Follow-up Low-density Lipoprotein Cholesterol Research Articles

Use of combination therapy is associated with improved LDL-cholesterol management: 1-year follow-up results from the European observational SANTORINI study.

To assess whether implementation of the 2019 ESC/EAS dyslipidaemia guidelines observed between 2020-2021 improved between 2021-2022 in the SANTORINI study. High- or very-high cardiovascular (CV) risk patients were recruited across 14 European countries from March 2020-February 2021, with 1-year prospective follow-up until May 2022. Lipid-lowering therapy (LLT) and 2019 ESC/EAS risk-based low-density lipoprotein cholesterol (LDL-C) goal attainment (defined as <1.4 mmol/L for patients at very high CV risk and <1.8 mmol/L for patients at high CV risk) at 1-year follow-up were compared with baseline. . Of 9559 patients enrolled, 9136 (2626 high risk, 6504 very high risk) had any follow-up data, and 7210 (2033 high risk, 5173 very high risk) had baseline and follow-up LDL-C data. LLT was escalated in one-third of patients and unchanged in two-thirds. Monotherapy and combination therapy usage rose from 53.6% and 25.6% to 57.1% and 37.9%, respectively. Mean LDL-C levels decreased from 2.4 mmol/L to 2.0 mmol/L. Goal attainment improved from 21.2% to 30.9%, largely driven by LLT use among those not on LLT at baseline. Goal attainment was greater with combination therapy compared with monotherapy at follow-up (39.4 vs 25.5%). LLT use and achievement of risk-based lipid goals increased over 1-year follow-up particularly when combination LLT was used. Nonetheless, most patients remained above goal, hence strategies are needed to improve implementation of combination LLT.

Association of LDL-cholesterol

Recent intensive low-density lipoprotein cholesterol (LDL-C) lowering trials, including FOURIER, ODYSSEY OUTCOMES, and Treat Stroke to Target (TST) trials, have mostly refuted the concern surrounding statin use, LDL-C lowering, and intracerebral hemorrhage (ICH) risk. However, the results from these trials may not be fully applied to ICH survivors, as the populations studied were mainly patients without prior ICH, in whom the inherent ICH risk is more than 10 times lower than that of ICH survivors. Although available literature on statin use after ICH has demonstrated no excess risk of recurrent ICH, other potential factors that may modify ICH risk, especially hypertension control and ICH etiology, have not generally been considered. Notably, data on LDL-C levels following ICH are lacking. We aim to investigate the association between LDL-C levels and statin use with ICH risk among ICH survivors, and to determine whether the risk differed with patients' characteristics, especially ICH etiology. Follow-up data of consecutive spontaneous ICH survivors enrolled in the University of Hong Kong prospective stroke registry from 2011 to 2019 were retrospectively analyzed. ICH etiology was classified as cerebral amyloid angiopathy (CAA) using the modified Boston criteria or hypertensive arteriopathy, while the mean follow-up LDL-C value was categorized as <1.8 or ⩾1.8 mmol/L. The primary endpoint was recurrent ICH. The association of LDL-C level and statin use with recurrent ICH was determined using multivariable Cox regression. Pre-specified subgroup analyses were performed, including based on ICH etiology and statin prescription. Follow-up blood pressure was included in all the regression models. In 502 ICH survivors (mean age = 64.2 ± 13.5 years, mean follow-up LDL-C = 2.2 ± 0.6 mmol/L, 28% with LDL-C <1.8 mmol/L), 44 had ICH recurrence during a mean follow-up of 5.9 ± 2.8 years. Statin use after ICH was not associated with recurrent ICH (adjusted hazard ratio (AHR) = 1.07, 95% confidence interval (CI) = 0.57-2.00). The risk of ICH recurrence was increased for follow-up LDL-C <1.8 mmol/L (AHR = 1.99, 95% CI = 1.06-3.73). This association was predominantly observed in ICH attributable to CAA (AHR = 2.52, 95% CI = 1.06-5.99) and non-statin users (AHR = 2.91, 95% CI = 1.08-7.86). The association between post-ICH LDL-C <1.8 mmol/L and recurrent ICH was predominantly observed in CAA patients and those with intrinsically low LDL-C (non-statin users). While statins can be safely prescribed in ICH survivors, LDL-C targets should be individualized and caution must be exercised in CAA patients.

The effect of LDL-C status on the association between increased coronary artery calcium score and compositional plaque volume progression in statins-treated diabetic patients: evaluated using serial coronary CTAs

BackgroundIn statins-treated diabetic mellitus (DM) patients, longitudinal coronary CTA (CCTA) evidence is scarce regarding the relationship between coronary Agatston artery calcification scores (CACs) and coronary plaque progression. This study was designed to investigate whether the association between CACs progression and compositional plaque volumes (PVs) progression differed between follow-up low-density lipoprotein cholesterol (LDL-C) controlled and uncontrolled groups in statins-treated DM patients.MethodsFrom January 2015 to June 2021, 208 patients who submitted serial clinically indicated CCTAs in our hospital were included in this study. Participants were further subdivided into LDL-C controlled (n = 75) and LDL-C uncontrolled (n = 133) groups according to whether the LDL-C reached the treatment goals at follow-up. Baseline and follow-up CCTA image datasets were quantified analysis at per-patient and per-plaque levels. The annual change of total PV (TPV), calcific PV(CPV), non-calcific PV (NCPV), low-density non-calcific PV (LD-NCPV), and CACs were assessed and further compared according to follow-up LDL-C status. The effect of CACs progression on the annual change of componential PVs was evaluated according to follow-up LDL-C status at both per-patient and per-plaque levels.ResultsThe annual change of CACs was positively associated with the annual change of TPV (β = 0.43 and 0.61, both p < 0.001), CPV (β = 0.23 and β = 0.19, p < 0.001 and p = 0.004, respectively), NCPV (β = 0.20 and β = 0.42, p < 0.001 and p = 0.006, respectively), and LD-NCPV (β = 0.08 and 0.13, p < 0.001 and p = 0.001, respectively) both on per-patients and per-plaque levels. LDL-C status had no effect on the annual change of TPV, CPV, NCPV, and LD-NCPV (all p > 0.05). After adjusting for confounding factors, on the per-patient level, the increase in CACs was independently associated with annual change of TPV (β = 0.650 and 0.378, respectively, both p < 0.001), CPV (β = 0.169 and 0.232, respectively, p = 0.007 and p < 0.001), NCPV (β = 0.469 and 0.144, respectively, both p = 0.001), and LD-NCPV (β = 0.082 and 0.086, respectively, p = 0.004 and p = 0.006) in LDL-C controlled and LDL-C uncontrolled group. On the per-plaque level, the increase in CACs was independently associated with the annual change of NCPV and LD-NCPV in LDL-C uncontrolled patient (β = 0.188 and 0.106, p < 0.001), but not in LDL-C controlled group (β = 0.268 and 0.056, p = 0.085 and 0.08).ConclusionsThe increase of CACs in statins-treated DM patients indicates the progression of compositional PVs. From a per-plaque perspective, there might be increased instability of individual plaques concomitant with CACs increase in LDL-C uncontrolled patients.

Changes in Impaired Fasting Glucose and Borderline High Low-Density Lipoprotein-Cholesterol Status Alter the Risk of Cardiovascular Disease: A 9-Year Prospective Cohort Study.

BackgroundWe aimed to characterize the relationships of the changes in impaired fasting glucose (IFG) and borderline high low-density lipoprotein-cholesterol (LDL-C) status with cardiovascular disease (CVD).MethodsA total of 36,537 participants who did not have previous CVD, diabetes mellitus, or high LDL-C (≥ 4.1 mmol/L), nor were taking lipid-lowering drugs were recruited from the Kailuan study. The participants were allocated to six groups according to their baseline and follow-up fasting blood glucose (FBG) and LDL-C concentrations: (1) both were normal; (2) both normal at baseline, one abnormality subsequently; (3) both normal at baseline, both abnormal subsequently; (4) at least one abnormality that became normal; (5) at least one abnormality at baseline, a single abnormality subsequently; and (6) at least one abnormality, two abnormalities subsequently. The outcomes were CVD and subtypes of CVD (myocardial infarction and stroke). Multiple Cox regression models were used to calculate adjusted hazard ratio (HR) and confidence interval (95% CI).ResultsDuring a median follow-up period of 9.00 years, 1,753 participants experienced a CVD event. After adjustment for covariates, participants with IFG in combination with a borderline high LDL-C status at baseline and follow-up had higher risks of CVD (HR: 1.52; 95% CI: 1.04–2.23 and HR: 1.38, 95% CI: 1.13–1.70, respectively) compared with those with normal fasting blood glucose and LDL-C. Compared with participants that remained normal, those who changed from normality to having two abnormalities were at a higher risk of CVD (HR: 1.26; 95% CI: 0.98–1.61), as were those who changed from at least one abnormality to two abnormalities (HR: 1.48, 95% CI: 1.02–2.15).ConclusionChanges in IFG and borderline high LDL-C status alter the risk of CVD and its subtype, implying that it is important to focus on such individuals for the prevention and control of CVD.

Impact of statin therapy on late target lesion revascularization after everolimus-eluting stent implantation according to pre-interventional vessel remodeling and vessel size of treated lesion

Clinical evidence demonstrating the impact of statins for preventing late target lesion revascularization (TLR) after newer-generation drug-eluting stent implantation and differences in the effect of statins on late TLR according to pre-interventional vessel remodeling and vessel size is limited. We retrospectively evaluated 1193 de novo lesions in 720 patients who underwent everolimus-eluting stent implantation using intravascular ultrasound from January 2010 to December 2012. The primary endpoint was late TLR. Lesions were divided into the statin group (n = 825) and non-statin group (n = 368). The incidence of late TLR was significantly lower in the statin than non-statin group (1.7% vs. 5.2%, respectively; p = 0.001), and within the statin group, it was significantly lower in the follow-up low-density lipoprotein cholesterol (LDL-C) < 100 than ≥ 100 mg/dL level subgroup (1.0% vs. 3.6%, respectively; p = 0.006). Furthermore, in positive remodeling lesions and non-small vessel size lesions, the incidence of late TLR was significantly lower in the statin than non-statin group (1.6% vs. 8.5% and 1.3% vs. 5.3%, respectively; p = 0.001 and p = 0.004). Lowering the LDL-C level using statins was more effective for preventing late TLR after everolimus-eluting stent implantation. Evaluating pre-interventional vessel remodeling patterns and vessel size might be helpful to stratify lesions at high risk of late TLR.

ESC/EAS guidelines for the detection, prevention, and treatment of individuals at risk of a first myocardial infarction: effect of 5 years of updates and the new SCORE2.

The European Society of Cardiology (ESC) has released three consecutive guidelines within 5 years addressing cardiovascular prevention, risk scores, and cholesterol treatment. This study aims to evaluate whether the 2021 ESC guidelines improved the eligibility of individuals for primary prevention statin therapy before their first ST-segment elevation myocardial infarction (STEMI), and for intensive lipid-lowering treatments in secondary prevention. The cardiovascular risk category of 2757 consecutive individuals admitted for a first STEMI was evaluated to assess whether they would have been eligible for primary prevention statins according to 2021 vs. 2019 and 2016 ESC guidelines. Eligibility for intensive lipid-lowering therapy in secondary prevention was assessed according to the real-life follow-up low-density lipoprotein cholesterol (LDL-C) and the expected follow-up LDL-C. More individuals would have been eligible for primary prevention statins according to 2021 and 2019 vs. 2016 guidelines (61.8% vs. 38.7% vs. 23.6%, P&lt;0.01), a finding observed in both men (62.3% vs. 35.0% vs. 24.9%, P&lt;0.01) and women (60.2% vs. 50.7% vs. 19.3%, P=0.18). Only 27% of individuals reached the LDL-C objective of 55mg/L in secondary prevention: using the ESC stepwise approach, 61.7% were eligible for higher doses of statins, 26.2% for ezetimibe, and 12.1% for a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (PCSK9i). Based on expected LDL-C reductions, eligibility for a PCSK9i in secondary prevention was greater with 2021 vs. 2016 guidelines (44.5% vs. 22.5%, P&lt;0.01). The 2021 ESC guidelines improved the detection and treatment of individuals at risk for a first myocardial infarction. In secondary prevention, 70% of patients kept LDL-C levels above 55mg/dL: increasing the statin dose and adding ezetimibe were the most frequently recommended therapeutic actions.

Abstract 12303: Management of Severe and Moderate Hypercholesterolemia in Young Adults

Introduction: Cardiovascular guidelines advise statin therapy for adults aged 20-75 years with low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL with a goal of lowering LDL-C by ≥50%. Further, early-life accumulation of cholesterol exposure increases future cardiovascular risk independent of total cumulative cholesterol exposure, highlighting the importance of LDL-C management in young adults. However, real-world management of hypercholesterolemia in young adults is not well described. Methods: Using the Mass General Brigham clinical data registry, we isolated 2 cohorts of patients with hypercholesterolemia who had cholesterol testing on ≥2 occasions and were 20-39 years old at the time of a qualifying LDL-C value between 2005-2018: those with LDL-C ≥190 mg/dL (Cohort 1) and LDL-C 160-&lt;190 mg/dL (Cohort 2). Follow-up LDL-C values were extracted through 2019. Primary endpoints were 50% reduction in LDL-C for Cohort 1 and 30% reduction for Cohort 2. Results: Cohort 1 (severe hypercholesterolemia) included 5,475 patients (37.9% female, mean [SD] age 32.6 [5.1] years at qualifying LDL-C), and Cohort 2 (moderate hypercholesterolemia) included 12,608 patients (39.6% female, mean [SD] age 32.6 [5.1] years). In Cohort 1, 1,638 individuals (29.9%) achieved ≥50% LDL-C reduction overall (31.7% of men vs. 27.1% of women, P&lt;0.001; Figure ) over median (IQR) 7.8 (4.5-11.3) years of follow-up. The youngest individuals were less likely to achieve 50% LDL-C reduction (e.g., 20-24 years old: 24.8% vs. 35-39 years old: 32.7%; P trend &lt;0.001). In Cohort 2, 4,515 individuals (35.8%) achieved ≥30% LDL-C reduction over median (IQR) 7.5 (4.2-11.1) years of follow-up. Conclusions: In a large, integrated healthcare system, &lt;30% of young adults with severe hypercholesterolemia achieved guideline-directed LDL-C-lowering over 8 years of follow-up. These findings highlight the need for strategies to promote guideline-recommended cholesterol management in young adults.

Impact of statin intensity on adverse cardiac and cerebrovascular events in older adult patients with myocardial infarction.

BACKGROUNDThere is insufficient evidence regarding the effect of high-intensity statin therapy in older adults. This study aimed to investigate the effects of high-intensity statin treatment on the clinical outcomes in older adults with myocardial infarction (MI).METHODSConsecutive patients with MI aged at least 75 years were analyzed retrospectively. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of all-cause death, MI, rehospitalization due to unstable angina, repeat revascularization, and ischemic stroke. The high-intensity group was compared to the low-to-moderate intensity group in the propensity score-matched cohort.RESULTSAverage age of total 546 patients was 81 years. Among them, 84% of patients underwent percutaneous coronary intervention. The unadjusted seven-year MACCE rate differed by statin intensity (high-intensity statin group: 38%, moderate-intensity statin group: 42%, low-intensity statin group: 56%, and no-statin group: 61%, P = 0.004). However, among these groups, many baseline characteristics were significantly different. Among the 74 propensity score-matched pairs, which lacked any significant differences in all baseline characteristics, the high-intensity group had a significantly lower rate of MACCE than the low-to-moderate intensity group (37% vs. 53%, P = 0.047). Follow-up low-density lipoprotein cholesterol levels were significantly lower in the high-intensity group than that in the low-to-moderate intensity group (69.4 ± 16.0 mg/dL vs. 77.9 ± 25.9 mg/dL, P = 0.026). CONCLUSIONSIn older adult patients with MI, the use of high-intensity statin caused significantly less occurrence of MACCE in comparison to that in low-to-moderate intensity for up to seven years of follow-up.

Abstract 17323: Personalizing Cholesterol Management Therapy Using Electronic Medical Records and Machine Learning

Introduction: Optimal statin treatment decisions for primary prevention of atherosclerotic cardiovascular disease (ASCVD) rely on shared decision-making between patient and provider. We sought to develop a machine learning-based algorithm to personalize cholesterol treatment decisions using electronic medical record (EMR) data. Methods: We included EMR data for adults aged 40 to 79 with no prior ASCVD or statin therapy from an outpatient Northern California system between January 1, 2009 and December 31, 2018 with at least two visits at least 1 year apart and at least two low density lipoprotein cholesterol (LDL-C) values. The outcome was the LDL-C measured closest to one year after a patient’s second visit. We modeled four different treatment decisions: no statin use, low-intensity statin use, moderate-intensity statin use, and high-intensity statin use. We trained weighted-K-nearest-neighbor (wKNN) regression models to identify similar patients using each line of therapy to a candidate patient. The algorithm compared outcomes of these similar patients and recommended the treatment which predicted the lowest LDL-C after one year. Results: Our study cohort consisted of 50,911 patients (age 54.6 ± 9.84 years, baseline LDL-C 122 ± 34.2 mg/dL, follow-up LDL-C 121 ± 35.9 mg/dL) including 54% female, 47% Non-Hispanic White, 32% Asian, and 7.5% Hispanic patients. Among 8,551 test patients visiting in 2015 or later, 96.9%, 3.08%, and 0.05% were recommended to begin high-intensity, moderate-intensity, and low-intensity statins, respectively. With these recommendations, the LDL-C values at 1-year follow-up were predicted to be 21.5 ± 43.5 mg/dL (17.6%) lower per patient, on average (Figure). Conclusions: EMR-trained wKNN models are able to determine patient LDL-C trajectories under different lines of statin therapy. Machine learning models leveraging real-world datasets may provide useful statin therapy treatment recommendations for primary ASCVD prevention.

Incidence and Predictors of Neoatherosclerosis in Patients with Early In-Stent Restenosis Determined Using Optical Coherence Tomography

In-stent restenosis (ISR) still exists after drug-eluting stent (DES) implantation, even up to one year. The incidence and risk factors for neoatherosclerosis in patients with early ISR have not yet been elucidated. Here, we used optical coherence tomography (OCT) to evaluate the incidence and predictors of neoatherosclerosis in patients with early ISRs.OCT was performed on ISR lesions in 185 patients in order to detect neoatherosclerosis. The median follow-up was 180 days, and neoatherosclerosis was detected in 37% of early ISR lesions. According to the presence of neoatherosclerosis, patients with ISR were divided into two groups: neoatherosclerosis (group A, n = 69) and non-neoatherosclerosis (group B, n = 116) groups.The risk factors were similar, except for hypercholesterolemia. Moreover, the tissue characteristics were not significantly different between patients with and without neoatherosclerosis. Follow-up low-density lipoprotein-cholesterol (LDL-C) levels were divided into three grades (LDL < 70 mg/dL, 70 mg/dL≤ LDL < 100 mg/dL, and LDL ≥ 100 mg/dL). The incidence of neoatherosclerosis was significantly lower (23% versus 57%, P < 0.0001) in the LDL < 70 mg/dL group. There was no significant difference in the incidence of neoatherosclerosis in patients with lipid levels between 70 and 100 mg/dL (P = 0.53). However, neoatherosclerosis was significantly more common in patients with a follow-up LDL-C level > 100 mg/dL (45% versus 15%, P < 0.0001).In patients with early ISR lesions, the LDL-C levels may be related to the formation and progression of early neoatherosclerosis, and poor LDL-C control may be a risk factor for the occurrence of early-stage neoatherosclerosis following DES implantation.

Prevalence, treatment, and control of severe hyperlipidemia

ObjectiveTo identify the prevalence, treatment, and low-density lipoprotein cholesterol (LDL-C) control of individuals with LDL-C ≥190 ​mg/dL in contemporary clinical practice. MethodsWe included adults (age ≥18 years) with LDL-C ≥190 ​mg/dL, at least one LDL-C level drawn from 255 health systems participating in Cerner HealthFacts database (2000–2017, n ​= ​4,623,851), and a detailed examination within Duke University Health System (DUHS, 2015–2017, n ​= ​267,710). Factors associated with LDL-C control were evaluated using multivariable logistic regression modeling. ResultsThe cross-sectional prevalence of LDL-C ≥190 ​mg/dL was 3.0% in Cerner (n ​= ​139,539/4,623,851) and 2.9% at DUHS (n ​= ​7728/267,710); among these, rates of repeat LDL-C measurement within 13 months were low: 27.9% (n ​= ​38,960) in Cerner, 54.5% (n ​= ​4211) at DUHS. Of patients with follow-up LDL-C levels, 23.6% in Cerner had a 50% of greater reduction in LDL-C, 18.3% achieved an LDL-C <100 ​mg/dL and 2.7% ​< ​70 ​mg/dL. At DUHS, 28.4% had a 50% or greater reduction in LDL-C, 28.4% achieved an LDL-C ≤100 ​mg/dL and 4.4% achieved <70 ​mg/dL. Within DUHS, 71.6% with LDL-C ≥190 ​mg/dL were on any statin during follow-up, but only 28.5% were on a high-intensity statin. In multivariable modeling, seeing a cardiologist (Cerner odds ratio [OR] 1.56, confidence interval [CI] 1.33–1.83; DUHS OR 1.89, 95% CI 1.18–3.01) and having diabetes (Cerner OR 1.34 CI 1.23–1.46; DUHS OR 2.07, CI 1.62–2.65) increased odds of LDL-C control, defined as a ≥50% reduction in LDL-C (at Cerner) or initiation of high intensity statin (at DUHS). Prior atherosclerotic cardiovascular disease (OR 1.19, CI 1.07–1.33), hypertension (OR 1.10, CI 1.03–1.18), African American race (OR 0.79, CI 0.71–0.89), and government (vs. private) insurance (OR 0.90, CI 0.83–0.98) were associated with LDL-C control at Cerner. Female sex was associated with lower odds of appropriate therapy (OR 0.69, CI 0.59–0.81) at DUHS. ConclusionsApproximately 3% of United States adults have LDL-C ≥190 ​mg/dL. Among those with very high LDL-C, rates of repeat measurement within one year were low; of those retested, only about one-fourth met guideline-recommended LDL-C treatment goals.

Preliminary Pilot Study of Combined Effects of Physical Activity and Achievement of LDL-Cholesterol Target on Coronary Plaque Volume Changes in Patients with Acute Coronary Syndrome.

Background: We investigated the combined effects of physical activity (PA) and aggressive low-density lipoprotein cholesterol (LDL-C) reduction on the changes in coronary plaque volume (PV) in patients with acute coronary syndrome (ACS) using volumetric intravascular ultrasound (IVUS) analysis. Methods: We retrospectively analyzed data from two different prospective clinical trials that involved 101 ACS patients who underwent percutaneous coronary intervention (PCI) and assessed the non-culprit sites of PCI lesions using IVUS at baseline and at the follow-up. After PCI, all the patients participated in early phase II comprehensive cardiac rehabilitation. Patients were divided into four groups based on whether the average daily step count, measured using a pedometer, was 7000 steps of more and whether the follow-up LDL-C level was <70 mg/dL. At the time of follow-up, we examined the correlation of changes in the PV with LDL-C and PA. Results: The baseline characteristics of the four study groups were comparable. At the follow-up, plaque regression in both the achievement group (PA and LDL-C reduction) was higher than that in the other three groups. In addition, plaque reduction independently correlated with increased PA and reduction in LDL-C level. Conclusions: Combined therapy of intensive PA and achievement of LDL-C target retarded coronary PV in patients with ACS.

Comparing Primary Prevention Recommendations: A Focused Look at United States and European Guidelines on Dyslipidemia.

Comparing Primary Prevention Recommendations: A Focused Look at United States and European Guidelines on Dyslipidemia.

Low-Density Lipoprotein Cholesterol Target Attainment in Patients With Established Cardiovascular Disease: Analysis of Routine Care Data.

BackgroundDirect feedback on quality of care is one of the key features of a learning health care system (LHS), enabling health care professionals to improve upon the routine clinical care of their patients during practice.ObjectiveThis study aimed to evaluate the potential of routine care data extracted from electronic health records (EHRs) in order to obtain reliable information on low-density lipoprotein cholesterol (LDL-c) management in cardiovascular disease (CVD) patients referred to a tertiary care center.MethodsWe extracted all LDL-c measurements from the EHRs of patients with a history of CVD referred to the University Medical Center Utrecht. We assessed LDL-c target attainment at the time of referral and per year. In patients with multiple measurements, we analyzed LDL-c trajectories, truncated at 6 follow-up measurements. Lastly, we performed a logistic regression analysis to investigate factors associated with improvement of LDL-c at the next measurement.ResultsBetween February 2003 and December 2017, 250,749 LDL-c measurements were taken from 95,795 patients, of whom 23,932 had a history of CVD. At the time of referral, 51% of patients had not reached their LDL-c target. A large proportion of patients (55%) had no follow-up LDL-c measurements. Most of the patients with repeated measurements showed no change in LDL-c levels over time: the transition probability to remain in the same category was up to 0.84. Sequence clustering analysis showed more women (odds ratio 1.18, 95% CI 1.07-1.10) in the cluster with both most measurements off target and the most LDL-c measurements furthest from the target. Timing of drug prescription was difficult to determine from our data, limiting the interpretation of results regarding medication management.ConclusionsRoutine care data can be used to provide feedback on quality of care, such as LDL-c target attainment. These routine care data show high off-target prevalence and little change in LDL-c over time. Registrations of diagnosis; follow-up trajectory, including primary and secondary care; and medication use need to be improved in order to enhance usability of the EHR system for adequate feedback.

Room for improvement: initiation of lipid-lowering treatment and achievement of lipid target levels-a Danish registry-based study.

Prevention of adverse outcomes in individuals with high cholesterol levels may be improved by intensified lipid-lowering treatment (LLT). We studied whether treatment goals of low-density lipoprotein cholesterol (LDL-C) were reached within 1 year from baseline (defined as first LDL-C measurement) in a Danish population. Danish registries were used to identify all persons in the Northern Region of Denmark who had LDL-C measured between 1997 and 2012 and who were naïve to LLT. Patients were categorized in LDL-C <5 or ≥5 mmol/L and further subdivided into low, high, and very high predicted cardiovascular (CV) risk as suggested by European guidelines for risk stratification. Initiation of LLT and lipid target levels were assessed after 1 year (3.0, 2.5, and 1.8 mmol/L, respectively). In this study, we examined the intensity of LLT and whether treatment goals were reached. More patients with LDL-C ≥5 mmol/L, regardless of the CV risk, initiated LLT compared with patients who had a very high CV risk and LDL-C <5 mmol/L. In total, 37.7% (n = 32581) of all patients with a follow-up LDL-C, and 25.1% (n = 3229) of patients with LDL-C ≥5 mmol/L, had achieved their target levels after 1 year. Only 45.2% (n = 4545) of the LDL-C ≥5 mmol/L high-risk patients with a follow-up LDL-C had started LLT 12 months after baseline. Less than half of patients presenting with an LDL-C ≥5 mmol/L start LLT within 1 year, representing a missed opportunity for both primary and secondary prevention of CV disease.

P824The clinical impact of polyunsaturated fatty acid on clinical outcomes in acute coronary syndrome with dyslipidemia: HIJ-PROPER sub-analysis

Abstract Background Polyunsaturated fatty acids, especially omega-3 and -6 series, are key essential nutrients that play an important role in humans to maintain cell membranes and function. A recent randomized trial reported that adding eicosapentaenoic acid (EPA) to statins was beneficial to cardiovascular disease patients who had a residual risk factor. Further, several studies have reported that the low baseline value for EPA to arachidonic acid (AA) ratio is related to worse clinical outcome and plaque vulnerability in coronary artery disease patients. However, effects of baseline EPA/AA ratio on clinical outcomes in ACS patients have not been thoroughly evaluated. Objectives This study aimed to examine the impact of baseline eicosapentaenoic acid to arachidonic acid (EPA/AA) ratio on clinical outcomes of acute coronary syndrome (ACS) patients and how lipid-lowering therapy affects serum EPA/AA levels in these patients. Methods This is a sub-analysis of HIJ-PROPER assessing the effect of aggressive low-density lipoprotein cholesterol (LDL-C)-lowering treatment with pitavastatin+ezetimibe in 1,734 ACS patients with dyslipidemia. Patients were divided into two groups based on EPA/AA level on admission (cut-off: 0.34 μg/mL; median of baseline EPA/AA level) and clinical outcomes were examined. Results Percent reduction of LDL-C from baseline to follow-up and mean LDL-C level during follow-up were similar regardless of baseline EPA/AA ratio. In the low EPA/AA group, the Kaplan–Meier estimate for the primary endpoint at 3 years was 27.2% in the pitavastatin+ezetimibe group, compared with 36.6% in the pitavastatin-monotherapy group [hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.52–0.93; P=0.015). However, in the high EPA/AA group, there was no significant reduction in the primary endpoint by pitavastatin+ezetimibe therapy (HR, 0.92; 95% CI, 0.70–1.20; P=0.52). Conclusions Aggressive lipid-lowering therapy with ezetimibe had a positive effect on clinical outcomes in the low EPA/AA group of ACS patients with dyslipidemia, but not in the high EPA/AA group. This effect was independent of LDL-C reduction and suggests that EPA/AA measurement on admission in ACS patients contributes to a “personalized” lipid-lowering approach.

Trends and predictors of high-intensity statin therapy and LDL-C goal achievement among Thai patients with acute coronary syndrome

BackgroundPrevious studies on the use of high-intensity statins and low-density lipoprotein cholesterol (LDL-C) goal achievement were mostly conducted in patients with acute coronary syndrome (ACS) receiving care before 2013. We aimed to determine trends and predictors of high-intensity statin therapy and LDL-C goal achievement in a more recent cohort of Thai ACS patients. MethodsWe analyzed data from electronic databases of ACS patients at a tertiary-care, teaching hospital in Thailand between 2013 and 2017. Trends and predictors of high-intensity statin therapy and LDL-C goal achievement after hospital discharge were determined with logistic regression analysis. ResultsAmong 1753 ACS patients, 987 (56.3%) received high-intensity statin at discharge. A higher proportion of ACS patients were prescribed high-intensity statins over time (p=0.033 for linear trend), rising from 10% in 2013 to 88% in 2017. Independent predictors of high-intensity statin therapy included age ≤75 years, a diagnosis of myocardial infarction, receiving P2Y12 inhibitors, and beta-blockers. Within 120 days after discharge, 427 (24.4%) patients had follow-up LDL-C measurements. Overall, 185 (43.3%) patients achieved LDL-C goals based on either of the following criteria: LDL-C <70mg/dL or ≥50% reduction in the baseline LDL-C. There was a non-significant trend (p=0.402 for linear trend) in the proportion of patients achieving LDL-C goals over the study period. Independent predictors of achieving LDL-C goal included high-intensity statin therapy after discharge and lower baseline LDL-C on admission. ConclusionsIn a more recent cohort of Thai ACS patients, a higher proportion of patients were prescribed high-intensity statins before discharge over the study period. However, the proportion of patients who achieved LDL-C goal did not increase accordingly. This finding should promote more discussion among health policy makers to improve statin treatment and quality of care for ACS patients.

1482-P: Low-Density Lipoprotein Cholesterol (LDL-C) Management in Patients with Atherosclerotic Cardiovascular Diseases (ASCVD) and Preexisting Diabetes in Alberta, Canada

Background: Lipid-lowering therapy (LLT) reduces the risk of CV events, however, limited real-world data exist on the management of LDL-C in patients with ASCVD and pre-existing diabetes in Canada. Our study describes the clinical characteristics and LDL-C management of patients with ASCVD and diabetes using health system data in Alberta. Methods: A retrospective study was conducted linking multiple health system datasets to examine clinical characteristics and LDL-C levels in those receiving LLT (e.g., statins) after the first LDL-C test. Patients with ASCVD were identified using ICD diagnostic codes between 2011-2015. Similarly, diabetes status was assessed in the year prior to ASCVD diagnosis. LDL-C was assessed at the first (index) and second (follow-up) tests during the study period. LDL-C levels were evaluated based on a threshold of 2.0 mmol/L, as per the 2016 Canadian blood cholesterol management guidelines. Results: Among 144,607 patients with ASCVD and a prescription for LLT (mean age=66.3; 66% male), 27,540 (19.0%) patients were identified with diabetes. Patients with diabetes were more likely to have stroke, myocardial infarction, or peripheral arterial disease. Congestive heart failure and hypertension were found in 26.8% and 87.8% of patients with diabetes compared to 12.5% and 71.5% in those without, respectively. Of the patients with diabetes who had an index and follow-up LDL-C test (n=18,214), 35.0% (n=6,380) did not achieve the guideline specified LDL-C threshold at index. At follow-up (mean=238.9 days after index), 49.0% (n=3,129) of those who did not achieve threshold at index failed to meet the threshold. Conclusions: Nearly half of patients above the LDL-C threshold at the index test did not achieve threshold at the follow-up test, despite receiving LLT. Multifaceted interventions may be required to improve cholesterol management of patients with ASCVD and diabetes in Alberta. Disclosure G. Chen: Consultant; Self; Medlior Health Outcomes Research Ltd. M.S. Farris: Employee; Self; Medlior Health Outcomes Research Ltd. T. Cowling: Stock/Shareholder; Self; Medlior Health Outcomes Research Ltd. M. Tai: Employee; Self; Amgen Inc. L. Pinto: Employee; Self; Amgen Inc. S. Colgan: Employee; Self; Amgen Inc. R. Rogoza: Employee; Self; Amgen Inc. Stock/Shareholder; Self; Amgen Inc. T.J. Anderson: None.

PCV88 REAL-WORLD STUDY OF TREATMENT INTENSIFICATION OF STATINS IN PATIENTS WITH UNCONTROLLED ATHEROSCLEROTIC CARDIOVASCULAR DISEASE (ASCVD)

Statins are effective in reducing low-density lipoprotein cholesterol (LDL-C) and cardiovascular disease risk, however, despite treatment, patients in the real-world setting may not reach lipid goals. Ensuring timely treatment intensification (TI) is important in reducing the risk of adverse outcomes. The objectives of this study, conducted in patients with ASCVD and baseline LDL-C>70 despite existing statin therapy were to (a) To evaluate predictors of TI (b) To assess the association between TI and LDL-C lowering. A retrospective cohort study was conducted using Truven MarketScan database from 2013-2017. The first prescription of statin between January 2014-February 2016 was identified as the index date. A pre-index period of 180 days to identify baseline characteristics and a follow-up period of 360 days for outcomes was determined. TI was defined as an increase in the intensity of statin from low to moderate, moderate to high or low to high. Logistic regression was conducted to identify predictors of TI. To measure the effect of TI on LDL-C reduction, multiple linear regression with follow-up LDL-C as the outcome was performed. There were 14,395 patients included in the study with 3,909 patients having follow-up LDL-C values. TI in the follow-up was observed in 1,914 (13.30%) patients. Age older than 75 [OR: 0.7(95%CI: 0.59-0.84)] was associated with lower likelihood of TI in the multivariable logistic regression model. Baseline characteristics positively associated with TI included higher LDL-C value and adherence, low and moderate statin intensity, male sex and diabetes. For patients with follow-up LDL-C values, TI was associated with significant mean reduction in LDL-C (β: -9.68, p=<0.0001). Even though TI was associated with significant LDL-C lowering, a significant proportion of patients not at goal were not intensified. Future studies need to examine the relationship of TI with factors such as patient adherence and side-effects as well as cardiovascular outcomes.

Clinical characteristics, patterns of lipid-lowering medication use, and health care resource utilization and costs among patients with atherosclerotic cardiovascular disease.

PurposeThe aim of this study was to investigate real-world patient characteristics, medication use, and health care resource utilization (HCRU) and costs among patients with clinical atherosclerotic cardiovascular disease (ASCVD) as defined by 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, to examine burden of disease and unmet needs, such as potential undertreatment.Patients and methodsThis retrospective cohort study utilized a nationally representative managed care database to identify newly diagnosed ASCVD patients between January 1, 2007, and November 30, 2012 (index = first ASCVD diagnosis date) in the USA. Patients had ≥12-month pre-index (baseline) and ≥12-month post-index (follow-up) health plan enrollment and no baseline lipid-lowering medication (LLM). Patient characteristics, LLM utilization patterns, HCRU, and costs were examined for all patients and by subgroups based on LLM use pattern and/or follow-up low-density lipoprotein cholesterol (LDL-C) levels.ResultsA total of 128,017 ASCVD patients were identified with a mean (SD) age of 59 (13) years, 43.1% female, and 48.8% with ≥36-month follow-up. Within 12-month follow-up, 10.6% had high-intensity statins and 56.9% had no LLM fills. Baseline mean (SD) all-cause costs were $8,852 ($25,608). At 12-month follow-up, mean (SD) all-cause and ASCVD-related costs were $31,443 ($54,040) and $20,289 ($45,159), respectively. The 36-month analyses showed similar distributions. Multivariable analyses showed that age, gender, region, health insurance type, baseline comorbidities, baseline use of specific medications, baseline lipid profiles, and index ASCVD type were significantly associated with all-cause and ASCVD-related health care costs.ConclusionPatients have nonoptimal treatment for ASCVD and substantial HCRU and costs associated with residual risk. Unmet needs and cost burdens of ASCVD patients merit additional investigation.