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

Abstract

Lowering of LDL-C < at least 2.0 mmol/L is recommended to decrease risk for CV events in high risk patients. Despite widespread use of statins, 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 enroll 3000 Canadian high CV risk patients with clinical vascular disease including CAD, cerebrovascular disease, abdominal aortic aneurysm, peripheral arterial disease or familial hypercholesterolemia (FH) and LDL-C > 2.0 mmol/L despite maximally tolerated statin therapy. During follow-up physicians manage patients as clinically indicated but with reminders of 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 IRB approved. As of April 9, 2018, 1585 patients were enrolled (median age 63 years, 42% female) by 237 physicians. Co-morbid conditions included: FH 46%, hypertension 61%, CAD 51%, smoking history 48%, diabetes 37%, other vascular disease 11%, and CKD 9%. Systolic blood pressure was 128 mmHg, diastolic 78 mm Hg, and BMI 29 kg/m2. Baseline LDL-C was 3.4±1.3 , non-HDL-C 4.2±1.5, HDL-C 1.3±0.4, and triglycerides 2.1±1.4 mmol/L. Lipid lowering therapy used at baseline was statin therapy in 75% (with 25% statin intolerant), and 21% ezetimibe. Statins used most frequently were rosuvastatin (39%) and atorvastatin (28%). Physicians indicated their next steps in lowering of LDL-C to be: addition of ezetimibe in 31%, addition of bile acid sequestrant in 5%, and addition of PCSK9 inhibitor in 42%. The three top reasons for not using recommended therapy with ezetimibe were: patient refusal 34%, not needed 25%, and intolerance 17%, while for PCSK9i were: cost 29%, not needed 26% or patient refusal 26%. Additional lipid modifying therapies during follow up are shown in Figure 1. The proportion of patients achieving the CCS recommended LDL-C target of <2.0 mmol/L is shown in Figure 2. Interim assessment of the GOAL program indicates frequent successful add-on of other lipid lowering therapies, associated with a greater proportion of patients achieving CCS Guideline recommended LDL-C target, in high risk patients with an LDL-C above target despite statin therapy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)