, Yadav R, Pasha Q, Yusuf J, Mukhopadhyay S, Tyagi S, Girish MP. Telomere length in young patients with acute myocardial infarction without conventional risk factors: A pilot study from a South Asian population. Indian heart journal. 2020 Nov 13; 72(6):619-622.
  43. Ahmed ST, Akeroyd JM, Mahtta D, Street R, Slagle J, Navar AM, Stone NJ, Ballantyne CM, Petersen LA, Virani SS. Shared Decisions: A Qualitative Study on Clinician and Patient Perspectives on Statin Therapy and Statin-Associated Side Effects. Journal of the American Heart Association. 2020 Nov 17; 9(22):e017915.
  44. Okunrintemi V, Tibuakuu M, Virani SS, Sperling LS, Volgman AS, Gulati M, Cho L, Leucker TM, Blumenthal RS, Michos ED. Sex Differences in the Age of Diagnosis for Cardiovascular Disease and Its Risk Factors Among US Adults: Trends From 2008 to 2017, the Medical Expenditure Panel Survey. Journal of the American Heart Association. 2020 Dec 15; 9(24):e018764.
  45. Jain V, Al Rifai M, Lee MT, Kalra A, Petersen LA, Vaughan EM, Wong ND, Ballantyne CM, Virani SS. Racial and Geographic Disparities in Internet Use in the U.S. Among Patients With Hypertension or Diabetes: Implications for Telehealth in the Era of COVID-19. Diabetes Care. 2021 Jan 1; 44(1):e15-e17.
  46. Yonas E, Alwi I, Pranata R, Huang I, Lim MA, Yamin M, Nasution SA, Setiati S, Virani SS. Elevated interleukin levels are associated with higher severity and mortality in COVID 19 - A systematic review, meta-analysis, and meta-regression. Diabetes & metabolic syndrome. 2020 Nov 1; 14(6):2219-2230.
  47. Mszar R, Mahajan S, Valero-Elizondo J, Yahya T, Sharma R, Grandhi GR, Khera R, Virani SS, Lichtman J, Khan SU, Cainzos-Achirica M, Vahidy FS, Krumholz HM, Nasir K. Association Between Sociodemographic Determinants and Disparities in Stroke Symptom Awareness Among US Young Adults. Stroke. 2020 Dec 1; 51(12):3552-3561.
  48. Al Rifai M, Kianoush S, Saeed A, Krittanawong C, Merchant AT, Virani SS. Temporal Trends in the Prevalence of Current E-Cigarette and Cigarette Use by Annual Household Income from 2016 to 2018 (from the Behavioral Risk Factor Surveillance System [BRFSS] Survey). The American journal of cardiology. 2020 Dec 15; 137:139-140.
  49. Krittanawong C, Kumar A, Hahn J, Wang Z, Zhang HJ, Sun T, Bozkurt B, Ballantyne CM, Virani SS, Halperin JL, Jneid H. Cardiovascular risk and complications associated with COVID-19. American journal of cardiovascular disease. 2020 Oct 15; 10(4):479-489.
  50. Jia X, Al Rifai M, Hussain A, Martin S, Agarwala A, Virani SS. Highlights from Studies in Cardiovascular Disease Prevention Presented at the Digital 2020 European Society of Cardiology Congress: Prevention Is Alive and Well. Current Atherosclerosis Reports. 2020 Oct 3; 22(12):72.
  51. Al Rifai M, Virani SS. The Reply. The American journal of medicine. 2020 Oct 1; 133(10):e608.
  52. Khera R, Secemsky EA, Wang Y, Desai NR, Krumholz HM, Maddox TM, Shunk KA, Virani SS, Bhatt DL, Curtis J, Yeh RW. Revascularization Practices and Outcomes in Patients With Multivessel Coronary Artery Disease Who Presented With Acute Myocardial Infarction and Cardiogenic Shock in the US, 2009-2018. JAMA internal medicine. 2020 Oct 1; 180(10):1317-1327.
  53. Tibuakuu M, Okunrintemi V, Savji N, Stone NJ, Virani SS, Blankstein R, Thamman R, Blumenthal RS, Michos ED. Nondietary Cardiovascular Health Metrics With Patient Experience and Loss of Productivity Among US Adults Without Cardiovascular Disease: The Medical Expenditure Panel Survey 2006 to 2015. Journal of the American Heart Association. 2020 Oct 20; 9(19):e016744.
  54. Jia X, Liu J, Mehta A, Ballantyne CM, Virani SS. Lipid-Lowering Biotechnological Drugs: from Monoclonal Antibodies to Antisense Therapies-a Clinical Perspective. Cardiovascular drugs and therapy. 2020 Sep 30.
  55. Kataruka A, Mahtta D, Akeroyd JM, Hira RS, Kazi DS, Spertus JA, Bhatt DL, Petersen LA, Ballantyne CM, Virani SS. Eligibility for Low-Dose Rivaroxaban Based on the COMPASS Trial: Insights from the Veterans Affairs Healthcare System. Cardiovascular drugs and therapy. 2021 Jun 1; 35(3):533-538.
  56. Mahtta D, Ahmed ST, Ramsey DJ, Akeroyd JM, Lee MT, Rodriguez F, Michos ED, Itchhaporia D, Nasir K, Alam M, Jneid H, Ballantyne CM, Petersen LA, Virani SS. Statin Prescription Rates, Adherence, and Associated Clinical Outcomes Among Women with PAD and ICVD. Cardiovascular drugs and therapy. 2020 Dec 1; 34(6):745-754.
  57. Mahtta D, Ramsey DJ, Al Rifai M, Nasir K, Samad Z, Aguilar D, Jneid H, Ballantyne CM, Petersen LA, Virani SS. Evaluation of Aspirin and Statin Therapy Use and Adherence in Patients With Premature Atherosclerotic Cardiovascular Disease. JAMA Network Open. 2020 Aug 3; 3(8):e2011051.
  58. Mahtta D, Gupta A, Ramsey DJ, Rifai MA, Mehta A, Krittanawong C, Lee MT, Nasir K, Samad Z, Blumenthal RS, Jneid H, Ballantyne CM, Petersen LA, Virani SS. Autoimmune Rheumatic Diseases and Premature Atherosclerotic Cardiovascular Disease: An Analysis From the VITAL Registry. The American journal of medicine. 2020 Dec 1; 133(12):1424-1432.e1.
  59. Jia X, Al Rifai M, Liu J, Agarwala A, Gulati M, Virani SS. Highlights of Studies in Cardiovascular Disease Prevention Presented at the 2020 American College of Cardiology Annual Scientific Session. Current Atherosclerosis Reports. 2020 Jun 18; 22(8):32.
  60. Hussain A, Ballantyne CM, Saeed A, Virani SS. Triglycerides and ASCVD Risk Reduction: Recent Insights and Future Directions. Current Atherosclerosis Reports. 2020 Jun 3; 22(7):25.
  61. Mszar R, Grandhi GR, Valero-Elizondo J, Caraballo C, Khera R, Desai N, Virani SS, Blankstein R, Blaha MJ, Nasir K. Cumulative Burden of Financial Hardship From Medical Bills Across the Spectrum of Diabetes Mellitus and Atherosclerotic Cardiovascular Disease Among Non-Elderly Adults in the United States. Journal of the American Heart Association. 2020 May 18; 9(10):e015523.
  62. Virani SS, Smith SC, Stone NJ, Grundy SM. Secondary Prevention for Atherosclerotic Cardiovascular Disease: Comparing Recent US and European Guidelines on Dyslipidemia. Circulation. 2020 Apr 7; 141(14):1121-1123.
  63. Liu J, Saeed A, Hussain A, Virani SS. The Way to a Woman's Heart: Assessing, Personalizing, and Reclassifying Atherosclerotic Cardiovascular Disease Risk in Female Patients. Texas Heart Institute journal. 2020 Apr 1; 47(2):125-127.
  64. Mahtta D, Ahmed ST, Shah NR, Ramsey DJ, Akeroyd JM, Nasir K, Hamzeh IR, Elgendy IY, Waldo SW, Al-Mallah MH, Jneid H, Ballantyne CM, Petersen LA, Virani SS. Facility-Level Variation in Cardiac Stress Test Use Among Patients With Diabetes: Findings From the Veterans Affairs National Database. Diabetes Care. 2020 May 1; 43(5):e58-e60.
  65. Al Rifai M, Mirbolouk M, Obisesan OH, Jia X, Nasir K, Merchant AT, Blaha M, Virani S. The Association of Electronic Cigarette Use and the Subjective Domains of Physical and Mental Health: The Behavioral Risk Factor Surveillance System Survey. Cureus. 2020 Feb 24; 12(2):e7088.
  66. Agarwala A, Michos ED, Samad Z, Ballantyne CM, Virani SS. The Use of Sex-Specific Factors in the Assessment of Women's Cardiovascular Risk. Circulation. 2020 Feb 18; 141(7):592-599.
  67. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW, American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020 Mar 3; 141(9):e139-e596.
  68. Mahtta D, Rodriguez F, Jneid H, Levine GN, Virani SS. Improving adherence to cardiovascular guidelines: realistic transition from paper to patient. Expert Review of Cardiovascular Therapy. 2020 Jan 1; 18(1):41-51.
  69. Rifai MA, Blaha MJ, Patel J, Xiaoming J, Cainzos-Achirica M, Greenland P, Budoff M, Yeboah J, Nasir K, Al-Mallah MH, Virani SS. Coronary Artery Calcification, Statin Use and Long-Term Risk of Atherosclerotic Cardiovascular Disease Events (from the Multi-Ethnic Study of Atherosclerosis). The American journal of cardiology. 2020 Mar 15; 125(6):835-839.
  70. Ahmed ST, Mahtta D, Rehman H, Akeroyd J, Al Rifai M, Rodriguez F, Jneid H, Nasir K, Samad Z, Alam M, Petersen LA, Virani SS. Association between frequency of primary care provider visits and evidence-based statin prescribing and statin adherence: Findings from the Veterans Affairs system. American heart journal. 2020 Mar 1; 221:9-18.
  71. Agarwala A, Kohli P, Virani SS. Popular Media and Cardiovascular Medicine: "with Great Power There Must Also Come Great Responsibility". Current Atherosclerosis Reports. 2019 Oct 31; 21(11):43.
  72. Dixon DL, Sharma G, Sandesara PB, Yang E, Braun LT, Mensah GA, Sperling LS, Deedwania PC, Virani SS. Therapeutic Inertia in Cardiovascular Disease Prevention: Time to Move the Bar. Journal of the American College of Cardiology. 2019 Oct 1; 74(13):1728-1731.
  73. Xian Y, Navar AM, Li S, Li Z, Robinson J, Virani SS, Louie MJ, Koren A, Goldberg A, Roger VL, Wilson PWF, Peterson ED, Wang TY. Intensity of Lipid Lowering With Statin Therapy in Patients With Cerebrovascular Disease Versus Coronary Artery Disease: Insights from the PALM Registry. Journal of the American Heart Association. 2019 Oct 1; 8(19):e013229.
  74. Khan MR, Kayani WT, Ahmad W, Manan M, Hira RS, Hamzeh I, Jneid H, Virani SS, Kleiman N, Lakkis N, Alam M. Effect of increasing age on percutaneous coronary intervention vs coronary artery bypass grafting in older adults with unprotected left main coronary artery disease: A meta-analysis and meta-regression. Clinical Cardiology. 2019 Nov 1; 42(11):1071-1078.
  75. Kazi DS, Virani SS. Implications of cost-effectiveness analyses of lipid-lowering therapies: From the policy-maker's desk to the patient's bedside. Progress in Cardiovascular Diseases. 2019 Sep 1; 62(5):406-413.
  76. Mitchell S, Malanda B, Damasceno A, Eckel RH, Gaita D, Kotseva K, Januzzi JL, Mensah G, Plutzky J, Prystupiuk M, Ryden L, Thierer J, Virani SS, Sperling L. A Roadmap on the Prevention of Cardiovascular Disease Among People Living With Diabetes. Global heart. 2019 Sep 1; 14(3):215-240.
  77. Nanna MG, Wang TY, Xiang Q, Goldberg AC, Robinson JG, Roger VL, Virani SS, Wilson PWF, Louie MJ, Koren A, Li Z, Peterson ED, Navar AM. Sex Differences in the Use of Statins in Community Practice. Circulation. Cardiovascular quality and outcomes. 2019 Aug 16; 12(8):e005562.
  78. Virani SS, Akeroyd JM, Smith SC, Al-Mallah M, Maddox TM, Morris PB, Petersen LA, Ballantyne CM, Grundy SM, Stone NJ. Very High-Risk ASCVD and Eligibility for Nonstatin Therapies Based on the 2018 AHA/ACC Cholesterol Guidelines. Journal of the American College of Cardiology. 2019 Aug 6; 74(5):712-714.
  79. Pokharel Y, Mouhanna F, Schneider ALC, Rawlings AM, Knopman DS, Nambi V, Virani SS, Hoogeveen RC, Alonso A, Heiss G, Coresh J, Mosley T, Gottesman R, Selvin E, Ballantyne C, Power MC. High-Sensitive Troponin T, Natriuretic Peptide, and Cognitive Change. Journal of the American Geriatrics Society. 2019 Nov 1; 67(11):2353-2361.
  80. Rehman H, Ahmed ST, Akeroyd J, Mahtta D, Jia X, Rifai MA, Nasir K, Jneid H, Khalid MU, Alam M, Toth PP, Virani SS. Relation Between Cardiology Follow-Up Visits, Evidence-Based Statin Prescribing, and Statin Adherence (from the Veterans Affairs Health Care System). The American journal of cardiology. 2019 Oct 15; 124(8):1165-1170.
  81. Quispe R, Elshazly MB, Zhao D, Toth PP, Puri R, Virani SS, Blumenthal RS, Martin SS, Jones SR, Michos ED. Total cholesterol/HDL-cholesterol ratio discordance with LDL-cholesterol and non-HDL-cholesterol and incidence of atherosclerotic cardiovascular disease in primary prevention: The ARIC study. European journal of preventive cardiology. 2020 Oct 1; 27(15):1597-1605.
  82. Santo K, Isiguzo GC, Atkins E, Mishra SR, Panda R, Mbau L, Fayomi SB, Ugwu C, Odili A, Virani S. Adapting a club-based medication delivery strategy to a hypertension context: the CLUBMEDS Study in Nigeria. BMJ open. 2019 Jul 9; 9(7):e029824.
  83. Dixon DL, Virani SS. Mortality reduction with PCSK9 inhibition: A case of cautious optimism. Journal of clinical lipidology. 2019 Sep 1; 13(5):712-713.
  84. Sardana M, Tang Y, Magnani JW, Ockene IS, Allison JJ, Arnold SV, Jones PG, Maddox TM, Virani SS, McManus DD. Provider-Level Variation in Smoking Cessation Assistance Provided in the Cardiology Clinics: Insights From the NCDR PINNACLE Registry. Journal of the American Heart Association. 2019 Jul 2; 8(13):e011412.
  85. Nanna MG, Navar AM, Wang TY, Li S, Virani SS, Li Z, Robinson JG, Roger VL, Wilson PWF, Goldberg AC, Koren A, Louie MJ, Peterson ED. Practice-level variation in statin use and low-density lipoprotein cholesterol control in the United States: Results from the Patient and Provider Assessment of Lipid Management (PALM) registry. American heart journal. 2019 Aug 1; 214:113-124.
  86. Jia X, Al Rifai M, Ramsey DJ, Ahmed ST, Akeroyd JM, Nambi V, Ballantyne CM, Petersen LA, Stone NJ, Virani SS. Association Between Lipid Testing and Statin Adherence in the Veterans Affairs Health System. The American journal of medicine. 2019 Sep 1; 132(9):e693-e700.
  87. Pokharel Y, Mouhanna F, Nambi V, Virani SS, Hoogeveen R, Alonso A, Heiss G, Coresh J, Mosley T, Gottesman RF, Ballantyne CM, Power MC. ApoB, small-dense LDL-C, Lp(a), LpPLA activity, and cognitive change. Neurology. 2019 May 28; 92(22):e2580-e2593.
  88. Trang A, Kampangkaew J, Fernandes R, Tiwana J, Misra A, Hamzeh I, Blaustein A, Aguilar D, Shah T, Ballantyne C, Quinones M, Nagueh SF, Dokanish H, Virani SS, Deswal A, Kirkpatrick JN, Nambi V. Understanding by General Providers of the Echocardiogram Report. The American journal of cardiology. 2019 Jul 15; 124(2):296-302.
  89. Mahtta D, Virani S, Bavry AA. Emerging Lipid-Lowering Therapies in Secondary Prevention. Current cardiovascular risk reports. 2019 Apr 17; 13(11):https://doi.org/10.1007/s12170-019-0607-z.
  90. Shah NR, Ahmed ST, Winchester DE, Ramsey DJ, Akeroyd JM, Wu WC, Waldo SW, Schofield RS, Ballantyne CM, Petersen LA, Virani SS. Facility-Level Variation in Stress Test Utilization in Veterans With Ischemic Heart Disease. JACC. Cardiovascular imaging. 2019 Jul 1; 12(7 Pt 1):1292-1293.
  91. Merchant AT, Virani SS. Childhood Oral Infections and Subclinical Atherosclerosis in Adulthood: Should We Wait for Causality or Just Treat?. JAMA Network Open. 2019 Apr 5; 2(4):e192489.
  92. Bradley CK, Wang TY, Li S, Robinson JG, Roger VL, Goldberg AC, Virani SS, Louie MJ, Lee LV, Peterson ED, Navar AM. Patient-Reported Reasons for Declining or Discontinuing Statin Therapy: Insights From the PALM Registry. Journal of the American Heart Association. 2019 Apr 2; 8(7):e011765.
  93. Jia X, Al Rifai M, Birnbaum Y, Smith SC, Virani SS. The 2018 Cholesterol Management Guidelines: Topics in Secondary ASCVD Prevention Clinicians Need to Know. Current Atherosclerosis Reports. 2019 Apr 2; 21(6):20.
  94. Jia X, Virani SS. CLEAR Serenity Trial: More Clarity for the Future of Bempedoic Acid in Patients Unable to Take Statins?. Journal of the American Heart Association. 2019 Apr 2; 8(7):e012352.
  95. Sandesara PB, Virani SS, Fazio S, Shapiro MD. The Forgotten Lipids: Triglycerides, Remnant Cholesterol, and Atherosclerotic Cardiovascular Disease Risk. Endocrine reviews. 2019 Apr 1; 40(2):537-557.
  96. Jia X, Akeroyd JM, Nasir K, Nambi V, Ballantyne CM, Petersen LA, Virani SS. Eligibility and Cost for Icosapent Ethyl Based on the REDUCE-IT Trial. Circulation. 2019 Mar 5; 139(10):1341-1343.
  97. Okunrintemi V, Khera R, Spatz ES, Salami JA, Valero-Elizondo J, Warraich HJ, Virani SS, Blankstein R, Blaha MJ, Pawlik TM, Dharmarajan K, Krumholz HM, Nasir K. Association of Income Disparities with Patient-Reported Healthcare Experience. Journal of general internal medicine. 2019 Jun 1; 34(6):884-892.
  98. Valero-Elizondo J, Khera R, Saxena A, Grandhi GR, Virani SS, Butler J, Samad Z, Desai NR, Krumholz HM, Nasir K. Financial Hardship From Medical Bills Among Nonelderly U.S. Adults With Atherosclerotic Cardiovascular Disease. Journal of the American College of Cardiology. 2019 Feb 19; 73(6):727-732.
  99. Hyman DA, Siebert V, Jia X, Alam M, Levine GN, Virani SS, Birnbaum Y. Risk Assessment of Stroke in Patients with Atrial Fibrillation: Current Shortcomings and Future Directions. Cardiovascular drugs and therapy. 2019 Feb 1; 33(1):105-117.
  100. Kamal AK, Khalid W, Zulfiqar M, Muqeet A, Zaidi F, Gowani A, Virani SS. The potential of m-Health-based interventions to improve medication literacy and adherence in non-communicable diseases in Pakistan. International journal of stroke : official journal of the International Stroke Society. 2019 Apr 1; 14(3):NP8-NP10.
  101. Mishra SR, Ghimire S, Shrestha N, Shrestha A, Virani SS. Socio-economic inequalities in hypertension burden and cascade of services: nationwide cross-sectional study in Nepal. Journal of Human Hypertension. 2019 Aug 1; 33(8):613-625.
  102. Virani SS, Akeroyd JM, Nambi V, Michos ED, Morris PB, Nasir K, Smith SC, Stone NJ, Petersen LA, Ballantyne CM. Applicability and Cost Implications for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors Based on the ODYSSEY Outcomes Trial. Circulation. 2019 Jan 15; 139(3):410-412.
  103. Lowenstern A, Navar AM, Li S, Virani SS, Goldberg AC, Louie MJ, Lee LV, Peterson ED, Wang TY. Association of Clinician Knowledge and Statin Beliefs With Statin Therapy Use and Lipid Levels (A Survey of US Practice in the PALM Registry). The American journal of cardiology. 2019 Apr 1; 123(7):1011-1018.
  104. Hira RS, Kataruka A, Akeroyd JM, Ramsey DJ, Pokharel Y, Gurm HS, Nasir K, Deswal A, Jneid H, Alam M, Ballantyne CM, Petersen LA, Virani SS. Association of Body Mass Index With Risk Factor Optimization and Guideline-Directed Medical Therapy in US Veterans With Cardiovascular Disease. Circulation. Cardiovascular quality and outcomes. 2019 Jan 1; 12(1):e004817.
  105. Saeed A, Sun W, Agarwala A, Virani SS, Nambi V, Coresh J, Selvin E, Boerwinkle E, Jones PH, Ballantyne CM, Hoogeveen RC. Lipoprotein(a) levels and risk of cardiovascular disease events in individuals with diabetes mellitus or prediabetes: The Atherosclerosis Risk in Communities study. Atherosclerosis. 2019 Mar 1; 282:52-56.
  106. Kamal AK, Khalid W, Muqeet A, Jamil A, Farhat K, Gillani SRA, Zulfiqar M, Saif M, Muhammad AA, Zaidi F, Mustafa M, Gowani A, Sharif S, Bokhari SS, Tai J, Rahman N, Sultan FAT, Sayani S, Virani SS. Making prescriptions "talk" to stroke and heart attack survivors to improve adherence: Results of a randomized clinical trial (The Talking Rx Study). PLoS ONE. 2018 Dec 20; 13(12):e0197671.
  107. Virani SS, Ballantyne CM. Low-Density Lipoprotein Cholesterol: Is 160 the New 190? Circulation. 2018 Nov 20; 138(21):2326-2329.
  108. Lloyd-Jones DM, Braun LT, Ndumele CE, Smith SC, Sperling LS, Virani SS, Blumenthal RS. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology. Circulation. 2019 Jun 18; 139(25):e1162-e1177.
  109. Lloyd-Jones DM, Braun LT, Ndumele CE, Smith SC, Sperling LS, Virani SS, Blumenthal RS. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology. Journal of the American College of Cardiology. 2019 Jun 25; 73(24):3153-3167.
  110. Rodwin BA, Salami JA, Spatz ES, Valero-Elizondo J, Virani SS, Blankstein R, Blaha MJ, Nasir K, Desai NR. Variation in the Use of Warfarin and Direct Oral Anticoagulants in Atrial Fibrillation and Associated Cost Implications. The American journal of medicine. 2019 Jan 1; 132(1):61-70.e1.
  111. Saeed A, Virani SS, Jones PH, Ballantyne CM, Nambi V. Case reports of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition nonresponse. Journal of clinical lipidology. 2018 Sep 1; 12(5):1141-1145.


DRA: Cardiovascular Disease
DRE: Prevention, Prognosis, Treatment - Implementation
Keywords: none
MeSH Terms: none

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