GUIDELINES ORIENTED APPROACH TO LIPID (GOAL) MEDICAL PRACTICE ACTIVITY (MPA) TO ACHIEVE LOW DENSITY LIPOPROTEIN CHOLESTEROL (LDL-C) TARGETS

Abstract

Lowering of LDL-C < 2.0 mmol/L is a key recommended step in decreasing the risk for cardiovascular (CV) events in high risk patients. Despite widespread use of statin therapy as first line therapy, it is estimated that 40 – 50% of Canadian patients with known CVD do not achieve LDL-C target. GOAL is an investigator initiated study aiming to ascertain the use of second and third line therapy and its impact on LDL-C target achievement in a real world setting. GOAL plans to engage 300 Canadian physicians who will enroll 3000 high CV risk patients with clinical vascular disease such as coronary artery disease (CAD), cerebrovascular disease, abdominal aortic aneurysm, peripheral arterial disease or familial hypercholesterolemia and LDL-C > 2.0 mmol/L despite stable, maximally tolerated statin therapy. Patients will be followed for a total of 3 visits over a period of 6 months. Physicians are asked to manage patients as they see fit but with awareness of the latest Canadian Cardiovascular Society (CCS) Dyslipidemia Guidelines. The program is led by a steering committee supported by the Canadian Heart Research Centre (data collection and physician interactive component) and is ethically approved. As of May 1, 2017, 260 physicians registered to participate and to date 1040 patients were enrolled (mean age 63±11 years, 41% female). Co-morbid conditions included: FH 45%, diabetes 39%, CAD 48%, other vascular disease 8%, HT 62%, CKD 8% and current smokers 15%. Systolic blood pressure (BP) was 129±15 mmHg, diastolic BP was 77±10 mm Hg, and body mass index was 29.9±6.8 kg/m2. Baseline LDL-C was 3.4±1.3 , HDL-C 1.3±0.4, non-HDL-C 4.2±1.5, and triglycerides 2.1±1.4 mmol/L. Lipid lowering therapy used at baseline was statin therapy in 75% (with 25% statin intolerant), and 50% ezetimibe. Among statin therapies used, the most frequent were rosuvastatin (39%) and atorvastatin (27%). Physicians indicated their next steps in the lowering of the LDL-C to be: addition of ezetimibe in 36%, addition of bile acid sequestrant in 7%, and addition of PCSK9 inhibitor in 39%. Among high risk patients with an LDL-C above target despite statin therapy, there is a need for further lipid lowering therapy based on CCS guidelines. Interim assessment of the GOAL study indicates a frequent use of additional lipid lowering therapy which is consistent with greater adherence with CCS guidelines.