Abstract
ObjectivesPrevious studies have demonstrated gaps in achievement of low-density lipoprotein-cholesterol (LDL-C) goals among patients at very high cardiovascular risk. We aimed to investigate lipid treatment patterns, rates and predictors of lipid targets attainment, in such outpatients in an urban area of Greece.MethodsThis was a prospective observational study, conducted in 19 outpatient clinics of Western Greece. We recruited patients with established cardiovascular disease (CVD) and/or diabetes mellitus (DM), previously (at least 3 months before baseline assessment) untreated with any lipid lowering medication. Lipid profile assessment was performed at baseline (prior to lipid-lowering treatment initiation) and at follow-up. Lipid lowering treatment choice was at physicians’ discretion and was kept constant until follow-up.ResultsWe recruited 712 patients with a mean age 61.4 ± 10.4 years, 68.0% males, 43.0% with DM, 64.7% with prior coronary artery disease-CAD. In total, 237/712 (33.3%) of prescribed regimens were of high or very high LDL-C lowering efficacy and out of them 113/237 (47.7%) comprised a combination of statin and ezetimibe. At follow-up the primary target of LDL-C < 70 mg/dL (1.8 mmol/L) was achieved in 71(10.0%) patients. The secondary target of non-HDL-C < 100 mg/dL (2.6 mmol/L) in the subgroup of patients with DM or increased triglycerides levels (>150 mg/dl or 1.7 mmol/L) was achieved in 45(11.6%) of patients. In multivariate logistic regression analysis (AUC = 0.71, 95% CIs 0.65-0.77, p < 0.001) male gender, smoking, baseline LDL-C and very high potency LDL-C lowering regimen emerged as independent predictors of LDL-C goal attainment (OR = 1.88, 95% CIs 1.03-3.44, p = 0.04, OR = 0.57, 95% CIs 0.33-0.96, p = 0.04, OR = 0.98, 95% CIs 0.98-0.99, p < 0.001 and OR = 2.21, 95% CIs 1.15-4.24, p = 0.02 respectively).ConclusionsFirst-line management of dyslipidemia among very-high cardiovascular risk outpatients in Western Greece is unsatisfactory, with the majority of treated individuals failing to attain the LDL-C and non-HDL-C targets. This finding points out the need for intensification of statin treatment in such patients.
Highlights
Cardiovascular disease (CVD) is the leading cause of global mortality, accounting for more deaths annually than any other cause [1]
In 2004 the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines were updated with the addition of the optional goal of low density lipoproteincholesterol (LDL-C) < 70 mg/dL (1.8 mmol/L) for those patients considered to be at very high cardiovascular risk, mainly based on evidence from Heart Protection Study (HPS) and The Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE IT) trials [6,7,8]
Incremental Increase in End Points Through Aggressive Lipid Lowering (IDEAL) and Treating to New Targets (TNT) studies provided evidence that more intensive versus moderate LDL-C lowering treatment reduces the risk of major cardiovascular events in patients with coronary artery disease (CAD) [9,10]
Summary
Cardiovascular disease (CVD) is the leading cause of global mortality, accounting for more deaths annually than any other cause [1]. It has been demonstrated that low density lipoproteincholesterol (LDL-C) reduction by statins substantially reduces cardiovascular morbidity and mortality in both primary and secondary prevention [3,4,5]. Incremental Increase in End Points Through Aggressive Lipid Lowering (IDEAL) and Treating to New Targets (TNT) studies provided evidence that more intensive versus moderate LDL-C lowering treatment reduces the risk of major cardiovascular events in patients with coronary artery disease (CAD) [9,10]. A recent meta-analysis of several clinical trials involving >170,000 patients revealed a dosedependent reduction in CVD morbidity and mortality with LDL-C reduction [3]. Accumulating evidence with respect to the beneficial effect on clinical outcome of intensified statin therapy led the 2011 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines to adopt LDL-C < 70 mg/dL (1.8 mmol/L) as the main treatment goal in the subgroup of patients considered to be at very high cardiovascular risk [2]
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