Cholesterol Management Guidelines Research Articles

Effect of lipid-lowering treatment on lipid and glycemic profile of patients with elevated lipoprotein(a) levels

Aim: The evaluation of the effect of lipid-lowering treatment in patients with elevated levels of lipoprotein(a) [Lp(a)]. Material and methods: A prospective study including 70 patients with dyslipidemia and elevated Lp(a) levels (>30 mg/dL) attending a Lipid Clinic in Greece. Subjects were allocated to the following therapies according to the national guidelines for cholesterol management: high-intensity statin monotherapy (S; n=28), ezetimibe added to high-intensity statin (SE; n=31), and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor added to high-intensity statin plus ezetimibe (SEP; n=11). Follow-up duration was 3 months. We investigated the effect of these lipid-lowering interventions on participants’ lipidemic and glycemic profile. Comparisons between groups were adjusted for the baseline levels of the studied parameters. Results: Mean age was 51 ± 15 years, 40% were male, 39% were diagnosed with familial hypercholesterolaemia (FH), 16% with atherosclerotic cardiovascular disease (ASCVD), while 36%, 33% and 15% were at very high, high, and moderate cardiovascular risk, respectively. All interventions significantly reduced apolipoprotein B (apoB), total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C), but only PCSK9 inhibitors significantly reduced Lp(a) levels (SEP: -28% vs SE: +11% vs S: +17%, p<0.05). Patients in the SE group achieved the highest rates of LDL-C target attainment (SEP: 36.4% vs SE: 12.9% vs S: 3.6% for LDL-C <55 mg/dL; SEP: 36.4% vs SE: 16.1% vs S: 7.1% for LDL-C <70 mg/dL, p<0.05 for the comparison among groups). No significant effect on glycemic profile across treatment groups was noted. Conclusions: Add-on PCSK9 inhibitors were associated with the highest rates of LDL-C target achievement compared with high-intensity statin ± ezetimibe in high-risk patients with elevated Lp(a) and were the only class to significantly lower Lp(a) levels.

Value of the clinical pharmacist interventions in the application of the American College of Cardiology (ACC/AHA) 2018 guideline for cholesterol management.

The study aims to examine the extent to which the updated ACC/AHA management of blood cholesterol guideline (2018) is implemented in practice and to assess the value of the clinical pharmacist interventions in improving physicians' adherence the guidelines recommendations. We utilized in this study an interventional before-after design. The study was conducted on 272 adult patients who visited the study site internal medicine clinics and were candidates for statin therapy based on the 2018 ACC/AHA guidelines for cholesterol management. Adherence to guideline recommendations was measured before and after clinical pharmacists' interventions by calculating the percentage of patients receiving statin therapy as per guideline recommendation, the type and intensity (moderate or high intensity) of statin therapy used, and the need for additional non-statin therapy. Adherence with guideline recommendations was significantly improved from 60.3% to 92.6% (X2 = 79.1, p = 0.0001) after clinical pharmacist interventions. Among patients who were on statin therapy, the percentage of those who were on proper statin intensity increased significantly from 47.6% to 94.4% (X2 = 72.5, p = 0.0001). The combination of statins with non-statin therapies such as ezetimibe and PCSK9 inhibitors increased from 8.5% to 30.6% (X2 = 95, p<0.0001) and from 0.0% to 1.6% (X2 = 6, p = 0.014), respectively. The use of other lipid-lowering agents was diminished from 14.6% to 3.2% (X2 = 19.2, p<0.0001). Collaboration between physicians and clinical pharmacists is a crucial strategy to improve patients' treatment and hence, achieve better health outcomes among patients suffering from dyslipidemia.

Antithrombotic therapy and bleeding risk in the era of aggressive lipid-lowering: current evidence, clinical implications, and future perspectives.

The clinical efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in reducing major cardiovascular adverse events related to atherosclerotic cardiovascular disease (ASCVD) has been well established in recent large randomized outcome trials. Although the cardiovascular and all-cause mortality benefit of PCSK9i remains inconclusive, current cholesterol management guidelines have been modified toward more aggressive goals for lowering low-density lipoprotein cholesterol (LDL-C). Consequently, the emerging concept of "the lower the better" has become the paradigm of ASCVD prevention. However, there is evidence from observational studies of a U-shaped association between baseline LDL-C levels and all-cause mortality in population-based cohorts. Among East Asian populations, low LDL-C was associated with an increased risk for hemorrhagic stroke in patients not on antithrombotic therapy. Accumulating evidence showed that low LDL-C was associated with an enhanced bleeding risk in patients on dual antiplatelet therapy following percutaneous coronary intervention. Additionally, low LDL-C was associated with a higher risk for incident atrial fibrillation and thereby, a possible increase in the risk for intracranial hemorrhage after initiation of anticoagulation therapy. The mechanism of low-LDL-C-related bleeding risk has not been fully elucidated. This review summarizes recent evidence of low-LDL-C-related bleeding risk in patients on antithrombotic therapy and discusses potential measures for reducing this risk, underscoring the importance of carefully weighing the pros and cons of aggressive LDL-C lowering in patients on antithrombotic therapy.

Abstract TP185: Lipoprotein(a) Levels In Patients With Embolic Stroke Of Undetermined Source And Its Association With Non-stenotic Atherosclerotic Disease

Background: Lipoprotein(a) [Lp(a)]has been linked to increased atherosclerotic cardiovascular disease risk however there is limited data on Lp(a) in ischemic stroke subtypes. Current cholesterol management and ASCVD prevention guidelines include Lp(a) &gt;50 mg/dL as a risk enhancer. Methods: This is a retrospective cohort of consecutive embolic stroke of undetermined source (ESUS) patients seen at the Emory Stroke Clinic and underwent Lp(a) testing in the outpatient setting from January 1, 2020 to March 31, 2022. Abnormal levels were defined as ≥ 30 mg/dl. Cerebrovascular imaging was reviewed by a board-certified neuroradiologist who was blinded to Lp(a) data. Results: Of 105 ESUS patients [median age 57 years (IQR 44-68), 51% female, 44% African American (AA)], median Lp(a) was 40 mg/dl (IQR 15-74) with 67 patients (64%) having Lp(a) ≥ 30 mg/dl, 45 (43%) ≥ 50 mg/dl and 30 (29%) having Lp(a) ≥ 70 mg/dl. Lp(a) levels were higher in AAs compared to other races (median 46 mg/dl vs 26 mg/dl , p= 0.002). Lp(a) level ≥ 30 mg/dl was associated with a higher serum D-dimer level median 536 (IQR 337-947, p=0.02), non-large vessel occlusion (LVO) stroke on initial imaging (p=0.012) and absence of MRI-FLAIR sequence abnormalities (p=0.044). In the subset of ESUS patients who underwent CT angiography of the head and neck (n=46), patients with Lp(a) level ≥ 50 mg/dl were more likely to have non-stenotic atherosclerotic plaque ipsilateral to the stroke territory (OR 6.1, 95% CI 1.3-28, p= 0.02). Conclusion: Lp(a) level ≥ 50 mg/dl was present in 43% of our cohort. This may be an under-recognized risk factor in ESUS. Further investigation is needed regarding the impact of Lp(a) on ESUS however our results suggest that ESUS patients with ≥ 50 mg/dl may benefit from a careful assessment of cerebrovascular imaging for ipsilateral non-stenotic atherosclerotic plaque in the territory of the stroke.

Physicians and pharmacists' clinical knowledge of statin therapy and monitoring parameters, and the barriers to guideline implementation in clinical practice.

Millions of individuals worldwide use statins, and their significant impact on cardiovascular disease (CVD) has been well-established. However, a lack of knowledge about the up-to-date guideline recommendations regarding statin therapy is a common barrier to implementation in clinical practice. Therefore, the present study aimed to assess the current clinical knowledge about statin therapy and its monitoring parameters. Also, we evaluated the barriers to cholesterol management guideline implementation in Yemen. This observational cross-sectional study was conducted over four months, from June/2021 to September/2021, in Sana'a, Yemen. A validated questionnaire was distributed face-to-face to 650 participants (350 physicians and 300 pharmacists). Physicians and pharmacists from governmental and private hospitals and those working in private clinics or community pharmacies were included in the study. A total of 496 participants filled out the survey, with 22 being excluded due to incomplete data. So, the study has an overall response rate of 72.9% (474). The majority of pharmacists (81.8%) and physicians (78.7%) could not identify the patient group that needed ASCVD risk assessment before statin therapy initiation. Although a significant proportion of respondents knew of the fact that high-intensity statins are recommended for patients with ASCVD (65.4%) and primary hypercholesterolemia (58.4%), the majority of physicians and pharmacists could not identify the high (61.6% and 66.7.3%, respectively) and moderate statin-intensity doses (72.2% and 68.6%, respectively). Only 21.9% of all respondents knew that atorvastatin and rosuvastatin can be administered at any time of the day. Similarly, a low overall rate of respondents (19.6%) knew that atorvastatin does not need dose adjustment in chronic kidney diseases, with a statistically significant difference in knowledge between physicians and pharmacists (12.5% vs. 25.6%, p <0.001, respectively). Notably, only 39.2% of participants were aware that statins are not safe to use during breastfeeding. Around half of respondents (52.3%) correctly identify the duration (4 to 12 weeks) at which LD-C measuring is recommended after therapy initiation or dose change. The lowest knowledge scores for respondents were related to statin-drug interactions. Age, experience, degree, and previous guideline exposure were all significantly associated with the knowledge scores (p <0.05). The four most perceived barriers to implementing cholesterol management guidelines were no audit on adherence to the guidelines in the workplace (73.4%), insufficient resources to adequately implement and follow up on the guideline's recommendations (73.6%), patient's financial status (75.7%), and lack of familiarity about the guideline's latest recommendations (63.3%). Physicians and pharmacists had suboptimal clinical knowledge regarding statin therapy, dose intensities, drug-drug interaction, contraindications, and monitoring parameters. Therefore, physicians' and pharmacists' educational interventions regarding the up-to-date recommendation about statins are recommended.

Influencing Appropriate Statin Use in a Charity Care Primary Clinic.

According to the American College of Cardiology/American Heart Association (ACC/AHA) new cholesterol management guidelines in 2019, statin regimen was prescribed to only about 46.4% and 30% of diabetes (DM) patients and patients with atherosclerotic cardiovascular disease (ASCVD), respectively. Atherosclerotic cardiovascular disease accounts for most deaths and disabilities in North America. This study argues that a systematic approach to identifying targeted interventions to adhere to the statin regimen for ASCVD is sparse in previous studies. This study seeks to address the research gap. Besides, the study argues that the statin regimen could improve cholesterol management with the enablers of pharmacy, providers, electronic medical records (E.M.R.), and patients. It paves the way for future research on cardiovascular and statin regimens from different perspectives. Current study has adopted the Qualitative observation method. Accordingly, the study approached the charity care primary clinic serving a large population in the northeastern part of the United States, which constitutes the project's setting. The facility has 51 internal medicine residents. The facility has E.H.R., which is used by the clinical staff. Besides, providers use electronic medication prescribing (E-Scribe). Four PDSA cycles were run in six months. Here, the interventions were intensified during each subsequent cycle. The interventions were then incorporated into routine clinical practice. Based on the observation, the study found a 25% relative improvement by six months based on the baseline data of the appropriate intensity statin prescription for patients with ASCVD or DM by medical resident trainees in our single-center primary care clinic. A total of 77% of cardiovascular disease patients were found to be on an appropriate statin dose at baseline. On the other hand, the proportion of patients with DM who were on proper dose statin was 80.4%. According to the study's findings, PDSA could result in a faster uptake and support of the ACC/AHA guidelines. Evidence indicates that overmedication of persons at low risk and time constraints are some of the most significant impediments to the greater use of prescription medications. Proactive panel management can help improve statins' use by ensuring they are used appropriately.

Trends in Lipid-Lowering Prescriptions: Increasing Use of Guideline-Concordant Pharmacotherapies, U.S., 2017‒2022

Almost one third of U.S. adults have elevated low-density lipoprotein cholesterol, increasing their risk of atherosclerotic cardiovascular disease. The 2018 American College of Cardiology/American Heart Association Multisociety Cholesterol Management Guideline recommends maximally tolerated statin for those at increased atherosclerotic cardiovascular disease risk and add-on therapies (ezetimibe and PCSK9 inhibitors) in those at very high risk and low-density lipoprotein cholesterol ≥70 mg/dL. Prescription fill trends are unknown. Using national outpatient retail prescription data from the first quarter of 2017 to the first quarter of 2022, authors determined counts of patients who filled low-, moderate-, or high-intensity statins alone and with add-on therapies. The overall percentage change and joinpoint regression were used to assess trends. Analyses were conducted in March 2022-May 2022. During the first quarter of 2017 to the first quarter of 2022, patients filling a statin increased by 25.0%, with the greatest increase in high-intensity statins (64.1%, range=6.6-10.9 million). Low-intensity statins decreased by 29.2% (range=3.3-2.4 million). Concurrent fills of high-intensity statin and ezetimibe rose by 210% to 579,012 patients by the first quarter of 2022, with an increase in slope by the first quarter of 2019 for all statin intensities (p<0.01). Concurrent fills of a statin and PCSK9 inhibitor increased to 2,629, 16,169, and 28,651 by the first quarter of 2022 for low-, moderate-, and high-intensity statins, respectively. For patients on all statin intensities and PCSK9 inhibitor, there were statistically significant increases in slope in the second quarter of 2019 and decreases in the first quarter of 2020. Patients filling moderate- and high-intensity statins and add-on ezetimibe and PCSK9 inhibitors have increased, indicating uptake of guideline-concordant lipid-lowering therapies. Improvements in the initiation and continuity of these therapies are important for atherosclerotic cardiovascular disease prevention.

Lowering LDL cholesterol in clinical practice: time for change?

Atherosclerotic cardiovascular disease (ASCVD) events are associated with cumulative exposure to LDL cholesterol. Clinical guidelines for blood cholesterol management in people with ASCVD recommend monotherapy with the highest tolerated dose of statin before consideration of additional non-statin therapy to reach the LDL cholesterol goal.1,2 Combination lipid-lowering therapy (LLT) reduces LDL cholesterol concentrations to a greater extent than doubling the statin dose.3 However, until now, no randomised clinical trial had compared the long-term clinical event outcomes of high-intensity statin monotherapy versus lower-intensity statin with ezetimibe.

Risk assessment of atherosclerotic cardiovascular diseases before statin therapy initiation: Knowledge, attitude, and practice of physicians in Yemen.

Risk evaluation of atherosclerotic cardiovascular disease (ASCVD) remains the cornerstone of primary prevention. The cardiovascular risk assessment can guide the decision-making on various preventive measures such as initiating or deferring statin therapy. Thus, our study aimed to assess the physicians' knowledge, attitude, and practices regarding atherosclerotic cardiovascular diseases risk assessment. Also, we evaluated the physician-patient discussion and counseling practices before statin therapy initiation in concordance with recommendations from the latest clinical practice guideline. A cross-sectional study was conducted between November 2020 and January 2021. A self-administered questionnaire was distributed to 350 physicians (GPs, residents, specialists, and consultants). Two trained pharmacists distributed the questionnaires in 5 major tertiary governmental hospitals and more than ten private hospitals. Also, private clinics were targeted so that we get a representative sample of physicians at different workplaces. A total of 270 physicians filled the questionnaire out of 350 physicians approached, with 14 being excluded due to high missing data, giving a final response rate of 73%. Participants had suboptimal knowledge and practices with a high positive attitude toward atherosclerotic cardiovascular diseases risk assessment. The knowledge and practices were higher among consultants, participants from the cardiology department, those with experience years of more than nine years, and those who reported following a specific guideline for cholesterol management or using a risk calculator in their practice. Notably, the risk assessment and counseling practices were lower among physicians who reported seeing more patients per day. Physicians had overall low knowledge, suboptimal practices, and a high positive attitude toward cardiovascular risk assessment. Therefore, physicians' training and continuing medical education regarding cholesterol management and primary prevention clinical practice guidelines are recommended. Also, the importance of adherence to clinical practice guidelines and their impact on clinical outcomes should be emphasized.

Abstract 10434: Gaps in Ldl-C Control According to Cardiovascular Risk Status and Statin Use in Us Adults

Background: Current US guidelines since 2013 have recommended statin use for high cardiovascular (CV) risk adults including those with atherosclerotic cardiovascular disease (ASCVD), regardless of LDL-C levels. Recent data among US population-representative adults regarding extent of LDL-C control in high CV risk persons are lacking. Methods: We examined among 4,484 US adults (representing 231 million) from the National Health and Nutrition Examination Surveys 2015-2018 the extent of statin use and remaining high LDL-C levels according to risk group as defined by the pooled cohort equation (PCE): low (&lt;5%), intermediate (5- &lt; 20%), high risk without ASCVD (&gt;20% 10-year risk), diabetes without ASCVD, and high and very high risk ASCVD as defined by the 2018 cholesterol management guideline based on multiple major ASCVD events or high risk conditions. Results: Overall, 18.9% (representing 43.7 million) of US adults were on statin therapy in our cohort; this varied across risk groups from 1.4% (low risk), 10.7% (intermediate risk), 26.2% (high risk without ASCVD), 48.8% (diabetes without ASCVD), 50.8% (ASCVD high risk) and 75.4% (ASCVD very high risk), with additional ezetimibe use &lt;5% in all groups. The figure below shows, despite statin therapy (with or without ezetimibe), &gt;45% of high-risk primary prevention persons still have LDL-C &gt; 100 mg/dL, &gt;70% of those with DM to have LDL-C &gt; 70 mg/dL, and &gt;60% of high risk and &gt;70% of very high-risk adults with ASCVD to have LDL-C &gt; 70 mg/dL. Conclusions: Despite statin-focused guidelines since 2013, many US adults recommended for statin therapy are not on statins, and of those on statins, many have suboptimal LDL-C levels, warranting further LDL-C lowering with higher intensity statins and/or non-statin agents.

Abstract 11605: Analysis of 10-yr MACE Risk of LDL-C ≥160-189 Mg/dL Compared to &lt;160 Mg/dL in Young Adults (ages 20-39) in an Integrated Healthcare System

Introduction: Adults &lt;40-yrs (20-39) may have elevated cardiovascular risk based on higher LDL-C (e.g., ≥160 mg/dL). We sought to compare the risk of MACE (all-cause death, MI, ischemic stroke, heart failure hospitalization, and peripheral vascular disease [PVD]) in adults &lt;40-yrs and LDL-C ≥160 to 189 compared with LDL-C &lt;160 mg/dL. Hypothesis: Adults &lt;40-yrs with LDL-C ≥160-189 mg/dL are minimally addressed in the current cholesterol management guidelines but may have a higher risk of MACE compared to other healthy controls. Methods: Patients (pts) from 20- 39 yrs of age with at least three lipid labs and outpatient primary care encounters at Intermountain Healthcare, a large integrated healthcare system, prior to January 2010 and an LDL-C measurement between January and December of 2020 (n=14,570) were included and followed for MACE until June 2021. Pts with LDL-C &gt;190 or &lt;160 on statin in 2010 but previously ≥160 were excluded. Pts were identified using MDClone (ADAMS self-service analytics platform). Outcome of interest was MACE during 10-yr follow-up, LDL-C was stratified as ≥160-189 vs &lt;160 mg/dL. Baseline characteristics were compared by either a chi-squared or t-test, as appropriate. Multivariate logistic regression was used to identify the role of LDL-C as a predictor of outcome. A p-value of &lt;0.05 was considered statistically significant. Results: Baseline characteristics are presented in the Table. MACE for LDL-C ≥160-189 mg/dL was not statistically significant compared to LDL-C &lt;160 (OR 1.28, 95% CI 0.94 - 1.74, p&lt;0.115). Conclusions: The risk of 10-yr MACE in adults &lt;40 yrs of age with LDL-C ≥160-189 mg/dL did not confer a statistically significant elevated risk. Our findings are consistent with current guidelines that statin therapy is not mandated in these individuals.

The United States 2020 Census data: implications for precision medicine and theresearch landscape.

The United States 2020 Census data: implications for precision medicine and theresearch landscape.

Baseline Low-Density Lipoprotein Cholesterol and Clinical Outcomes of Combining Ezetimibe With Statin Therapy in IMPROVE-IT

BackgroundThe 2018 U.S. cholesterol management guideline recommends additional lipid-lowering therapy with ezetimibe for secondary prevention in very high-risk patients with low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dL despite maximally tolerated statin. ObjectivesThe purpose of this study was to evaluate the relationship between baseline LDL-C above and below 70 mg/dL and the benefit of adding ezetimibe to statin in patients post–acute coronary syndrome (ACS). MethodsIMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial) was a double-blind, placebo-controlled, randomized trial of ezetimibe/simvastatin vs placebo/simvastatin in post-ACS patients followed for 6 years (median). A total of 17,999 patients were stratified by LDL-C at qualifying event into 3 groups (50-<70, 70-<100, and 100-125 mg/dL). The primary endpoint was a composite of cardiovascular death, major coronary events, or stroke. ResultsAbsolute differences in median LDL-C achieved at 4 months between treatment arms were similar (17-20 mg/dL). The effect of ezetimibe/simvastatin vs placebo/simvastatin on primary endpoint was consistent regardless of baseline LDL-C of 50-<70 mg/dL (HR: 0.92 [95% CI: 0.80-1.05]), 70-<100 mg/dL (HR: 0.93 [95% CI: 0.87-1.01]), or 100-125 mg/dL (HR: 0.94 [95% CI: 0.86-1.03]; P interaction = 0.95). Normalized relative risk reductions per 1-mmol/L difference in achieved LDL-C at 4 months between treatment arms were 21% in patients with baseline LDL-C of 50-<70 mg/dL, 16% in those with 70-<100 mg/dL, and 13% in those with 100-125 mg/dL (P interaction = 0.91). No significant treatment interactions by baseline LDL-C were present for safety endpoints. ConclusionsAdding ezetimibe to statin consistently reduced the risk for cardiovascular events in post-ACS patients irrespective of baseline LDL-C values, supporting the use of intensive lipid-lowering therapy with ezetimibe even in patients with baseline LDL-C <70 mg/dL. (IMPROVE-IT: Examining Outcomes in Subjects With Acute Coronary Syndrome: Vytorin [Ezetimibe/Simvastatin] vs Simvastatin [P04103]; NCT00202878)

Implication Of Thoracic Aortic Calcification Over Coronary Calcium Score Regarding The 2018 Acc/aha Cholesterol Guideline: Results From The Cac Consortium

Introduction: Thoracic aortic calcification (TAC) is associated with an increased atherosclerotic cardiovascular disease (ASCVD) risk, but it is unclear how to interpret TAC findings in conjunction with ASCVD risk and coronary artery calcium (CAC) score. We evaluated the implication of TAC over CAC for reclassifying statin eligibility groups according to 2018 ACC/AHA cholesterol management guidelines.

Quel objectif de LDL en prévention secondaire ?

Quel objectif de LDL en prévention secondaire ? M. John Chapman, Endocrinology-Metabolism Service, Pitie-Salpetriere University Hospital, Sorbonne University, Paris. An extensive data base derived from randomised, placebo-controlled intervention trials in dyslipidemic subjects has established that targeted lowering of LDL-cholesterol reduces the incidence of cardiovascular events, including ischemic stroke, in secondary prevention. Recent findings from the FOURIER and ODYSSEY OUTCOMES trials in secondary prevention patients involving use of PCSK9 inhibitors as add-on therapy to statin treatment have demonstrated a continuum of clinical benefit to LDL-C levels well below 50 mg/dL (1.3 mmol/L). As a consequence, the 2019 ESC/EAS guidelines for cholesterol management in secondary prevention propose an LDL-C goal of < 55 mg/dL (1,4 mmol/L), together with a 50 % reduction from baseline levels. This proposal is entirely consistent with the recent “Treat stroke to target” trial in post-stroke patients with atherosclerotic disease after a median follow-up of 3,5 years (Amarenco et al, NEJM, 2019), in which the lowest risk of ischemic stroke was observed in subjects whose target LDL-C level was < 70 mg/dL (1,8 mmol/L). Considered together, no increase in intracranial hemorrhagic relative to the placebo groups was observed in these studies. Future studies are now required to evaluate the effectiveness of LDL-C targets of 55 mg/dL or lower in further reducing stroke incidence in clinically-defined cohorts of stroke patients.

Comparison of equations for the calculation of low-density lipoprotein cholesterol in thai population

Background: Low-density lipoprotein cholesterol (LDL-C) has been established as a major risk factor for cardiovascular diseases. Various equations have been proposed for LDL-C calculation; however, the accuracy of these equations varies among different ethnicities. This study aimed to assess the accuracy and concordance of LDL-C equations for dyslipidemia classifications in Thai adults. Materials and Methods: The lipid profiles of 1091 healthy Thai adults were measured using a homogenous enzymatic assay. The estimated LDL-C equations by Friedewald, Ahmadi, Anandaraja, Chen, Cordova, Densethakul, Hattori, Martin, Puavillai, Sampson, and Vujovic were compared to directly measured LDL-C using Pearson's correlation test. Cohen's kappa statistic was also used to test the concordance of the LDL-C equations with directly measured LDL-C levels, according to the standard guidelines for blood cholesterol management. Results: The LDL-C values calculated by Friedewald, Sampson, and Chen equations showed a high degree of correlation and values close to directly measured LDL-C levels with mean differences ranging from − 0.04 to 0.07 mmol/L. All these three equations had a high degree of concordances with directly measured LDL-C levels for classifying the degree of dyslipidemia. Conclusion: Friedewald, Sampson, and Chen equations showed better estimations of LDL-C levels and had higher accuracy in classifying the degree of LDL-C strata than other equations in the Thai population.

Factors Associated with Disparities in Appropriate Statin Therapy in an Outpatient Inner City Population.

Lipid-lowering therapies are essential for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The aim of this study is to identify discrepancies between cholesterol management guidelines and current practice with a focus on statin treatment in an underserved population based in a large single urban medical center. Among 1042 reviewed records, we identified 464 statin-eligible patients. Age was 61.0 ± 10.4 years and 53.9% were female. Most patients were black (47.2%), followed by Hispanic (45.7%) and white (5.0%). In total, 82.1% of patients were prescribed a statin. An appropriate statin was not prescribed in 32.4% of statin-eligible patients who qualified based only on a 10-year ASCVD risk of ≥7.5%. After adjustment for gender and health insurance status, appropriate statin treatment was independently associated with age >55 years (OR = 4.59 (95% CI 1.09–16.66), p = 0.026), hypertension (OR = 2.38 (95% CI 1.29–4.38), p = 0.005) and chronic kidney disease (OR = 3.95 (95% CI 1.42–14.30), p = 0.017). Factors independently associated with statin undertreatment were black race (OR = 0.42 (95% CI 0.23–0.77), p = 0.005) and statin-eligibility based solely on an elevated 10-year ASCVD risk (OR = 0.14 (95% CI 0.07–0.25), p < 0.001). Hispanic patients were more likely to be on appropriate statin therapy when compared to black patients (86.8% vs. 77.2%). Statin underprescription is seen in approximately one out of five eligible patients and is independently associated with black race, younger age, fewer comorbidities and eligibility via 10-year ASCVD risk only. Hispanic patients are more likely to be on appropriate statin therapy compared to black patients.

Clinical Application of High-Sensitivity Troponin Testing in the Atherosclerotic Cardiovascular Disease Framework of the Current Cholesterol Guidelines

The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol management guidelines identified 2 distinct groups of patients with atherosclerotic cardiovascular disease (ASCVD) prompting different treatment recommendations. To investigate whether the addition of high-sensitivity troponin (hsTn) testing to guideline-derived ASCVD risk can improve risk classification and downstream treatment recommendations. A prospective cohort biomarker substudy was performed that included 8635 patients enrolled in the Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction 54 (PEGASUS-TIMI 54) trial. Patients were assigned to risk groups of either very high-risk ASCVD or lower-risk ASCVD based on their cardiovascular history and comorbidities, in line with the 2018 AHA/ACC cholesterol management guidelines criteria. Patients were also classified on the basis of hsTnI level (ARCHITECT assay; Abbott) using cut points of 2 ng/L (limit of detection) and 6 ng/L (risk threshold), followed by joint classification on the basis of clinical features and hsTnI level. The setting was a nested prospective cohort study in a completed multinational trial. Participants were all patients who had a myocardial infarction 1 to 3 years before enrollment, were at least 50 years of age, and had at least 1 high-risk feature. The study dates were October 2010 to December 2014. The dates of analysis were June 2019 to January 2020. The primary end point was a composite of cardiovascular death, myocardial infarction, or stroke. Among 8635 patients enrolled in the PEGASUS-TIMI 54 trial, the median age was 65 years (interquartile range, 58-71 years), and 6614 (76.6%) were men; 8340 (96.6%) were White individuals and 176 (2.0%) were Black individuals. Patients meeting clinical criteria for the very high-risk ASCVD group had a primary end point 3-year event rate of 8.8% compared with 5.0% in the lower-risk ASCVD group (hazard ratio, 2.01; 95% CI, 1.58-2.57; P < .001). When patients in the very high-risk ASCVD group were further risk stratified by hsTnI level, 614 of 6789 patients (9.0%) with an undetectable hsTnI level had a 3-year event rate of 2.7% (<1% per year), which was less than the overall rate in the lower-risk ASCVD group. Analogously, in the lower-risk ASCVD group, 417 of 1846 patients (22.6%) with an hsTnI level exceeding 6 ng/L had an event rate of 9.1%, comparable to the overall rate in the very high-risk ASCVD group. The addition of hsTnI to guideline-derived ASCVD risk led to a net reclassification index at event rate of 0.15 (95% CI, 0.10-0.21). Overall, use of hsTnI reclassified 1031 of 8635 patients (11.9%) (1 in 11 with very high-risk ASCVD and 1 in 4 with lower-risk ASCVD). The findings of this cohort substudy suggest that a strategy incorporating hsTn into a guideline-derived ASCVD risk algorithm provides enhanced risk stratification and reclassifies 11.9% of patients into a more appropriate risk group. This application of hsTn testing might be used to optimize the care of patients with ASCVD.

New Recommendations and Revised Concepts in Recent Guidelines on the Management of Dyslipidemias to Prevent Cardiovascular Disease: the 2018 ACC/AHA and 2019 ESC/EAS Guidelines.

The purpose of this review is to discuss the updated guideline recommendations on management of dyslipidemia for prevention and treatment of cardiovascular disease. The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) published revised cholesterol management guidelines in 2018 and 2019, respectively, to reflect new evidence in the field. Broadly speaking, both emphasize refining cardiovascular disease risk estimation and aggressively lowering low-density lipoprotein-cholesterol (LDL-C) with statin and non-statin agents to curb cardiovascular risk. While they share the same guiding principles, there are important differences in the recommendations from both societies including how they define risk categories and goals for LDL-C lowering. This review summarizes current methods of managing dyslipidemia with a focus on the common themes and notable differences between the 2018 ACC/AHA and 2019 ESC/EAS cholesterol management guidelines.

Examination of physicians' adherence to the 2013 ACC/AHA statin/cholesterol guidelines using a framework of awareness to adherence: A cross-sectional study.

BackgroundCurrently, limited data exists regarding primary care physicians’ awareness and implementation of the 2013 cholesterol guidelines.ObjectivesTo evaluate primary care physicians’ adherence to the 2013 ACC/AHA cholesterol management guidelines using the framework of the awareness-to-adherence model.MethodsThe study was a cross-sectional pre-post survey design based on the constructs of the awareness-to-adherence model to capture physicians’ awareness of, agreement with, adoption of, and adherence to the 2013 ACC/AHA guidelines for cholesterol treatment and statin and cholesterol management software applications. Physicians with a Medicare Advantage organization in Texas were surveyed before and after educational interventions.ResultsA total of 170 responses were considered usable (post-survey). A significant difference was observed when physicians were divided into 2 groups (any intervention vs no intervention) (P = .027). Physicians with a higher level of agreement were 4.8 times more likely to be adherent to the guidelines (P = .011), compared with those with a lower level of agreement. Also, physicians practicing in the Rio Grande Valley area were 4.7 times more likely to be adherent to the guidelines (P = .001) compared with those from the Greater Houston area.ConclusionA high level of awareness, but a lower level of adherence to the guidelines was reported among responding physicians. The awareness-to-adherence model was useful in examining physicians’ level of adherence to the cholesterol guidelines and the utilization of statin and cholesterol management cellular apps and online websites. Future studies are required to examine physicians’ adoption and adherence of new guidelines.