Women are less likely to be prescribed statins than men. Existing reports explain only a fraction of this difference. We conducted a study to identify factors that account for sex differences in statin therapy among patients with coronary artery disease (CAD).
Methods and Results
We retrospectively studied 24,338 patients with CAD who were followed for at least a year between 2000 and 2011 at two academic medical centers. Women (9,006 / 37% of study patients) were less likely to either have initiated statin therapy (81.9% women vs. 87.7% men) or to have persistent statin therapy at the end of follow-up (67.0% women vs. 71.4% men). Women were older (72.9 vs. 68.4 years), less likely to have ever smoked (49.8% vs. 65.6%), less likely to have been evaluated by a cardiologist (57.5% vs. 64.5%) and more likely to have reported an adverse reaction to a statin (27.1% vs. 21.7%) (p < 0.0001 for all). In multivariable analysis, patients with history of smoking (OR 1.094; p 0.017), younger age (OR 1.013 / year), cardiologist evaluation (OR 1.337) and no reported adverse reactions to statins (OR 1.410) were more likely (p < 0.0001 for all) to have persistent statin therapy. Together, these four factors accounted for 90.4% of the sex disparity in persistent statin therapy.
Citation: Zhang H, Plutzky J, Shubina M, Turchin A (2016) Drivers of the Sex Disparity in Statin Therapy in Patients with Coronary Artery Disease: A Cohort Study. PLoS ONE 11(5): e0155228. https://doi.org/10.1371/journal.pone.0155228
Editor: Marie-Pierre Dubé, Universite de Montreal, CANADA
Received: October 20, 2015; Accepted: April 26, 2016; Published: May 5, 2016
Copyright: © 2016 Zhang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Partners HealthCare policy requires a data use agreement for release of de-identified patient data. Consequently, we will not be able to make the de-identified data used in this study public but will be able to provide it to interested investigators upon request from Dr. Turchin (email@example.com), conditional on their signing a data use agreement with Partners HealthCare.
Funding: AT: National Library of Medicine (5RC1LM010460). http://www.nlm.nih.gov. HZ: Chinese National Key Program of Clinical Science (WBYZ2011873), http://www.nhfpc.gov.cn. HZ: Young Scientific Research Fund of Peking Union Medical College Hospital (pumch-2013-060), http://www.pumch.cn/. HZ: National Natural Science Foundation of China (NSFC71432004), http://www.nsfc.gov.cn. JP: Brigham and Women's Hospital Linda Joy Pollin Women's Heart Center. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: AT received investigator-initiated research grant funding from Merck, Sharp and Dohme. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors.
Coronary artery disease (CAD) is the leading cause of death and disability in both men and women in United States and many developed countries.[1–3] Although on average the onset of CAD is about 10 years later in women than in men, women carry a greater burden of cardiovascular risk factors and have higher prevalence of symptoms, myocardial ischemia, and mortality relative to men.[4,5] While mortality rates from CAD have fallen significantly in both men and women over the past 30 years, this decline has been much more dramatic among men. The reason for this difference is multifactorial, but lower adherence to evidence-based guidelines in women may be a key contributor.[6,7]
Statins are highly effective in decreasing the risk of secondary coronary events[8–10] and they are equally effective in men and women.[11–13] Consequently consensus guidelines recommend statin therapy for all adult patients with CAD irrespective of sex.[1,8] Nevertheless women are less likely to be prescribed statins than men in patients with CAD.[14–28] The reasons for the sex disparity in statin therapy are not clear. Prior reports suggest that patients' characteristics including demographics, economic status, physical health status, depression and lifestyle risk factors account for less than one third of the difference in statin use. Among women and men, Latino race/ethnicity, lack of prescription drug coverage and greater functional disability were negatively associated with statin use. African American race and low educational status were negatively associated with statin use in men alone. There was a higher likelihood of statin use among both women and men who had fair health status, those who were overweight or obese, and among men who were smokers in the past (but not current smokers).  We therefore conducted a retrospective cohort study to evaluate the contribution of age, smoking history, evaluation by a cardiologist and history of reported adverse reactions to statins to sex disparities in statin therapy in patients with CAD.
In order to identify factors that could explain the difference in statin therapy between women and men, we first established patient and treatment characteristics that were associated with statin therapy in patients with CAD. Among the characteristics that were significantly associated with higher probability of statin therapy, we then identified the ones that had different distribution between men and women. As the final step, we calculated the relative contributions of the characteristics that had different prevalence in women vs. men to the sex disparities in statin therapy.
Study participants included adult patients (> = 18 years old) with CAD followed in primary care practices affiliated with Brigham and Women’s Hospital (BWH) or Massachusetts General Hospital (MGH) for at least a year during the study period from January 1st, 2000 to December 31st, 2011. Treatment in a primary care practice was defined as having notes in a primary care clinic on at least two distinct dates during the study period. Patients were excluded from the study if demographic information (sex and median income by zip code) was not available.
For an individual patient study entry date was defined as the later of a) date of diagnosis of CAD and b) the first primary care practice note after January 1st, 2000. We included only patients who had notes in a primary care clinic for at least 1 year after the study entry date in order to ensure sufficient data for analysis. Date of the last note in a primary care clinic during the study period served as the study exit date. This study was approved by Partners Human Research Committee which is the institutional review board at the Partners HealthCare System and the requirement for written informed consent was waived. Patient records were de-identified and analyzed anonymously.
An individual patient served as the unit of analysis. Statin use was defined as at least one statin prescription during study period. Patient was categorized as having persistent statin therapy if they had an active statin electronic medical record (EMR) medication record upon study exit (defined as a statin medication record updated within twelve months prior to the study exit without a subsequent explicit discontinuation).
Patient age was calculated at study entry. Diagnoses of CAD and diabetes mellitus (DM), history of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) and myocardial infarction (MI), and family history of CAD were established from the EMR data. The definition of CAD was based on the diagnosis of CAD or MI on the problem list or history of CABG or PCI. Highest low-density lipoprotein cholesterol (LDL-C) level was defined as the highest LDL-C recorded before the study exit. Baseline body mass index (BMI) and smoking status were identified from the EMR records prior to the study entry. Patient was categorized as having been evaluated by a cardiologist if they had at least one note in a cardiology clinic within the Partners system during the study period. Information on reported adverse reactions to statins (clinical events / symptoms documented by healthcare providers as thought to have been caused by a statin) was obtained from a combination of structured EMR data and computational processing of narrative electronic provider notes using specially designed natural language processing software (Canary). The software utilizes a language model of documentation of clinical events related to medications that includes over 1,200 rules. These rules recognize clinical events that are etiologically linked in the text to a set of specific medications (e.g. "Lipitor") or classes (e.g. "statins"). While the software can recognize documentation of clinical events related to any set of medications, it was specifically validated for identification of adverse reactions to statins, whereupon it achieved sensitivity of at least 86.5% and specificity of at least 91.9%. The software is available from the authors upon request.
Demographic information, medication and laboratory data were obtained from the EMR at Partners HealthCare System—an integrated health care delivery network in eastern Massachusetts that includes BWH and MGH. The Partners HealthCare EMR system was fully integrated by 2000, so includes all prescription and laboratory records for patients over the study period. No changes were made to these systems over the 12 years of this study.
Summary statistics were calculated using frequencies and proportions for categorical data and means (SDs), medians, and ranges for continuous variables. Quantitative variables were compared across multiple patient categories using one-way ANOVA and categorical variables using chi-square. A multivariable logistic regression model was used to identify patient characteristics associated with use or persistence of statin therapy, compared to no statin therapy or non-persistent use of statins. Patient demographics (age, sex, race, health insurance, primary language, and median income by zip code), diagnosis of diabetes mellitus, family history of CAD, history of smoking, maximum LDL level, baseline BMI, cardiologist evaluation and reported adverse reactions (only in the analysis of persistence of statin therapy) were included as covariates in the analysis. Primary language was represented as a binary variable (“English” vs. “Other”). Multiple imputation technique was used to account for missing data for all variables that had missing information for at least one patient (smoking status, maximum LDL level and baseline BMI). For variables that describe diagnoses (e.g. CABG, MI) absence of information was interpreted as absence of diagnosis, since absence of diagnosis is not routinely recorded in the EMR. The analysis was adjusted for clustering within primary care providers. Clustering adjustment was done using GEE (generalized estimating equations) models. Thresholds for statistical significance were adjusted for multiple hypothesis testing using Simes-Hochberg method[30,31].
Candidate variables were selected a priori based on their perceived clinical relevance. Additionally, all available demographic data were included.
To estimate the impact of a covariate or a group of covariates of interest on sex differences in probabilities of a binary event of interest (statin use or persistence of statin therapy for statin users), we directly standardized (re-weighted) the distribution of a covariate or a group of covariates of women to those of men to estimate adjusted probabilities of the event for women. Direct standardization was also applied for estimation of adjusted probability of persistence of statin therapy in all study population for covariates which were defined for all subjects. To estimate adjusted probabilities for covariates which are pertinent only to statin users, we used two level direct standardization: first by covariates defined for every subject, then for remaining covariates within each stratum defined by the first group of covariates.
The adjusted sex disparity was defined as the difference between the observed probability of the event for men and the adjusted probability of the event for women. Disparity explained by a covariate or a set of covariates was defined as the difference between the observed disparity and adjusted disparity, and the disparity fraction explained by the covariates of interest was calculated as a ratio of the explained disparity to observed disparity.
We applied direct standardization to estimate adjusted probabilities and fractions of sex disparity in statin use explained by cardiology evaluation, smoking and age group for each covariate and jointly by all three. For statin users direct standardization was applied to estimate adjusted probabilities and fractions of sex disparity in persistence in statin therapy explained univariately by cardiology evaluation, history of smoking, and age group. Two-level direct standardization was used to calculate the univariate contribution of adverse reaction attributed to statin as well as the joint contribution of all four variables. Bootstrap method, stratified by sex, was used to estimate variances for adjusted probabilities, adjusted and explained disparities and disparity fractions explained by covariates. All data was analyzed using SAS, version 9.3 (SAS Institute, Cary, North Carolina). The authors had full access to and take full responsibility for the integrity of the data. All authors have read and agree to the manuscript as written.
We identified 24,809 patients with a diagnosis of CAD who were followed for at least 1 year by BWH or MGH primary care physicians between 2000 and 2010. We excluded 471 patients who had missing demographics information; the remaining 24,338 patients were included in the analysis (Table 1). Two thirds of the patients were men; 20,830 (85.6%) received statins during the study period (Table 2) and 16,792 (69.7%) had persistent statin therapy.
Abbreviations: LDL-C, low density lipoprotein-cholesterol; BMI, body mass index; CAD, coronary artery disease.
Abbreviations: LDL-C, low density lipoprotein-cholesterol; BMI, body mass index; CAD, coronary artery disease.
In univariate analysis, women were less likely than men to have been treated with a statin but equally likely to have persistent statin therapy over the course of the study. Women were older, less likely to have ever smoked, less likely to have been evaluated by a cardiologist and more likely to have reported an adverse reaction to a statin. (Tables 1 & 2)
Predictors for statin use and persistence
In multivariable analysis, diagnosis of diabetes, family history of CAD, younger age, history of smoking and cardiologist evaluation were associated with greater likelihood of statin use (Table 3) while female sex was associated with lower likelihood. In multivariable analysis in patients who had initiated statin therapy, diagnosis of diabetes, family history of CAD, female sex, younger age, history of smoking, and cardiologist evaluation were associated with greater likelihood of persistent statin therapy, while reported adverse reactions to statins were associated with lower likelihood of remaining on statin treatment (Table 4). There were no significant differences in distribution of diabetes or family history of CAD between men and women (Tables 1 & 2). On the other hand, women were significantly older, less likely to smoke, less likely to have been evaluated by a cardiologist and more likely to have reported an adverse reaction to a statin than men (Tables 1 & 2). These four patient and treatment characteristics were therefore subsequently examined as possible candidates for the explanation of the differences in statin therapy between women and men. We have also conducted a sensitivity analysis excluding patients with race equal to "Other", with the results similar to the original analysis.
Abbreviations: CAD, coronary artery disease; LDL-C, low density lipoprotein-cholesterol; BMI, body mass index.
Contribution of age, smoking, cardiologist evaluation and reported adverse statin reactions to sex differences in statin use
Direct estimates of the effect of differences in joint distributions of covariates between two groups can be used to assess the relative contributions of specific covariates to these differences. In applying this method to differences in statin use between men and women, the following contributions were identified: age 29.5%, smoking 22.1%, and cardiologist evaluation 17.9%. Together, these three factors contributed 48.9% to the sex disparity in statin use. Patients with possible evidence of more severe CAD were more likely to be seen by a cardiologist. Among patients with history of CABG, 78.5% were evaluated by a cardiologist while only 59.1% of patients without history of CABG received evaluation by a cardiovascular specialist. Cardiologists saw 68.6% of patients with history of MI while only 57.9% of patients without history of MI were evaluated by a cardiologist. However, this difference in CAD severity accounted only for a fraction of the contribution of cardiologist evaluation to the sex disparity. Including history of CABG and MI in the model only reduced the contribution of cardiologist evaluation to 13.2%.
Direct estimates of the effect of the differences in joint distributions of the covariates between men and women showed the following contributions to sex differences in persistent statin therapy: age 51.5%, smoking 31.9%, cardiologist evaluation 25.1%, and reported adverse statin reactions 6.3%. Together, these four factors accounted for 90.4% of the sex disparity in persistent statin therapy.
In this large retrospective study we found that only 85.6% of the patients with a diagnosis of CAD ever received statins during the study period and less than 70% had persistent therapy by the end of follow-up. Importantly, four patient characteristics–age, smoking history, evaluation by a cardiologist and reported adverse reactions to statins–underlie most of the sex differences in persistent statin therapy. This is the first study that was able to identify patient characteristics and other factors that account for a large fraction of the sex disparity in statin therapy. These findings therefore have significant public health implications by pointing out both areas where interventions might be applied to reduce sex disparities in statin therapy as well as important population differences between women and men with CAD (e.g. in age and rates of smoking) that may be giving rise to a large component of the apparent disparity.
The present study has several strengths. Access to EMR data from two large hospital systems allowed us to analyze data on more than 24,000 patients with CAD with diverse backgrounds. The EMR data enabled us to analyze a comprehensive dataset that included laboratory data, body mass index, family history and smoking status, which are generally not available in claims data. Use of a specially designed natural language processing software identified a large number of reported adverse reactions to statins that were only documented in provider notes. Finally, we were able to follow the patients longitudinally providing a more comprehensive assessment compared to a cross-sectional analysis.
Current guidelines recommend statin therapy for all adult patients with CAD irrespective of age based on randomized placebo-controlled evidence for statin benefits across various clinical profiles.[8,9] The guidelines for treatment of patients with CAD didn’t change significantly over the study period.[34,35] In clinical trials statin therapy reduces the risk of cardiovascular events in patients with CAD older than 75 years of age. [36,37] However, acknowledging that older participants in clinical trials were likely to be healthier than many older individuals in the general population, guidelines recommend that the use of statin therapy should be individualized in persons with CAD >75 years of age.  In clinical practice, older people are thought to be less likely to be on statins. [38,39] Our study supports this finding of decreased persistence of statin therapy as a function of age. Women in our study were on average 4.5 years older than men–in keeping with the known later onset of CAD in women– 48% of them were older than 75. Thus the older age of CAD onset in women may have contributed to the sex disparities of statin therapy in our study. The fact that statin therapy in older individuals remains a matter of debate could be an explanation for this finding.
Smoking is a well-known risk factor for cardiovascular events.[40,41] However, all patients in our analysis already had a documented diagnosis of CAD and therefore were at sufficiently high risk of cardiovascular events to justify statin therapy. Nevertheless, other investigators have also observed that in clinical practice patients at higher cardiovascular risk are more likely to receive statin therapy.[24,42] This approach may be supported by clinical trial evidence that smokers as a subgroup are amongst those benefiting the most from statin use.  Since smoking rates are higher in men than women , tobacco use may drive greater statin use in men versus women as identified in this study and also seen by others. 
We found that women were less likely to be evaluated by a cardiologist, which may contribute to sex disparity in statin use given that cardiologist evaluation contributes to statin use in general. Prior studies support the notion that women are less likely to see a cardiovascular specialist although this has not been directly linked to differences in statin use. While it is possible that cardiologists are more aggressive in prescribing statins because their patients have a higher risk profile, our findings were not consistent with this explanation. Even though patients evaluated by a cardiologist were more likely to have a history of MI or CABG, these factors accounted for only a fraction (4.7% out of 17.9%) of the sex disparity in statin therapy explained by differences in cardiology evaluation. Specialist consultation may narrow the gap in clinical performance measures between women and men [44–46] suggesting a role of referrals in improving outcomes and mitigating performance disparities. Other studies have suggested that management of hypertension and other cardiovascular parameters may be more aggressive and effective when done by a cardiologist rather than an internist.[44,45] Given the potential impact on appropriate use, further research is needed to establish the reasons for both this unexplained sex disparity in cardiology referrals as well as the under-prescribing patterns among primary care physicians. At the same time, we must bear in mind that "evaluation by a cardiologist" includes not just the actions by cardiologists but also referral patterns by PCPs and patients' acceptance of such referrals, all of which could be contributing to the sex differences in statin therapy.
Adverse reactions are commonly reported by patients receiving statins in clinical setting as opposed to clinical trials.[47,48] In our study women were more likely than men to report adverse reactions to statins, as also reported by others [49–51]. The difference in reported adverse events to statin treatment was a significant contributor to the sex disparity in statin therapy. The reasons for differences in frequency of reported adverse reactions to statins between men and women require further exploration. Several known risk factors for adverse reactions to statins may contribute to these differences, including older age, more metabolic syndrome factors, smaller body size, etc.
Successful statin therapy in appropriate patients involves two components: initiation and persistence. We found that women were less likely to have been ever used statin therapy than men. However, women already on statin therapy were more likely to persist on it. The reasons for this difference are uncertain, and existing literature on statin therapy adherence in women is mixed.[53,54] More research is needed to gain better understanding of sex differences in persistence on statin therapy.
When effects of the differences in initiation and persistence were combined, women were less likely to receive statin treatment overall. In our study, women were 6.6% less likely to have ever used statins and 6.2% less likely to have persistent statin therapy, comparable with previously published research. [14–27] Less frequent preventive therapy recommendations by physicians for women have been attributed to the lower perceived CVD risk for women by the physicians, despite the evidence demonstrating statin efficacy in decreasing the risk of secondary CVD events in both women and men. These findings suggest the clinicians’ assumptions regarding cardiovascular risk in women require further consideration and attention.
It is important to note that a degree of controversy continues to exist about the benefits women derive from statin therapy. A recent meta-analysis focused on secondary prevention and limited to placebo-controlled trials confirmed a reduction in cardiovascular events similar to men but did not find a benefit in all-cause mortality or stroke. On the other hand, a larger meta-analysis that included primary prevention and “usual care” controlled trials found a similar reduction in all-cause mortality in both women and men. The debate continues about the relative merits of these analyses and consequently some clinicians may remain unconvinced about the benefits of statin therapy in women, leading to lower treatment rates. However, in the secondary prevention population that was the focus of our study, the reduction in the incidence of cardiovascular events–an important clinical endpoint—has been a consistent finding.[13,56] Consequently, the most recent AHA / ACC as well as ESC / EAS guidelines recommend statin therapy for secondary prevention in both women and men ≤ 75 years of age, with the evidence rating of NHLBI Grade A or AHA/ACC Class of Recommendation I (highest in both cases). [58,59]
Our findings must be interpreted in the light of several limitations. Our analysis was observational in nature and therefore could only establish associations rather than causal relationships. Our study population included patients from two primarily academic hospitals in eastern Massachusetts, so the results may not be generalizable to patients in other settings. Information on patients who received some of their care outside of Partners HealthCare may have been incomplete. We did not have the information of the maximum LDL while off statin and the number of years since CAD diagnosis and could not assess their contribution to statin therapy. Not all patients in the study may have had clinical ASCVD–for example, some patients who had a diagnosis of “CAD” recorded in the electronic medical records could have had asymptomatic partial occlusion of coronary arteries identified on angiography. Accuracy of the natural language processing algorithm while high, was not perfect and some adverse reactions may have been missed. Finally, EMR medication data may not comprehensively reflect statin utilization by patients.
In summary, in 24,809 patients with CAD in whom indications for statin therapy were unequivocal, a discrete set of four specific factors appear to account for the majority of differences between men and women in statin use and persistent use. Our data reveals significant issues and opportunities for improving cardiovascular outcomes in women by eliminating sex disparity in statin use in scenarios where their clinical benefits are indisputable. As an example, statin rechallenge after an adverse reaction could be a potential strategy for the practicing clinician to decrease sex disparity in statin therapy. Identifying drivers for decreased appropriate statin use in women may facilitate interventions and stimulate research to overcome sex differences in applying proven interventions for cardiovascular risk reduction.
Conceived and designed the experiments: HZ JP MS AT. Performed the experiments: HZ JP MS AT. Analyzed the data: HZ JP MS AT. Contributed reagents/materials/analysis tools: HZ JP MS AT. Wrote the paper: HZ MS AT.
- 1. Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, et al. (2012) 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 126: e354–471. pmid:23166211
- 2. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, et al. (2014) Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 129: e28–e292. pmid:24352519
- 3. Gholizadeh L, Davidson P (2008) More similarities than differences: an international comparison of CVD mortality and risk factors in women. Health Care Women Int 29: 3–22. pmid:18176877
- 4. Bairey Merz CN, Shaw LJ, Reis SE, Bittner V, Kelsey SF, et al. (2006) Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol 47: S21–29. pmid:16458167
- 5. Shaw LJ, Bairey Merz CN, Pepine CJ, Reis SE, Bittner V, et al. (2006) Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies. J Am Coll Cardiol 47: S4–S20. pmid:16458170
- 6. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, et al. (2011) Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. J Am Coll Cardiol 57: 1404–1423. pmid:21388771
- 7. Lewis WR, Ellrodt AG, Peterson E, Hernandez AF, LaBresh KA, et al. (2009) Trends in the use of evidence-based treatments for coronary artery disease among women and the elderly: findings from the get with the guidelines quality-improvement program. Circ Cardiovasc Qual Outcomes 2: 633–641. pmid:20031902
- 8. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, et al. (2014) 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129: S1–S45. pmid:24222016
- 9. European Association for Cardiovascular P, Rehabilitation, Reiner Z, Catapano AL, De Backer G, et al. (2011) ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J 32: 1769–1818. pmid:21712404
- 10. Mills EJ, Wu P, Chong G, Ghement I, Singh S, et al. (2011) Efficacy and safety of statin treatment for cardiovascular disease: a network meta-analysis of 170,255 patients from 76 randomized trials. QJM 104: 109–124. pmid:20934984
- 11. Cholesterol Treatment Trialists C, Baigent C, Blackwell L, Emberson J, Holland LE, et al. (2010) Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet 376: 1670–1681. pmid:21067804
- 12. Cholesterol Treatment Trialists C, Kearney PM, Blackwell L, Collins R, Keech A, et al. (2008) Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 371: 117–125. pmid:18191683
- 13. Kostis WJ, Cheng JQ, Dobrzynski JM, Cabrera J, Kostis JB (2012) Meta-analysis of statin effects in women versus men. J Am Coll Cardiol 59: 572–582. pmid:22300691
- 14. Murphy NF, Simpson CR, MacIntyre K, McAlister FA, Chalmers J, et al. (2006) Prevalence, incidence, primary care burden and medical treatment of angina in Scotland: age, sex and socioeconomic disparities: a population-based study. Heart 92: 1047–1054. pmid:16399851
- 15. Gouni-Berthold I, Berthold HK, Mantzoros CS, Bohm M, Krone W (2008) Sex disparities in the treatment and control of cardiovascular risk factors in type 2 diabetes. Diabetes Care 31: 1389–1391. pmid:18375411
- 16. Ferrara A, Mangione CM, Kim C, Marrero DG, Curb D, et al. (2008) Sex disparities in control and treatment of modifiable cardiovascular disease risk factors among patients with diabetes: Translating Research Into Action for Diabetes (TRIAD) Study. Diabetes Care 31: 69–74. pmid:17934157
- 17. Vimalananda VG, Miller DR, Hofer TP, Holleman RG, Klamerus ML, et al. (2013) Accounting for clinical action reduces estimates of gender disparities in lipid management for diabetic veterans. J Gen Intern Med 28 Suppl 2: S529–535. pmid:23807061
- 18. Chen CY, Chuang SY, Fang CC, Huang LC, Hsieh IC, et al. (2014) Gender disparities in optimal lipid control among patients with coronary artery disease. J Atheroscler Thromb 21 Suppl 1: S20–28. pmid:24452112
- 19. Vimalananda VG, Miller DR, Palnati M, Christiansen CL, Fincke BG (2011) Gender disparities in lipid-lowering therapy among veterans with diabetes. Womens Health Issues 21: S176–181. pmid:21724138
- 20. Driscoll A, Beauchamp A, Lyubomirsky G, Demos L, McNeil J, et al. (2011) Suboptimal management of cardiovascular risk factors in coronary heart disease patients in primary care occurs particularly in women. Intern Med J 41: 730–736. pmid:21627740
- 21. Vulic D, Lee BT, Dede J, Lopez VA, Wong ND (2010) Extent of control of cardiovascular risk factors and adherence to recommended therapies in US multiethnic adults with coronary heart disease: from a 2005–2006 national survey. Am J Cardiovasc Drugs 10: 109–114. pmid:20334448
- 22. Naicker K, Liddy C, Singh J, Taljaard M, Hogg W (2014) Quality of cardiovascular disease care in Ontario's primary care practices: a cross sectional study examining differences in guideline adherence by patient sex. BMC Fam Pract 15: 123. pmid:24938405
- 23. Arnold SV, Spertus JA, Tang F, Krumholz HM, Borden WB, et al. (2011) Statin use in outpatients with obstructive coronary artery disease. Circulation 124: 2405–2410. pmid:22064595
- 24. Johansen ME, Green LA, Sen A, Kircher S, Richardson CR (2014) Cardiovascular risk and statin use in the United States. Ann Fam Med 12: 215–223. pmid:24821892
- 25. Morrell J, Zeymer U, Baumgartner I, Limbourg T, Rother J, et al. (2011) Differences in management and outcomes between male and female patients with atherothrombotic disease: results from the REACH Registry in Europe. Eur J Cardiovasc Prev Rehabil 18: 270–277. pmid:20606595
- 26. Bhattacharjee S, Findley PA, Sambamoorthi U (2012) Understanding gender differences in statin use among elderly Medicare beneficiaries: an application of decomposition technique. Drugs Aging 29: 971–980. pmid:23160960
- 27. Victor BM, Teal V, Ahedor L, Karalis DG (2014) Gender differences in achieving optimal lipid goals in patients with coronary artery disease. Am J Cardiol 113: 1611–1615. pmid:24698458
- 28. Virani SS, Woodard LD, Ramsey DJ, Urech TH, Akeroyd JM, et al. (2015) Gender disparities in evidence-based statin therapy in patients with cardiovascular disease. Am J Cardiol 115: 21–26. pmid:25456865
- 29. Skentzos S, Shubina M, Plutzky J, Turchin A (2011) Structured vs. Unstructured: Factors Affecting Adverse Drug Reaction Documentation in an EMR Repository. AMIA Proceedings: 1270–1279.
- 30. Simes RJ (1986) An improved Bonferroni procedure for multiple tests of significance. Biometrika 73: 751–754.
- 31. Hochberg Y (1988) A sharper Bonferroni procedure for multiple tests of significance. Biometrika Trust. pp. 800–802.
- 32. Rothman KJ (2012) Epidemiology: An Introduction: Oxford University Press.
- 33. Efron B, Tibshirani R. J. (1993) Introduction to the Bootstrap: Chapman & Hall.
- 34. (2002) Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 106: 3143–3421. pmid:12485966
- 35. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr., Clark LT, et al. (2004) Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 110: 227–239. pmid:15249516
- 36. Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, et al. (2002) Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 360: 1623–1630. pmid:12457784
- 37. Afilalo J, Duque G, Steele R, Jukema JW, de Craen AJ, et al. (2008) Statins for secondary prevention in elderly patients: a hierarchical bayesian meta-analysis. J Am Coll Cardiol 51: 37–45. pmid:18174034
- 38. Chokshi NP, Messerli FH, Sutin D, Supariwala AA, Shah NR (2012) Appropriateness of statins in patients aged >/ = 80 years and comparison to other age groups. Am J Cardiol 110: 1477–1481. pmid:22901970
- 39. Ko DT, Mamdani M, Alter DA (2004) Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox. JAMA 291: 1864–1870. pmid:15100205
- 40. Frey P, Waters DD, DeMicco DA, Breazna A, Samuels L, et al. (2011) Impact of smoking on cardiovascular events in patients with coronary disease receiving contemporary medical therapy (from the Treating to New Targets [TNT] and the Incremental Decrease in End Points Through Aggressive Lipid Lowering [IDEAL] trials). Am J Cardiol 107: 145–150. pmid:21129718
- 41. Task Force M, Montalescot G, Sechtem U, Achenbach S, Andreotti F, et al. (2013) 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 34: 2949–3003. pmid:23996286
- 42. Ma J, Sehgal NL, Ayanian JZ, Stafford RS (2005) National trends in statin use by coronary heart disease risk category. PLoS Med 2: e123. pmid:15916463
- 43. McAlister FA, Majumdar SR, Eurich DT, Johnson JA (2007) The effect of specialist care within the first year on subsequent outcomes in 24,232 adults with new-onset diabetes mellitus: population-based cohort study. Qual Saf Health Care 16: 6–11. pmid:17301194
- 44. Cook NL, Ayanian JZ, Orav EJ, Hicks LS (2009) Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care. Circulation 119: 2463–2470. pmid:19398667
- 45. Ho PM, Masoudi FA, Peterson ED, Grunwald GK, Sales AE, et al. (2004) Cardiology management improves secondary prevention measures among patients with coronary artery disease. J Am Coll Cardiol 43: 1517–1523. pmid:15120805
- 46. Ayanian JZ, Landrum MB, Guadagnoli E, Gaccione P (2002) Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med 347: 1678–1686. pmid:12444183
- 47. Zhang H, Plutzky J, Skentzos S, Morrison F, Mar P, et al. (2013) Discontinuation of statins in routine care settings: a cohort study. Ann Intern Med 158: 526–534. pmid:23546564
- 48. Bruckert E, Hayem G, Dejager S, Yau C, Begaud B (2005) Mild to moderate muscular symptoms with high-dosage statin therapy in hyperlipidemic patients—the PRIMO study. Cardiovasc Drugs Ther 19: 403–414. pmid:16453090
- 49. Wenger NK, Lewis SJ, Welty FK, Herrington DM, Bittner V, et al. (2008) Beneficial effects of aggressive low-density lipoprotein cholesterol lowering in women with stable coronary heart disease in the Treating to New Targets (TNT) study. Heart 94: 434–439. pmid:18070940
- 50. Buettner C, Davis RB, Leveille SG, Mittleman MA, Mukamal KJ (2008) Prevalence of musculoskeletal pain and statin use. J Gen Intern Med 23: 1182–1186. pmid:18449611
- 51. Hippisley-Cox J, Coupland C (2010) Individualising the risks of statins in men and women in England and Wales: population-based cohort study. Heart 96: 939–947. pmid:20489220
- 52. Golomb BA, Evans MA (2008) Statin adverse effects: a review of the literature and evidence for a mitochondrial mechanism. Am J Cardiovasc Drugs 8: 373–418. pmid:19159124
- 53. Lewey J, Shrank WH, Bowry AD, Kilabuk E, Brennan TA, et al. (2013) Gender and racial disparities in adherence to statin therapy: a meta-analysis. Am Heart J 165: 665–678, 678 e661. pmid:23622903
- 54. Ellis JJ, Erickson SR, Stevenson JG, Bernstein SJ, Stiles RA, et al. (2004) Suboptimal statin adherence and discontinuation in primary and secondary prevention populations. J Gen Intern Med 19: 638–645. pmid:15209602
- 55. Mosca L, Linfante AH, Benjamin EJ, Berra K, Hayes SN, et al. (2005) National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation 111: 499–510. pmid:15687140
- 56. Gutierrez J, Ramirez G, Rundek T, Sacco RL (2012) Statin therapy in the prevention of recurrent cardiovascular events: a sex-based meta-analysis. Arch Intern Med 172: 909–919. pmid:22732744
- 57. Taylor F, Ebrahim S (2012) Statins work just as well in women as in men. Arch Intern Med 172: 919–920. pmid:22732745
- 58. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, et al. (2014) 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129: S1–45. pmid:24222016
- 59. Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, et al. (2011) ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J 32: 1769–1818. pmid:21712404