Perceptions and Barriers on the Use of Proprotein Subtilisin/Kexin Type 9 Inhibitors in Heterozygous Familial Hypercholesterolemia (From a Survey of Primary Care Physicians and Cardiologists)

Nathan D Wong,Matthew Bang,Robert C Block,Amy L.H Peterson,Dean G Karalis

doi:10.1016/j.amjcard.2021.04.034

Abstract

Heterozygous familial hypercholesterolemia (HeFH) results in significant elevations in LDL-C and premature atherosclerotic cardiovascular disease (ASCVD). Current guidelines recommend add-on proprotein subtilisin/kexin type 9 inhibitor (PCSK9i) therapy for additional LDL-C lowering beyond statins. Data are sparse, however, regarding treatment patterns and barriers relating to PCSK9i in HeFH patients. We examined physician attitudes, use, and barriers for treatment in patients with HeFH. We surveyed 1,000 physicians (500 primary care providers [PCPs] and 500 cardiologists in the US regarding their preferred treatments, experience and barriers associated with using PCSK9is. Cardiologists compared to PCPs were more likely to rank a PCSK9i as most important for an HeFH patient needing additional LDL-C lowering (68.6% vs. 64.8%; p <0.05), as well as prescribing and having a patient on a PCSK9i. PCPs vs. cardiologists were less likely (odds ratio [OR] [95% confidence interval]=0.46 [0.34-0.63]), private vs. academic practice more likely (OR=1.53 [1.02-2.28]), and those who would prescribe a PCSK9i in an HeFH patient with (OR=3.86 [2.57-5.78]) or without (OR=1.96 [1.40-2.72]) ASCVD needing additional LDL-C reduction beyond a statin were more likely to actually prescribe a PCSK9i. Those practicing in an urban vs. rural setting were less likely (OR=0.56 [0.34-0.93]), and those indicating they would prescribe a PCKS9i in an HeFH patient with (OR=2.80 [1.74-4.49]) or without (OR=1.43 [1.02-2.02]) ASCVD needing additional LDL-C lowering beyond a statin were more likely to face difficulty prescribing a PCSK9i (all p <0.05 to p <0.01). Greater physician education and assistance among both cardiologists and PCPs are needed to address the gaps in understanding and treatment regarding PCSK9is.

Highlights

From multiple logistic regression (Table 2) PCPs vs. cardiologists were less likely, private vs. academic practice providers more likely (OR = 1.53 [1.02-2.28]) associated with prescribing a PCSK9i. Those noting they were likely to prescribe a PCSK9i in a HeFH patient with (OR = 3.86 [2.57-5.78]) or without (OR = 1.96 [1.402.72]) ASCVD on maximum statin needing additional LDL-C lowering were more likely to prescribing a PCSK9i
Our study using the largest survey of physicians on the identification and care of patients with HeFH noted that as initial therapy, physicians identified a high-intensity statin followed by diet and exercise to be the most important therapies
Our survey documents the priority physicians place on the use of a PCSK9i in patients with HeFH and the barriers for successfully prescribing them

Summary

Methods

The National Lipid Association (NLA), utilizing MedSurvey (Southampton, PA), an independent survey research vendor, surveyed 500 cardiologists and 500 PCPs, consisting of family medicine, general medicine, and internal medicine specialties throughout the United States between August 29 and September 30, 2019. The American Journal of Cardiology (www.ajconline.org) introducing the survey as one on hyperlipidemia or familial hypercholesterolemia to avoid enrolling physicians with a strong interest or expertise in lipid management. Physicians who self-identified as lipid specialists (including endocrinologists) who would already be expected to be knowledgeable about HeFH, or pediatricians, and those certified by the American Board of Clinical Lipidology or Accreditation Council for Clinical Lipidology were excluded. Those completing the survey received a small honorarium. Multiple logistic regression performed in a stepwise manner with forward selection, allowing for factors with a p-value of

Results

Discussion

Findings

Disclosures