Using Cardiovascular Age Equivalent to Close the Treatment Gap for Dyslipidemia

Abstract

THE LARGE GAP IN THE QUALITY OF CARE REceived by the public 1 and what we know from clinical trials to be efficacious treatment (evidence-based clinical guidelines) has prompted the study of finding more effective methods of getting evidence into practice. 2,3 The CHECK-UP (Cardiovascular Health Evaluation to Improve Compliance and Knowledge Among Uninformed Patients) Study in this issue of the Archives 4 is an excellent example of this newly emerging discipline of implementation research. Grover et al 4 present findings from a well-designed practice-based clinical trial that tested whether providing high-risk cardiovascular patients with a cardiovascular risk profile conceptualized as an “age equivalent” along with lipid profile results improved optimal cholesterol management consistent with the 2000 Canadian Working Group on Hypercholesterolemia and Other Dyslipidemias lipid guidelines in a primary care setting. Although the intention-to-treat analysis showed a small benefit after 1 year (=�3.3 mg/dL [to convert to millimoles per liter, multiply by 0.0259] for low-density lipoprotein cholesterol between treatment arms) that reached statistical significance (P=.02), when the cardiovascular age was significantly discrepant (see Figure 3, quintiles 4 and 5, in the article by Grover et al 4 ), the percentage of patients reaching guidelinerecommended cholesterol goals increased by close to 50%. Such results, if confirmed in other studies, could have real clinical relevance. These results suggest that an informed, activated patient using an “age-equivalent risk communication strategy” as part of a patient-centered approach to cholesterol management seems to be quite effective. Other investigators 5 using a similar approach have also demonstrated promising results. Of note, the control group had major improvement in cholesterol management (�48 mg/dL in 1 year), suggesting that identifying high-risk patients not previously treated by their primary care physician led to muchimproved management. How these patients were selected was left up to each physician, but it suggests that the evaluation of unrecognized hyperlipidemic patients in the context of a clinical trial led to markedly improved management that was as or more important than the calculated coronary risk strategy used. In addition, the 4-visits-peryear paradigm used in this study was associated with a high retention rate (88%), and continued improvement in cholesterol values seems to have occurred during the entire year. Most nonpractice-based clinical trials show early improvement followed by regression to the mean. One explanation for these findings is that patients either saw the benefits of behavioral or drug therapy during the study or had high adherence to guideline recommendations that was reinforced during the 4 visits. Thus, a patient-centered, continuity-of-care model by a patient’s primary care physician seems to have been indirectly validated in this study as improving quality of care for cholesterol management, although this model was not specifically tested as part of the implementation research strategy. The results of this study are for the most part promising, but it should be pointed out that only 45% to 66% of these high-risk cardiovascular patients had reached their respective lipid targets after 1 year, and thus, a large treatment gap still persisted. More research testing the systematic identification of high-risk patients (eg, a dyslipidemia disease registry) combined with a calculated coronary risk strategy using the cardiovascular age paradigm seems to be warranted. In particular, evaluating the incremental cost-effectiveness of this strategy would be most useful.