cardiovascular diseases are among the leading causes of death worldwide , with more than 2150 deaths each day .
many studies have found a direct relationship between levels of low - density lipoprotein ( ldl ) cholesterol ( or total cholesterol ) and the rate of new - onset coronary heart disease ( chd ) in men and women who were initially free of chd . when other risk factors are present , including diabetes and hypertension , this risk increases even more .
this has led to large numbers of clinical trials providing strong evidence that chd incidence is reduced in cholesterol - lowering therapy .
a meta - analysis involving 10 trials of 79,494 subjects found that statins reduce coronary events , strokes , and all - cause mortality without increasing non - coronary mortality .
high cholesterol is one of the major controllable risk factors for coronary heart disease , heart attack , and stroke , consequently increasing the use of statins throughout the years .
it is evident that statin use has a clear benefit on stroke and total mortality by greatly reducing cholesterol . despite the positive results linking statin use and reduction in chd
, studies have shown poor adherence to these medications . a systematic review and meta - analysis of 22 cohorts determined several sociodemographic , medical , and healthcare utilization characteristics
these factors are useful guides for targeting statin adherence interventions , especially since adherence is an essential factor to receiving the full benefits of these medications .
although there have been studies identifying predictors of adherence and non - adherence to statins , there is less evidence identifying reliable predictive variables of mortality among new statin users . in particular ,
the veteran population is of importance due to the prevalence of risk factors within this group . over 90%
are male and more than 40% are over 65 years of age , both of which are risk factors of chd - related deaths .
this study aims to identify variables in the first year of statin therapy that are predictive of long - term mortality .
this retrospective cohort study used data from the veterans affairs facilities within the veterans integrated service network 22 , including sites from loma linda , long beach , los angeles , san diego , and las vegas .
data were collected on study subjects identified as new statin users between december 1 , 2006 , and november 30 , 2007 .
socioeconomic status was determined by zip code median household income and divided into five quintiles from lowest to highest income .
mpr was calculated as the number of days of statin drug supply the patient filled divided by the number of days in the specific time period .
inclusion criteria included age 18 years or older , diagnosis of dyslipidemia , new statin user per the dates listed above , enrollment in the va system for at least 2 years before the study period , and eligibility to receive prescription benefits from the va .
patients were excluded if they had missing baseline or follow - up body mass index ( bmi ) , ldl , and total cholesterol ( tc ) laboratory data , or if they were missing zip code income data ( figure 1 ) .
baseline comparisons between the mortality group and the survival group were performed using t - test and chi - square test .
the primary outcome measure of mortality predictors at 6 years follow - up for new statin users were analyzed using a logistic regression model .
the independent variables assessed included race , age , ethnicity , bmi , socioeconomic status , ldl outcomes at 1 year , and baseline comorbidities .
all analyses were performed using spss version 18 ( spss inc , chicago , il ) .
baseline comparisons between the mortality group and the survival group were performed using t - test and chi - square test .
the primary outcome measure of mortality predictors at 6 years follow - up for new statin users were analyzed using a logistic regression model .
the independent variables assessed included race , age , ethnicity , bmi , socioeconomic status , ldl outcomes at 1 year , and baseline comorbidities .
all analyses were performed using spss version 18 ( spss inc , chicago , il ) .
there were a total of 7735 patients who met inclusion criteria , and 4566 patients were included in the final analysis after applying the exclusion criteria .
patients in the mortality group were older ( p  <  0.001 ) , on more medications ( p  <  0.001 ) , had higher total cholesterol levels ( p    0.001 ) and had higher incidence of hypertension ( p  <  0.001 ) , vascular disease ( p  <  0.001 ) , chronic obstructive pulmonary disease ( p  =  0.001 ) , congestive heart failure ( p  <  0.001 ) , history of myocardial infarction ( p  <  0.001 ) , and angina ( p  =  0.008 ) .
patients in the survival group were more likely to be hispanic ( p  <  0.001 ) , with higher bmi ( p  <  0.001 ) and ldl cholesterol ( p  < 
0.001 ) ( table 1 ) . age , medication count , ethnicity , and bmi were predictors of long - term mortality .
in addition , patients with comorbidities such as hypertension ( or  =  1.46 , 95% ci  =  1.081.98 , p  =  0.015 ) , diabetes ( or  =  1.36 , 95% ci  =  1.071.72 , p  =  0.012 ) , tobacco use ( or  =  1.52 , 95% ci  =  1.161.99 , p  =  0.002 ) , copd ( or  =  1.88 , 95% ci  =  1.402.53 , p    0.001 ) , and congestive heart failure ( or  =  1.80 , 95% ci  =  1.232.63 , p  =  0.002 ) all showed an increased risk of mortality .
there were no significant associations between mortality and race , ldl outcomes at 1 year , and annual income level , as shown in table 2 .
there were a total of 7735 patients who met inclusion criteria , and 4566 patients were included in the final analysis after applying the exclusion criteria .
patients in the mortality group were older ( p  <  0.001 ) , on more medications ( p  <  0.001 ) , had higher total cholesterol levels ( p    0.001 ) and had higher incidence of hypertension ( p  <  0.001 ) , vascular disease ( p  <  0.001 ) , chronic obstructive pulmonary disease ( p  =  0.001 ) , congestive heart failure ( p  <  0.001 ) , history of myocardial infarction ( p  <  0.001 ) , and angina ( p  =  0.008 ) .
patients in the survival group were more likely to be hispanic ( p  <  0.001 ) , with higher bmi ( p  <  0.001 ) and ldl cholesterol ( p  < 
age , medication count , ethnicity , and bmi were predictors of long - term mortality .
in addition , patients with comorbidities such as hypertension ( or  =  1.46 , 95% ci  =  1.081.98 , p  =  0.015 ) , diabetes ( or  =  1.36 , 95% ci  =  1.071.72 , p  =  0.012 ) , tobacco use ( or  =  1.52 , 95% ci  =  1.161.99 , p  =  0.002 ) , copd ( or  =  1.88 , 95% ci  =  1.402.53 , p    0.001 ) , and congestive heart failure ( or  =  1.80 , 95% ci  =  1.232.63 , p  =  0.002 ) all showed an increased risk of mortality . there were no significant associations between mortality and race , ldl outcomes at 1 year , and annual income level , as shown in table 2 .
this study showed that different lipid outcomes after the first year of statin therapy were not indicative of long - term mortality .
other significant predictors of mortality in new start statin users were seen after a 6 year follow - up period .
age , race , number of medications , comorbidities , and bmi were shown to be predictive of long - term mortality in a veteran population , much of which was expected .
statin users in the mortality groups were more likely to be taking more medications , an indicator of their underlying diseases , also predictive of mortality .
previous studies have shown a highly significant negative association between statin use and mortality . in an overview of 16 individual trials including 29,000 subjects ,
patients assigned to statin drugs experienced significant reductions in risks of stroke and total mortality .
however , the results of our study showed that actual differences in ldl levels at a given point in time among statin users appeared to confer no predictive effect on long - term mortality outcomes .
patient stratification between high potent ( rosuvastatin and atorvastatin ) vs non - potent statins did not affect the outcome .
sub - groups including hdl , tg , and tc further showed no predictive value of long - term mortality .
statin doses and whether the treatment goal of ldl was attained at 1 year follow - up were not assessed in this study .
the study by blackburn et al . reported a detectable excess of cardiovascular morbidity associated with non - adherence to statin therapy .
numerous other studies have shown that a reduction in ldl is associated with a decreased risk in cardiovascular events and total mortality .
these findings suggest that occurrences of cardiovascular events can be prevented with improvements in maintaining adherence in statin users .
although our analysis showed no significant difference in adherence as a predictor of long - term mortality , it should be mentioned that cardiovascular outcomes were not assessed .
in addition , ldl values in both survival and mortality groups suggest uncontrolled ldl levels at 1 year follow - up , which may be due to the low adherence rates to statin therapy in both groups .
therefore , risk factors for cardiovascular events and total mortality including male gender , older age , vascular disease , copd , hypertension , and diabetes took the lead in the risk factor evaluation in the multiple regression analysis , despite the great differences in their baseline rates .
in addition , some degree of time immortal bias may be present because no patient s died in the first year ( as per inclusion criteria requiring ldl outcomes at 1 year ) .
in addition , follow - up ldl outcomes were performed after 1 year only , extrapolation of values beyond that time point are not possible .
the study was performed in a veteran population primarily comprised of male patients , limiting generalizability of the analysis .
although this group is of particular interest when looking at the risk factors associated with coronary heart disease , associations between lipid variables and mortality in a broader patient population may vary .
in addition , homeless veterans without a zip code were excluded from this study . according to the annual homeless assessment report ( ahar ) to congress from the us department of housing and urban development , there were an estimated 75,609 homeless veterans on a single night in the us in 2009 .
the exclusion of this population omitted patients with significant health risks not accounted for in this study .
while many studies have examined the risks and benefits between statin and non - statin users , this study attempts to recognize the predictors of mortality in new start statin users .
multiple independent variables have been identified as predictors of mortality in statin users after a 6 year follow - up .
different lipid outcomes after the first year of statin therapy were not indicative of long - term mortality .
future studies should further assess optimal lipid - lowering therapies in the veteran population , especially in the later stages of life to improve clinical outcomes .
skaggs school of pharmacy and pharmaceutical sciences provided funding for the research assistant , as part of their summer research internship program .
declaration of financial / other interests the authors have no relevant financial or other relationships to disclose .
jda peer reviewers on this manuscript have received an honorarium from jda for their review work , but have no other relevant financial relationships to disclose .
skaggs school of pharmacy and pharmaceutical sciences provided funding for the research assistant , as part of their summer research internship program .
declaration of financial / other interests the authors have no relevant financial or other relationships to disclose .
jda peer reviewers on this manuscript have received an honorarium from jda for their review work , but have no other relevant financial relationships to disclose .
 backgroundcardiovascular diseases are among the leading causes of death worldwide and studies have found a direct relationship between levels of low - density lipoprotein cholesterol and coronary heart disease . 
 statins are the most commonly prescribed medications to lower cholesterol , a major controllable risk factor for coronary heart disease.objectivethis study aims to find what factors in the first year of statin therapy are predictive of long - term all - cause mortality.methodsdata for this retrospective cohort study were collected on patients identified as new statin users between december 1 , 2006 and november 30 , 2007 at five veterans affairs healthcare systems from southern california and nevada . 
 multiple independent variables were assessed utilizing a logistic regression model assessing for all cause mortality at 6 years follow - up . 
 the independent variables included race , age , ethnicity , body mass index , socioeconomic status , and baseline comorbidities . 
 secondary analysis analyzed high - density lipoprotein levels , adherence , total cholesterol , and triglycerides.resultsincreased age , increased medication count , hypertension , diabetes , tobacco use , chronic obstructive pulmonary disease , and congestive heart failure were all associated with an increased risk of mortality . 
 hispanic ethnicity , asian race , and increased body mass index were associated with decreased risk of mortality . 
 there were no significant associations between mortality and race , ldl outcomes at 1 year , or annual income level.conclusionthere is clear evidence that statin use is associated with decreased events in cardiovascular disease and total mortality . 
 this study found multiple independent variables as predictors of mortality in new start statin users after a 6 year follow - up , but differences in lipid groups after 1 year were not predictive of long - term mortality in the cohort studied . 
Introduction
Methods
Statistical analysis
Results
Study population
Independent variables
Discussion
Conclusion
Transparency
Declaration of funding