Comparison of the Four Major US Guidelines for Lipid Lowering Therapy for the Primary Prevention of ASCVD in Patients with Diabetes

Abstract

<h3>Lead Author's Financial Disclosures</h3> Nothing to disclose. <h3>Study Funding</h3> None. <h3>Background/Synopsis</h3> Four US organizations (AHA/ACC, ADA, NLA, and AACE/ACE) have guidelines on statin and other lipid-lowering medication use for the primary prevention of ASCVD in patients with diabetes mellitus (DM). While all four guidelines recommend moderate to high-intensity statin as first-line therapy, the NLA and AACE/ACE have LDL-C goals based on risk and advocate non-statin LDL cholesterol lowering drugs for patients who need additional LDL-C lowering. <h3>Objective/Purpose</h3> To compare the four major guidelines in a contemporary cohort of patients with DM in a large cardiology practice. <h3>Methods</h3> We identified 8,834 patients (age > 20) with DM and no history of ASCVD who had at least one office visit between December 2019 and November 2020. Patient clinical characteristics, laboratory data, and medications were extracted from their electronic health record (EHR). Patients were considered to have met the AHA/ACC and ADA guidelines if they were aged 40 to 75 and were on a moderate or high-intensity statin. Adherence to the NLA and AACE/ACE guidelines was assessed among the 7,212 patients with DM (81.6%) who had an LDL-C value recorded in the EHR. Patients were stratified into high (LDL-C goal < 100 mg/dL) and very high-risk (LDL-C goal < 70 mg/dL) groups based on additional risk factors. <h3>Results</h3> The mean age of the study patients was 67.8 +/- 12.1 years, 50.4% were female and 70.1% were white. Among the 7,212 patients with an LDL-C in the EHR, 90.2% were stratified as very high-risk by the NLA and 98.8% by the AACE/ACE guidelines. Of the very high-risk patients not at their LDL-C goal, 69.9% were not on a high intensity statin and 92.6% not on any intestinal blocking agent. <h3>Conclusions</h3> In a contemporary cohort of primary prevention patients with DM seen in a cardiology practice almost all are very high risk and almost 60% have not achieved their NLA or AACE/ACE guideline directed LDL-C goal. Although the AHA/ACC and ADA guidelines are less stringent, over 25% have not met these goals. The use of non-statin LDL-C lowering drugs was low. Strategies are needed to improve guideline directed lipid lowering therapy in these high-risk patients.