Low-density Lipoprotein Cholesterol Goal Attainment Research Articles

Frequency of High-Risk Patients Not Receiving High-Potency Statin (from a Large Managed Care Database)

We examined trends in low-density lipoprotein cholesterol (LDL-C) goal attainment in high-risk patients and use of high-potency statins (HPS) in a large, managed-care database from 2004 to 2012. The 2013 American Heart Association/American College of Cardiology prevention guidelines recommend that subjects with atherosclerotic cardiovascular disease (ASCVD) should be prescribed HPS therapy, irrespective of LDL-C levels. Previous guidelines recommend an LDL-C target <70 mg/dl. Patients diagnosed with ASCVD based on International Classification of Diseases, Ninth Revision codes with ≥1 LDL-C test from January 2004 to December 2012 were identified in the Optum Insight database. Patients were identified as treated if they received lipid-lowering therapy (LLT) within 90 days of the LDL-C measurement and untreated if they did not receive LLT treatment. LLT treated patients were stratified into HPS users or non-HPS LLT users. There were 45,101 eligible patients in 2004 and 40,846 in 2012. The proportion of high-risk patients who were treated with LLT increased from 61.4% (2004) to 70.5% (2008) then remained relatively constant until 2012 (67.9%). Mean LDL-C values in treated patients decreased from 103.7 ± 32.1 (2004) to 90.8 ± 31.4 mg/dl (2012). The proportion of patients treated with HPS increased from 13% in 2004 to 26% in 2012. Although the proportion of treated high-risk patients who achieve LDL-C <70 mg/dl levels has increased sharply from 2004, approximately 3 of 4 patients still did not meet this target. Only 1/4 of ASCVD patients are on HPS. In conclusion, our findings highlight the need for renewed efforts to support guideline-based LDL-C treatment for high-risk patients.

Combination of Statin Plus Renin Angiotensin System Inhibition for the Prevention or the Treatment of Atherosclerotic Cardiovascular Disease

Statins effectively reduce cardiovascular disease (CVD) morbidity and mortality. However, even after low-density lipoprotein cholesterol goal attainment there is a residual CVD risk. To reduce this risk, combining statins with drugs acting on the renin-angiotensin system (RAS) was investigated. The GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE), Japanese Coronary Artery Disease (JCAD), Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) and The Assessing the Treatment Effect in Metabolic Syndrome Without Perceptible Diabetes (ATTEMPT) trials suggest that the statin plus RAS inhibition combination reduces CVD events more than a statin alone and considerably more than RAS inhibition alone. This benefit seems to be related to effects on endothelial function, vascular inflammation and the initiation, progression and rupture of atheromatous plaques. These effects are, at least in part, driven by mediators, the microRNAs (miRs), that are implicated in the pathogenesis and clinical manifestations of atherosclerosis (e.g. restoration of endothelial function and attenuation of vascular inflammation). Some miRs are favourably affected by statins and others by RAS inhibition. There is a miR family (miR-146a/b), related to coronary artery plaque destabilization that is beneficially affected by both statins and RAS inhibition. Statins and RAS inhibition combination should be routinely prescribed in high risk patients with CVD, hypertension, obesity, metabolic syndrome, and/or diabetes to maximize clinical benefit.

Lipid-lowering therapy and lipid goal attainment in patients with metabolic syndrome in China: Subgroup analysis of the Dyslipidemia International Study-China (DYSIS-China)

ObjectiveTo objectively evaluate lipid-lowering therapy and low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) goal attainment in metabolic syndrome (MetS) patients in China. MethodsData regarding patient demographics, lipid-lowering agents, lipid parameters, and cardiovascular risk profiles were analyzed for 25,317 patients of the Dyslipidemia International Study-China. MetS was defined according to criteria of the NCEP-ATP III and the 2007 Chinese Guidelines on Prevention and Treatment of Dyslipidemia in Adults. ResultsThe prevalence of MetS was 39.9% and 37.4% according to the NCEP-ATP III and 2007 Chinese Guidelines, respectively. LDL-C goal attainment occurred less frequently among MetS patients than in those without MetS (NCEP-ATP III: 46.9% vs 68.6%; 2007 Chinese Guidelines: 52.2% vs 67.1%; p < 0.001). Similar results were obtained for non-HDL-C goal attainment (2007 Chinese Guidelines: 51.0% vs 72.0%; p < 0.001). As the risk class increased, LDL-C and non-HDL-C goal attainment decreased. In multivariate logistic regression analysis, DM, CHD, ischemic cerebrovascular disease, and higher SBP were independently associated with failure to achieve LDL-C and non-HDL-C goal attainment. The type of lipid-lowering agent was not significantly correlated with LDL-C not at goal attainment but was correlated with non-HDL-C not at goal attainment. ConclusionGoal attainment for both LDL-C and non-HDL-C occurs less frequently in MetS patients than in those without MetS. The residual risk due to elevated non-HDL-C levels should be considered in MetS patients. Strategies for controlling multiple risk factors in order to decrease the residual risk related to dyslipidemia in MetS patients should be recommended in future guidelines.

FRI0050 Rosuvastatin Induced Carotid Plaque Regression in Patients with Inflammatory Joint Diseases

BackgroundPatients with rheumatoid arthritis (RA) and carotid artery plaques (CP) have increased risk of acute coronary syndrome. Statin treatment with low density lipoprotein cholesterol (LDL-c) goal ≤1.8 mmol/L is recommended...

Lipid target achievement among patients with very high and high cardiovascular risk in a lipid clinic.

This was a retrospective study that assessed achievement of lipid-lowering treatment targets in the setting of a University Hospital Lipid Clinic. Low-density lipoprotein cholesterol (LDL-C) goal attainment according to National Cholesterol Education Program-Adult Treatment Panel III (NCEP ATP III) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines was recorded in 1000 consecutive adult patients followed for ≥3 years (mean 8 years). The LDL-C targets according to the NCEP ATP III were attained by 66% and 86% of patients with "very high" (n = 477) and "high" (n = 408) cardiovascular risk, respectively. Fewer patients were within LDL-C goals according to the ESC/EAS guidelines: 25% and 42%. Overall, 92% of the patients were on statins: 67% were on statin monotherapy, while 33% were on combinations with ezetimibe (25%), ω-3 fatty acids (5%), fibrates (4%), or colesevelam (2%). Even in a specialist lipid clinic, a large proportion of patients are not at goal according to the recent ESC/EAS guidelines.

PCV20 - The Effect Of Low-Density Lipoprotein Cholesterol Goal Attainment On Cardiovascular Outcomes In Patients With Acute Coronary Syndrome: A Real World Practice In Thailand

PCV20 - The Effect Of Low-Density Lipoprotein Cholesterol Goal Attainment On Cardiovascular Outcomes In Patients With Acute Coronary Syndrome: A Real World Practice In Thailand

Factors Associated With Therapeutic Goal Attainment in Patients With Concomitant Hypertension and Dyslipidemia

Background: Hypertension and dyslipidemia are the most prevalent cardiovascular risk factors, with approximately 30 million patients in the United States having these concomitant conditions. Further, the presence of high body mass index (BMI) has a negative effect on the achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) targets. Objective: This study evaluates the demographic, diagnostic, and medication-related factors associated with BP and LDL-C goal attainment in patients with concomitant hypertension and dyslipidemia stratified by BMI. Methods: This retrospective study utilized the GE Centricity Electronic Medical Records database (2004–2011) of a primary care physician group. Patients aged ≥ 18 years with concomitant hypertension and dyslipidemia were included. The attainment of BP and LDL-C targets were assessed based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines. Patients were classified into 3 cohorts based on their BMI: normal weight (≤ 24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (≥ 30.0 kg/m2). Multivariate logistic regression analysis was conducted to identify the predictors of goal attainment. Results: A total of 9086 patients with concomitant hypertension and dyslipidemia were identified, of which 7723, 6724, and 5824 patients did not attain BP, LDL-C, and dual BP and LDL-C goals, respectively. Age was a significant predictor of BP and LDL-C goal attainment in those who were of normal weight or overweight, and obese women had a decreased likelihood of achieving these goals (P < 0.05). Failure to attain BP and LDL-C goals was more likely in patients with diabetes across all BMI groups (P < 0.001). Further, patients with stage 1 hypertension and higher baseline total cholesterol levels were less successful in attaining BP and LDL-C goals, respectively (P < 0.001). Conclusions: These variations in therapeutic goal attainment in patients with concomitant hypertension and dyslipidemia across different BMI groups suggest that future research is needed to determine the underlying reasons for these disparities.

The association between low-density lipoprotein cholesterol goal attainment, physician and patient attitudes and perceptions, and healthcare policy.

Withholding effective treatment is clinically prevalent. The CEntralized Pan-Asian survey on tHE Under-treatment of hypercholeSterolemia (CEPHEUS-PA) indicated suboptimal low-density lipoprotein cholesterol (LDL-C) goal attainment in Taiwan, which may be attributable to clinical inertia. We herein analyzed the Taiwanese cohort in the CEPHEUS-PA to identify key elements regarding clinical inertia and unsatisfactory LDL-C control. A questionnaire regarding the attitudes and perceptions for each physician and patient was included in the CEPHEUS-PA. Physicians completed the physician questionnaire before enrolling patients, who completed the patient questionnaire before the assessment. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guideline was used by 81.8% of physicians to establish the individual therapeutic targets; 50.2% of patients failed to take medications persistently. Regarding perceptions to hypercholesterolemia management, 75.9% of physicians were confident of having a sufficient number of patients at cholesterol targets; 80.2% and 65.9% of patients felt satisfied and motivated, respectively, but 46.0% had no strong feeling. The healthcare reimbursement policy used for treatment guidance was a significant determinant for LDL-C goal attainment (OR=0.32, 95% CI: 0.15-0.69, P=0.006) in addition to patient compliance. Low patient involvement indexed by having no strong feeling was associated with poor LDL-C control (OR=0.73, 95% CI: 0.56-0.95, P=0.020). The referenced healthcare reimbursement policy, poor patient compliance, and low patient involvement with hypercholesterolemia management were associated with failure of LDL-C control. Our findings highlight the need to overcome those barriers to improve the under-treatment of hypercholesterolemia.

Determinants of low-density lipoprotein cholesterol goal attainment: Insights from the CEPHEUS Pan-Asian Survey

BackgroundPrevious studies have reported that the attainment of goals for low-density lipoprotein cholesterol (LDL-C) are globally suboptimal, but contemporary data are scarce. The CEntralized Pan-Asian survey on tHE Under-treatment of hypercholeSterolemia (CEPHEUS-PA) is the largest evaluation of pharmacological treatment for hypercholesterolemia in Asia. The study reported here analyzed the Taiwan cohort in CEPHEUS-PA to identify the determinants of successful treatment. MethodsThe patients eligible for this study were adults (≥18 years old) with hypercholesterolemia and with at least two coronary heart disease (CHD) risk factors who had been receiving lipid-lowering drugs for at least 3 months before enrollment, without adjustment for at least 6 weeks before enrollment. Demographic and clinical information and lipid concentrations were recorded. Cardiovascular risk levels and LDL-C targets were determined using the updated Adult Treatment Panel III. ResultsIn this group of 999 Taiwanese patients, 50%, 25%, and 24% had LDL-C goals set at <70 mg/dL, <100 mg/dL, and <130 mg/dL, respectively. The overall attainment rate was 50%, with the lowest rate in patients set at the most stringent target (22%), followed by those whose therapeutic goals were <100 mg/dL (69%) and <130 mg/dL (87%). The success of LDL-C control was lower in patients with multiple risk factors other than CHD or its equivalents than in those without these multiple risk factors (37% vs. 53%, p < 0.001), and lower in patients with metabolic syndrome than in those without (43% vs. 66%, p < 0.001). Baseline LDL-C and cardiovascular risk were inversely associated with goal attainment, whereas treatment with statins was directly associated with the achievement of LDL-C goals. Patients with diabetes (odds ratio 0.49, 95% confidence interval 0.29–0.84, p = 0.010) and with metabolic syndrome (odds ratio 0.15, 95% confidence interval 0.05–0.40, p < 0.001) were less likely to be treated with statins. ConclusionThis study showed that there is a discrepancy between the updated Adult Treatment Panel III recommendations for LDL-C control and the control attained by this group of Taiwanese patients. In particular, treatment with statins was largely underused in patients with diabetes and in those with metabolic syndrome. These findings highlight the need for more intensive treatment in high-risk patients and those with multiple risk factors, particularly patients with metabolic syndrome.

First-line treatment patterns and lipid target levels attainment in very high cardiovascular risk outpatients.

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.

The Need for a Systematic Approach to Statin Switching

In the advent of generic statins becoming increasingly available and with the recent addition of atorvastatin to the generic market, healthcare providers are often encouraged by payers to switch from a branded statin to an alternate, less costly agent. The aim of this study was to determine the impact of a therapeutic switch on cholesterol goal attainment among patients with existing cardiovascular disease (CVD) or risk factors for CVD. A cross-sectional, multisite retrospective review of patient records evaluating low-density lipoprotein cholesterol (LDL-C) control before and after switching statins was conducted. Participants were 18 to 89 years olds who were stable on statin therapy and had 1 or more risk factors for CVD. Patients meeting switch criteria (n = 833) were evaluated for changes in their statin therapy and LDL-C goal attainment. Drug/dose information, cholesterol values, and goal attainment in accordance with National Cholesterol Education Panel Third Adult Treatment Panel guidelines were determined before and after the switch. Dose potency was based on mean LDL-C reductions. Data were collected from 22 US sites. Risk factors for CVD were common, with 88.5% of patients identified as high risk. Overall, patients' mean LDL-C levels improved from 87.1 to 81.5 mg/dL, and goal attainment increased from 75.5% to 82.5% (P < .05). Switches to a comparable or higher statin/dose improved mean LDL-C and goal attainment (P < .05). However, in patients transitioned to a lower statin/dose equivalency (36.4%), mean LDL-C level increased from 79.8 to 85.6 mg/dL and goal attainment fell from 84.2% to 78.6% (P < .05). Logistic regression confirmed that LDL-C goal attainment was reduced by 53% in patients switched to a lower statin/dose (odds ratio, 0.47; 95% confidence interval, 0.30-0.76; P = .002) compared with patients switched to an equipotent dose. The use of adjunctive lipid-lowering therapies increased in patients switched to a lower statin/dose (P < .05). Cholesterol values and goal attainment can be negatively impacted when a systematic approach is not used and patients are switched to lower potency therapies.

Can Group Medical Clinics Improve Lipid Management in Diabetes?

BackgroundGroup medical clinics may improve diabetes and hypertension control, but data about dyslipidemia are limited. We examined the impact of group medical clinics on lipids among patients with uncontrolled diabetes and hypertension. MethodsPrespecified secondary analysis of 239 veterans randomized to group medical clinics or usual care. Lipids were assessed at study baseline, midpoint, and end. We used linear mixed models to compare lipid levels between arms and generalized estimating equation models to compare low-density lipoprotein cholesterol (LDL-C) goal attainment. An additional post hoc analysis examined intensification of cholesterol-lowering medications in both arms. ResultsAt baseline, mean total cholesterol was 169.7 mg/dL (SD 47.8), LDL-C 98.2 mg/dL (SD 41.7), and high-density lipoprotein cholesterol (HDL-C) 39.3 mg/dL (SD 13.0). Median baseline triglycerides were 131 mg/dL (interquartile range 122). By study end, mean total cholesterol and LDL-C in group medical clinics were 14.2 mg/dL (P = .01) and 9.2 mg/dL (P = .02) lower than usual care, respectively; 76% of group medical clinic patients met goals for LDL-C, versus 61% of usual care patients (P = .02). Triglycerides and HDL-C remained similar between study arms. Treatment intensification occurred in 52% of group medical clinic patients, versus 37% of usual care patients between study baseline and end (P = .04). The mean statin dose was higher in group medical clinic patients at study midpoint and end. ConclusionsGroup medical clinics appear to enhance lipid management among patients with diabetes and hypertension. This may be a result of greater intensification of cholesterol-lowering medications in group medical clinics relative to usual care.

Use of health information technology (HIT) to improve statin adherence and low-density lipoprotein cholesterol goal attainment in high-risk patients: Proceedings from a workshop

The workshop discussions focused on how low-density lipoprotein cholesterol (LDL-C) goal attainment can be enhanced with the use of health information technology (HIT) in different clinical settings. A gap is acknowledged in LDL-C goal attainment, but because of the passage of the American Recovery & Reinvestment Act and the Health Information Technology for Economic and Clinical Health Acts there is now reason for optimism that this gap can be narrowed. For HIT to be effectively used to achieve treatment goals, it must be implemented in a setting in which the health care team is fully committed to achieving these goals. Implementation of HIT alone has not resulted in reducing the gap. It is critical to build an effective management strategy into the HIT platform without increasing the overall work/time burden on staff. By enhancing communication between the health care team and the patient, more timely adjustments to treatment plans can be made with greater opportunity for LDL-C goal attainment and improved efficiency in the long run. Patients would be encouraged to take a more active role. Support tools are available. The National Lipid Association has developed a toolkit designed to improve patient compliance and could be modified for use in an HIT system. The importance of a collaborative approach between nongovernmental organizations such as the National Lipid Association, National Quality Forum, HIT partners, and other members of the health care industry offers the best opportunity for long-term success and the real possibility that such efforts could be applied to other chronic conditions, for example, diabetes and hypertension.

Therapeutic practice patterns related to statin potency and ezetimibe/simvastatin combination therapies in lowering LDL-C in patients with high-risk cardiovascular disease

Statin combination therapy and statin uptitration have been shown to be efficacious in low-density lipoprotein cholesterol (LDL-C) lowering and are recommended for patients with high-risk coronary heart disease (CHD) who do not reach guideline-endorsed LDL-C goals on statin monotherapy. This analysis evaluated treatment practice patterns and LDL-C lowering for patients with CHD/CHD risk equivalent on statin monotherapy in a real-world practice setting in the United States. In this retrospective, observational study, patients with CHD/CHD risk equivalent on statin therapy were identified during 2004 to 2008 in a US managed care database. Prescribing patterns and effect of switching from statin monotherapy to combination ezetimibe/simvastatin therapy vs uptitration to higher statin dose/potency level and no change from initial statin potency on LDL-C lowering were assessed. Percentage of change from baseline in LDL-C levels and odds ratios for LDL-C goal attainment were estimated with analyses of covariance and logistic regression. Of 27,919 eligible patients on statin therapy, 2671 (9.6%) switched to ezetimibe/simvastatin therapy, 11,035 (39.5%) uptitrated statins, and 14,213 (50.9%) remained on the same statin monotherapy. LDL-C reduction from baseline and attainment of LDL-C <100 and <70 mg/dL were substantially greater for patients who switched to ezetimibe/simvastatin therapy (-24.0%, 81.2%, and 35.2%, respectively) than for patients who titrated (-9.6%, 68.0%, and 18.4%, respectively) or remained on initial statin therapy (4.9%, 72.2%, and 23.7%, respectively). The odds ratios for attainment of LDL-C <100 and <70 mg/dL were also higher for patients who switched than for patients who uptitrated and had no therapy change than for patients who titrated vs no therapy change. Similarly, among a subgroup of patients not at LDL-C <100 mg/dL on baseline therapy, attainment of LDL-C <100 and <70 mg/dL was greater for patients who switched than for statin uptitration vs no change, as well as for patients who uptritrated statins vs no therapy change. In this study, LDL-C lowering and goal attainment rates improved substantially for patients with high-risk CHD on statin monotherapy who switched to combination ezetimibe/statin or uptitrated their statin therapies; however, approximately one-third of these patients still did not attain the optional recommended LDL-C goal of <70 mg/dL. Moreover, these higher efficacy lipid-lowering therapies were infrequently prescribed, indicating the need for further assessment of barriers to LDL-C goal attainment in actual practice settings.

Attainment of normal lipid levels among high cardiovascular risk patients: Pooled analysis of observational studies from the United Kingdom, Sweden, Spain and Canada

BackgroundAlthough low-density lipoprotein cholesterol (LDL-C) is the primary lipid target for cardiovascular disease (CVD) risk reduction, high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) have also emerged as risk factors. This study evaluated attainment of goal/normal lipid levels in current clinical practice among high-risk patients following lipid-modifying therapy (LMT). MethodsData for patients aged ≥35years and on LMT for ≥12months were identified from electronic medical records (United Kingdom and Sweden) and extracted from medical charts (Canada and Spain). High CVD risk was defined according to the Adult Treatment Panel III guidelines. An index period was defined, from January 1995–July 2008, during which patients received an initial LMT prescription. Prevalence of lipid abnormalities was assessed 12months before and after the index date. Multivariate logistic regressions evaluated predictors of attaining goal/normal lipid levels. ResultsAmong 12,768 high-risk patients, 75% had elevated LDL-C, 37% low HDL-C, and 30% elevated TG before LMT. Despite therapy (97% statins only), 23% had elevated LDL-C, 36% low HDL-C, 16% elevated TG, and 17% had ≥2 abnormal lipid levels. Framingham risk score >20% (Odds Ratio, 95% confidence interval: 0.37,0.31–0.43), diabetes (0.75,0.64–0.88), hypertension (1.26,1.09–1.46), current smoker (0.82,0.70–0.95) and increased body mass index (0.95,0.94–0.96) were associated with the likelihood of attaining ≥2 normal lipid levels (vs. LDL-C goal only). ConclusionCurrent approaches to lipid management improve LDL-C goal attainment; however, control of multiple lipid risk factors remains poor. Patients may benefit from more comprehensive approaches to lipid management, which treat multiple lipid abnormalities, as suggested in clinical guidelines.

Changes in LDL-C levels and goal attainment associated with addition of ezetimibe to simvastatin, atorvastatin, or rosuvastatin compared with titrating statin monotherapy

BackgroundMany high-risk coronary heart disease (CHD) patients on statin monotherapy do not achieve guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals, and combination lipid-lowering therapy may be considered for these individuals. The effect of adding ezetimibe to simvastatin, atorvastatin, or rosuvastatin therapy versus titrating these statins on LDL-C changes and goal attainment in CHD or CHD risk-equivalent patients was assessed in a large, managed-care database in the US.MethodsEligible patients (n = 17,830), initially on statin monotherapy who were ≥18 years with baseline and follow-up LDL-C values, no concomitant use of other lipid-lowering therapy, and on lipid-lowering therapy for ≥42 days, were identified between November 1, 2002 and September 30, 2009. The percent change from baseline in LDL-C levels and the odds ratios for attainment of LDL-C <1.8 and <2.6 mmol/L (70 and 100 mg/dL) were estimated using an analysis of covariance and logistic regression, respectively, adjusted for various baseline factors.ResultsLDL-C reductions from baseline and goal attainment improved substantially in patients treated with ezetimibe added onto simvastatin, atorvastatin, or rosuvastatin therapy (n = 2,312) versus those (n = 13,053) who titrated these statins. In multivariable models, percent change from baseline in LDL-C was −13.1% to −14.8% greater for those who added ezetimibe onto simvastatin, atorvastatin, or rosuvastatin versus those who titrated. The odds of attaining LDL-C <1.8 and <2.6 mmol/L (70 and 100 mg/dL) increased by 2.6–3.2-fold and 2.5–3.1-fold, respectively, in patients who added ezetimibe onto simvastatin, atorvastatin, or rosuvastatin versus titrating statins.ConclusionCHD/CHD risk-equivalent patients in a large US managed-care database, who added ezetimibe onto simvastatin, atorvastatin, or rosuvastatin, had greater LDL-C reductions and goal attainment than those who uptitrated these statin therapies. Our study suggests that high-risk CHD patients in need of more intensive LDL-C lowering therapy may benefit by adding ezetimibe onto statin therapy.

Lipid Goal Attainment and Prescription Behavior in Asian Patients with Acute Coronary Syndromes: Experience from a Tertiary Hospital

Lipid goal attainment studies in Asian patients with acute coronary syndrome (ACS) are limited. The objectives of this study were to determine low-density lipoprotein cholesterol (LDL-C) goal attainment rate at 4 months, and to examine prescription behavior influencing lipid goal attainment in Asian patients with ACS. A retrospective analysis of 267 patients with ACS was performed. The mean follow-up duration was 41.2±10.7 months. LDL-C goal attainment rate was highest at 4 months (36.7%) but declined progressively throughout follow-up. More than 85% of patients were discharged with equipotent statin dose of 2 (equivalent to simvastatin 20 mg) or less. In patients who did not attain LDL-C goals, the statin dose remained low throughout follow-up because of a lack in responsive dose titration. Aggressive lipid-lowering therapy should be initiated early to improve goal attainment in these high-risk patients.

Lack of Goal Attainment Regarding the Low-density Lipoprotein Cholesterol Level in the Management of Type 2 Diabetes Mellitus

The management of diabetes mellitus includes controlling the blood glucose level, body weight, blood pressure and serum lipid level. The coexistence of diabetes and a high low-density lipoprotein cholesterol (LDL-C) level promotes atherosclerosis of the coronary arteries and increases the risk of coronary artery disease (CAD). We compared the rates of attainment of LDL-C goals in type 2 diabetes patients receiving primary and secondary prevention therapy, the former without a history of CAD and the latter with a history of CAD. Because patients receiving secondary prevention are at greater risk of coronary events, LDL-C management is especially important in this group. This study was designed to determine how frequently diabetic patients attain their LDL-C goals and identify the reasons for the lack of attainment. The groups were distinguished according to the patients' medical records. Contributory factors for the patients not achieving their goals were recorded in a questionnaire filled out by each patient's physician. The overall attainment rate in both groups was 61%. The most frequent impediment in both groups was "an LDL-C level above or below the goal at every hospital visit" followed by "continuously sufficient effects of dietary therapy only" and the "management of LDL-C by other departments or hospitals," the latter reflecting the increasing problems of polydisease and polypharmacy in diabetes care. Polydisease and polypharmacy issues in diabetes patients with a history of CAD constitute a growing barrier to medication adherence and the attainment of treatment goals.

Relation of Statin Nonadherence and Treatment Intensification

Failure to intensify medication and failure to adhere to medication have been shown to contribute to suboptimal low-density lipoprotein cholesterol goal attainment. To examine whether nonadherence to statins in 126,903 patients on stable statin therapy is associated with subsequent treatment intensification, we conducted a retrospective analysis using an integrated pharmacy and medical claims database. Pharmacy claims were analyzed to determine whether nonadherence, as measured by proportion of days covered on statins <80%, was associated with intensification of statin treatment over a 360-day follow-up. Of 11,361 patients who had treatment intensification, 44% were previously nonadherent to statins. Patients whose treatment was intensified had slightly lower adherence to statin therapy than those without intensification (76% vs 78%, p <0.0001) and were more likely to be nonadherent as defined by proportion of days covered <80% (44% vs 37%, p <0.0001). After controlling for confounding factors, patients nonadherent to statins were 30% more likely to have treatment intensification compared to adherent patients (odds ratio 1.30, 95% confidence interval 1.25 to 1.36). In addition, patients with statin intensification were more likely to be younger, women, and have coronary artery disease, diabetes, hypertension, dyslipidemia, stroke, peripheral arterial disease, heart failure, or depression. Primary care physicians were more likely to escalate therapy than cardiologists. In conclusion, nearly 1/2 of patients with therapy escalation were nonadherent to statins. Clinicians should inquire about adherence and consider adherence before escalating statin therapy.

Attainment of Normal Lipid Levels Among Patients on Lipid-Modifying Therapy in Hong Kong

Although low-density lipoprotein cholesterol (LDL-C) is the primary lipid target for coronary heart disease (CHD) risk reduction, high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) have also emerged as CHD risk factors. The objective of this study was to evaluate attainment of lipid goals and normal levels following lipid-modifying therapy (LMT) and its predictors in a representative sample of Chinese patients from Hong Kong. Using longitudinal data collected from patient medical records, the study identified 706 patients who initiated LMT from January 2004 to December 2006 and had full lipid panels 12 months before and after therapy. LDL-C goals and normal levels of HDL-C and TG were defined according to the National Cholesterol Education Program Adult Treatment Panel 3 guidelines. Patients with previous CHD, diabetes, and 10-year CHD risk > 20% were classified as high risk. Multiple logistic regressions evaluated predictors of normal lipid-level attainment. Among 706 patients (mean age 64.6 years, 58.6% male), 71.7% had elevated LDL-C, 32.4% had low HDL-C, and 24.9% had elevated TG before LMT. Despite therapy (91.2% statins only), 22.7% had elevated LDL-C, 31.9% had low HDL-C, 12.3% had elevated TG, and 13.9% had multiple abnormal lipid levels. The strongest predictors of attaining ≥ 2 normal lipid levels included male gender (odds ratio [OR]: 2.11 [1.12 to 4.01]), diabetes (OR: 0.43 [0.23 to 0.78]), obesity (OR: 0.91 [0.86 to 0.97]), and CHD risk > 20% (OR: 0.33 [0.15 to 0.71]). Current approaches to lipid management in Hong Kong, primarily using statins, considerably improve attainment of LDL-C goal. However, a large proportion of patients do not achieve normal HDL-C levels and control of multiple lipid parameters remains poor. Patients could benefit from a more comprehensive approach to lipid management that treats all three lipid risk factors, as suggested in clinical guidelines.