Low-density Lipoprotein Cholesterol Goal Attainment Research Articles

The therapeutic management of South African dyslipidaemic patients at very high cardiovascular risk (CARDIO TRACK): a cross-sectional study.

Dyslipidaemia is a major modifiable risk factor for atherosclerotic cardiovascular disease. At the time the study was conducted, guidelines recommended a low-density lipoprotein cholesterol (LDL-C) target of less than 1.8 mmol/l and a reduction of at least 50% if the baseline LDL-C was between 1.8 and 3.5 mmol/l in patients with either very high cardiovascular risk or established atherosclerosis. In South Africa, there is a paucity of data on attainment of LDL-C goal in patients with very high cardiovascular risk who are on maximum tolerated statin with or without ezetimibe. The aim was to assess the percentage of very high cardiovascular risk South African patients with dyslipidaemia not reaching an LDL-C goal of less than 1.8 mmol/l, despite maximum tolerated statin with or without ezetimibe. This was a multi-centre, observational, cross-sectional study conducted at 15 private healthcare sector sites and one public sector site. Adults (> 18 years) with very high cardiovascular risk of familial hypercholesterolaemia receiving stable, maximum-tolerated statin therapy for at least four weeks prior to their latest lipid profile were enrolled into the study, and electronic case report forms were completed after written informed consent was provided. LDL-C goal attainment was modelled, first assuming an increase in the statin dose to the registered maximum, followed by the addition of ezetimibe or a PCSK9-inhibitor. In total, 507 patients were screened, of whom 492 were eligible for study participation. One patient was excluded from the analysis because of a missing LDL-C value. Most participants were male (male 329, 67%; female 162, 33%). Most patients were either obese (223, 46.0%) or overweight (176, 36.3%). Hypertension and diabetes mellitus were frequent co-morbidities and were found in 381 (77.6%) and 316 (64.4%) patients, respectively. Eighty (16.3%) patients reported current smoking. Only 68 (13.8%) patients were taking ezetimibe in addition to a statin. Reasons for not using ezetimibe included no requirement for ezetimibe in the opinion of the treating physician (229, 48.7%), cost (149, 31.7%), Physician's choice (39, 8.3%), or other (53, 11.3%). Only 161 (32.8%) of the patients attained their goal LDL-C level. In our modelling analysis, increasing the statin dose to the registered maximum and adding ezetimibe brought an additional 34.5% of patients to goal, while adding a PCSK9-inhibitor, irrespective of any other changes to lipid-lowering therapy brought over 90% of not-at-goal patients to goal. Most study participants were not at LDL-C goal despite maximum-tolerated statin, highlighting the need for treatment intensification in this high-risk population. Although intensifying treatment by adding a PCSK9-inhibitor brought more patients to goal, the initial addition of ezetimibe would be more reasonable, given the cost of PCSK9-inhibitors.

Low-density lipoprotein cholesterol goal attainment and treatment patterns in a cohort of >143,000 patients with atherosclerotic cardiovascular disease in Ontario, Canada

Abstract Background/Introduction Limited real-world data are available on attainment of low-density lipoprotein cholesterol (LDL-C) treatment goals in patients with atherosclerotic cardiovascular disease (ASCVD) in Canada. Purpose A retrospective observational study was conducted to describe types of ASCVD events/procedures, time between events and use of lipid lowering treatment (LLT) in patients who did not achieve LDL-C goal. Methods Patients in Ontario ≥65 years with a primary ASCVD event/procedure between 1 Apr 2005 and 31 Mar 2016, treated with an LLT and with index and follow up LDL-C values were identified from claims data at the Institute for Clinical Evaluative Sciences data repository. Patients were assessed over a 1-year follow up period for LDL-C goal attainment (<2.0 mmol/L or 50% reduction from index LDL-C) and analysed by LLT and by index event type. Results Overall, 28% of 143,302 patients ≥65 years on LLT failed to attain LDL-C goal at follow up (Figure). The proportion of patients failing to achieve LDL-C goal decreased from 35% to 22% over the 11-year study period. Mean time between index and follow up LDL-C (based on lowest score >2 weeks and up to 1 year after index LDL-C) was 203±97 days. When analysed by low-, moderate- or high-intensity statin, 57%, 30%, and 22% of patients failed to achieve LDL-C goal at follow up, respectively. Conclusions In this study, more than 1 in 4 patients with ASCVD in Ontario failed to achieve guideline recommended LDL-C goal despite treatment. In particular, ∼1 in 3 patients with cerebral and peripheral arterial disease were not at goal. An opportunity exists to better manage these high risk ASCVD patients with further statin intensification and additional LLTs This study made use of de-identified data from the ICES Data Repository, which is managed by the Institute for Clinical Evaluative Sciences with support from its funders and partners: Canada's Strategy for Patient-Oriented Research (SPOR), the Ontario SPOR Support Unit, the Canadian Institutes of Health Research and the Government of Ontario. The opinions, results and conclusions reported are those of the authors. No endorsement by ICES or any of its funders or partners is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed in the material are those of the author(s), and not necessarily those of CIHI Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Amgen Canada Inc.

Management of dyslipidaemia and hypertension in patients with rheumatoid arthritis in 19 countries

Abstract Background/Introduction The realisation that subjects with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease (CVD) has led to a growing interest in risk factor control in such people, but whether this has influenced the management of dyslipidaemia and hypertension (HT) is uncertain. Purpose To describe differences in lipid and blood pressure (BP) levels among patients with RA from five world regions. Furthermore, to evaluate attainment of guideline recommended targets for lipid lowering and antihypertensive treatment. Methods The SUrvey of CVD Risk Factors in patients with RA (SURF-RA) was conducted at 53 centres in 19 countries from 2014 to 2019. Data including demographics, RA disease characteristics, CVD comorbidity, risk factors and use of preventive treatment was collected. HT was defined as self-reported HT, and/or measured BP >140/90 mmHg, and/or use of anti HT medication (a-HT). The treatment goal of a-HT was BP <140/90 mmHg. The 10-year risk of a fatal CVD event was calculated by the European CVD risk calculator, the Systematic COronary Risk Evaluation (SCORE), and was thereafter multiplied with 1.5 as recommended by the European League Against Rheumatism. Patients were classified in a high or very high CVD risk group according to the 2012 European Society of Cardiology guidelines, with low density lipoprotein cholesterol (LDL-c) goal at <2.6 and <1.8 mmol/L, respectively. Results In total, 14503 RA patients were included. The mean age was 59.8±13.6 years, most of whom (74%) were female. Nearly 2/3 of the patients were hypertensive. Use of a-HT in the total population differed substantially between the cohorts with limited use in West Europe and Latin America (17.4% and 24.8%), in contrast to North America and East Europe (46.8% and 57.0%). On average, half of those with HT were at the recommended BP goal. The lowest BP goal attainment was seen in Asia, West and East Europe (40.8–43.1%), and the highest in North America (63.5%). Overall 51.5% had an indication for lipid lowering therapy (LLT), and of these only 43.5% were taking LLT. Only 34.0% of patients with an indication for LLT were at recommended LDL-c goals. The proportion of RA patients on target for LDL-c varied greatly between regions, from 23.1% in East Europe to 51.0% in North America. The LDL-c goal attainment was higher in RA patients at high risk (45.1%) compared to those at very high risk of CVD (18.0%). Conclusion(s) This large international survey on RA patients revealed considerable geographical differences in CVD preventive treatment. Only one half of subjects were at blood pressure goals, and achievement of lipid goals was even poorer at one third of those eligible for treatment, which is lower than what is reported for subjects with coronary heart disease. We conclude that there is a substantial need for improvement in CVD preventive measures in RA patients. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted research collaboration with Lilly

Differences in lipid treatment patterns in women versus men in a large cohort of patients with atherosclerotic cardiovascular disease in Ontario, Canada

Abstract Background/Introduction The prevalence of ischaemic heart disease is lower in women vs men in Canada. Studies have shown that women are more likely to be underdiagnosed and less likely to receive guideline-recommended treatments than men. Women receiving lipid-lowering therapies (LLTs) are also less likely to attain treatment goals vs men. Purpose We analysed use of LLTs and attainment of low-density lipoprotein cholesterol (LDL-C) treatment goals in a recent longitudinal cohort of patients with ASCVD with public drug coverage in Ontario to describe differences observed between female and male patients. Methods Patients ≥65 years with a primary ASCVD event/procedure between 1 Apr 2005 and 31 Mar 2016, treated with an LLT and with index and follow up LDL-C values were identified from claims data at the Institute for Clinical Evaluative Sciences data repository. Patients were assessed over a 1 year follow up period for LDL-C goal attainment (<2.0 mmol/L or 50% reduction from index LDL-C as per Canadian Cardiovascular Society Guidelines) and analysed by LLT category. Results 143,302 patients with ASCVD ≥65 years on LLTs were identified of which 41% were female. A higher proportion of female vs male patients were prescribed low (3% vs 2%) and medium intensity statins (51% vs 44%) compared with high intensity statins (43% vs 52%). A higher proportion of women failed to attain LDL-C goal compared to men (33% vs 24%) (Figure). When analysed by low, moderate or high intensity statin, 65%, 35%, and 27% of female patients and 49%, 25% and 19% of male patients failed to attain LDL-C goal at follow up. Conclusions In this retrospective study, women with a diagnosis of ASCVD were more frequently treated with low/moderate intensity statins whereas men were more frequently treated with high intensity statins. Approximately 2 of 3 women and 3 of 4 men receiving statin treatment attained LDL-C goal during the 1-year follow up period. Overall, there appear to be treatment differences between female and male patients with ASCVD, with males receiving higher intensity statin therapy and attaining LDL-C goal more frequently. Further research is needed to determine why these discrepancies exist. This study made use of de-identified data from the ICES Data Repository, which is managed by the Institute for Clinical Evaluative Sciences with support from its funders and partners: Canada's Strategy for Patient-Oriented Research (SPOR), the Ontario SPOR Support Unit, the Canadian Institutes of Health Research and the Government of Ontario. The opinions, results and conclusions reported are those of the authors. No endorsement by ICES or any of its funders or partners is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed in the material are those of the author(s), and not necessarily those of CIHI. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Amgen Canada Inc

DA VINCI study: Change in approach to cholesterol management will be needed to reduce the implementation gap between guidelines and clinical practice in Europe

DA VINCI study: Change in approach to cholesterol management will be needed to reduce the implementation gap between guidelines and clinical practice in Europe

PATTERNS OF LOW-DENSITY LIPOPROTEIN CHOLESTOEROL MANAGEMENT AND GOAL ATTAINMENT IN PATIENTS WITH ATHEROSCLEROTIC CARDIOVASCULAR DISEASE 65 YEARS AND OLDER FROM ALBERTA AND ONTARIO

Despite advances in lipid-lowering therapies (LLT) and public health interventions, ischemic heart disease remains a leading cause of hospitalization and mortality in Canada. Differences in disease management between provinces may lead to variations in treatment outcomes for patients with similar diagnoses. The availability of large data sets from population-based health databases has enabled analysis of lipid management and goal attainment in patients with public coverage. The goal of this study was to describe treatment patterns and low-density lipoprotein cholesterol (LDL-C) goal attainment in patients with atherosclerotic cardiovascular disease (ASCVD) from Alberta (AB) and Ontario (ON).

Role of Lipid-Lowering Therapy in Low-Density Lipoprotein Cholesterol Goal Attainment: Focus on Patients With Acute Coronary Syndrome.

:Dyslipidemia is a major risk factor for cardiovascular (CV) disease, which is the leading cause of death globally. Acute coronary syndrome (ACS) is a common cause of death, accounting for nearly half of the global burden of CV mortality. Epidemiologic studies have identified low-density lipoprotein cholesterol (LDL-C) as an independent CV risk factor, and this is now the primary target for initiating and adjusting lipid-lowering therapies in most current guidelines. Evidence from pivotal studies supports the use of high-intensity statin therapy and a lower level for optimal LDL-C in secondary prevention of atherosclerotic CV disease, especially in patients with ACS undergoing percutaneous coronary intervention. However, current research has identified a gap between the target LDL-C goal attainment and target LDL-C levels recommended by the guidelines. Statins have proven benefits in the management of CV disease and are the cornerstone of lipid-lowering management in patients with ACS. Recent randomized controlled trials have also demonstrated the benefits of cholesterol absorption inhibitors and proprotein convertase subtilisin/kexin type 9 inhibitors. This review summarizes the current evidence for LDL-lowering therapy in patients with ACS, with an emphasis on the importance of LDL-C goal attainment, rapid LDL-C lowering, and duration of LDL-C–lowering therapy.

Lipid-lowering therapy and low-density lipoprotein cholesterol goal attainment after acute coronary syndrome: a Danish population-based cohort study

BackgroundPatients with acute coronary syndrome (ACS) are at high risk of recurrent cardiovascular (CV) event. The European guidelines recommend low-density lipoprotein cholesterol (LDL-C) levels < 1.8 mmol/L and early initiation of intensive lipid-lowering therapy (LLT) to reduce CV risk.In order to reduce the risk of further cardiac events, the study aimed to evaluate LDL-C goal attainment and LLT intensity in an incident ACS population.MethodsA cohort study of patients with residency at Funen in Denmark at a first-ever ACS event registered within the period 2010–2015. Information on LLT use and LDL-C levels was extracted from national population registers and a Laboratory database at Odense University Hospital. Treatments and lipid patterns were evaluated during index hospitalization, at 6-month and 12-month follow-up.ResultsAmong 3040 patients with an LDL-C measurement during index hospitalization, 40.7 and 39.0% attained the recommended LDL-C target value (< 1.8 mmol/L) within 6- and 12-month follow-up, respectively. During 6- and 12-month follow-up, a total of 89.2% (20.2%) and 88.4% (29.7%) used LLT (intensive LLT). Of the intensive LLT users, 43.4 and 47.7% reached the LDL-C target value at 6- and 12-month follow-up. The frequency of lipid monitoring was low: 69.5, 77.7 and 53.6% in patients with a first-ever ACS during index hospitalization, 6- and 12-month follow-up, respectively.ConclusionUsing national health registers and laboratory data, a considerably gap was observed between treatment guidelines and clinical practice in the management of dyslipidemia leaving very high-risk patients without adequate lipid management strategy. Therefore, improved lipid management strategies aimed at reaching treatment targets are warranted.

Clinical and Genetic Characteristics of Familial Hypercholesterolemia at Sultan Qaboos University Hospital in Oman.

ObjectivesWe sought to describe the clinical and genetic characteristics of patients with familial hypercholesterolemia (FH) that presented to the lipid clinic at Sultan Qaboos University Hospital, Muscat, Oman.MethodsPatients who presented with high low-density lipoprotein cholesterol (LDL-C) levels (> 189.0 mg/dL or 4.9 mmol/L) were recruited to the study. FH was diagnosed according to the Dutch Lipid Clinic Network criteria. Analyses were performed using univariate statistics.ResultsThe study enrolled 450 patients with a mean age of 48.0±12.0 years, 56.0% (n = 252) were males and 11.3% (n = 51) were smokers. At admission, the proportion of ‘probable/definite’, ‘possible’, and ‘unlikely’ FH were 27.6% (n = 124), 70.0% (n = 315), and 2.4% (n = 11), respectively. Overall, 26.0% (n = 117) of patients had hypertension, 22.4% (n = 101) had a history of coronary artery disease, and 17.3% (n = 78) had diabetes mellitus. Those with ‘probable/definite’ FH were more likely to be prescribed high-intensity statin therapy (75.8% vs. 54.5%; p < 0.001) and statin ezetimibe combination (50.8% vs. 27.3%; p < 0.001) when compared to the ‘unlikely’ FH cohort. Additionally, those with very high atherosclerotic vascular disease (ASCVD) risk were also associated with high-intensity statin therapy (54.7% vs. 42.7%; p = 0.006) and statin ezetimibe combination (26.4% vs. 17.2%; p = 0.023). Patients with ‘probable/definite’ FH were less likely to achieve their LDL-C goal attainment compared to those with ‘unlikely’ FH (13.0% vs. 57.1%; p < 0.001). Furthermore, those with very high ASCVD risk were less likely to achieve their LDL-C goals compared to the high ASCVD risk cohort (9.6% vs. 32.0%; p < 0.001).ConclusionsFH patients are underdiagnosed, undertreated, and less likely to attain their LDL-C goals in Oman.

Pharmacists' Utilization of Non-HDL-C Levels in Managing Patients With Lipid Disorders.

Background: Since 2013 there have been cholesterol guideline changes impacting pharmacists' clinical practice in managing lipid disorders. For more than a decade, cholesterol management was based on the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol Adult Treatment Panel III guideline, highlighting non-high-density lipoprotein cholesterol (non-HDL-C) as a secondary target in persons with triglycerides ≥200 mg/dL, after low-density lipoprotein cholesterol goal attainment. The 2013 American College of Cardiology and American Heart Association (ACC/AHA) guideline differed from the traditional management of dyslipidemia, in part no longer emphasizing the utilization of non-HDL-C levels. Objective: To measure pharmacists' attitudes and behavior regarding utilization of non-HDL-C level calculation before and after the inception of the 2013 ACC/AHA cholesterol guideline. Methods: Pharmacists in the American College of Clinical Pharmacy ambulatory care listserv participated in an electronic survey in November 2013, before the inception of the 2013 ACC/AHA guideline, and again in October 2018. Results: We collected 391 usable responses from participants; 212 responses in 2013 and 179 responses in 2018. The before and after comparison revealed that respondents in 2013 reported significantly higher frequency of calculating non-HDL-C levels (mean = 1.88, SD = 0.80) than respondents in 2018 (mean = 1.66, SD = 0.79) (P ≤ .001). Also, the frequency that non-HDL-C level calculation alters decisions regarding course of treatment was lower in the 2018 (mean = 3.50, SD = 1.06) in comparison with 2013 (mean = 3.77, SD = 0.88) (P ≤ .05). Furthermore, pharmacists were more favorable toward the inclusion of non-HDL-C level calculation in 2018 (mean = 3.77, SD = 1.05) than in 2013 (mean = 3.13, SD = 1.33) (P ≤ .001). Conclusion and Relevance: Clinical pharmacists' utilization of non-HDL-C levels in the clinical management of patients with hypercholesterolemia has decreased, highlighting the need for further education on the importance of evaluating non-HDL-C levels in the very high-risk atherosclerotic cardiovascular disease population.

Low-density lipoprotein cholesterol goal attainment rates in high-risk patients with cardiovascular diseases and diabetes mellitus in Korea: a retrospective cohort study

BackgroundReal-world evidence of low-density lipoprotein cholesterol (LDL-C) goal attainment rates for Asian patients is deficient. The objective of this study was to assess the status of dyslipidemia management, especially in high-risk patients with cardiovascular disease (CVD) including stroke and acute coronary syndrome (ACS).MethodsThis was a retrospective cohort study of 514,866 subjects from the National Health Insurance Service-National Health Screening Cohort database in Korea. Participants were followed up from 2002 to 2015. Subjects with a high-risk of CVD prior to LDL-C measurement and subjects who were newly-diagnosed for high-risk of CVD following LDL-C measurement were defined as known high-risk patients (n = 224,837) and newly defined high-risk patients (n = 127,559), respectively. Data were analyzed by disease status: stroke, ACS, coronary heart disease (CHD), peripheral artery disease (PAD), diabetes mellitus (DM) and atherosclerotic artery disease (AAD).ResultsOverall, less than 50% of patients in each disease category achieved LDL-C goals (LDL-C < 70 mg/dL in patients with stroke, ACS, CHD and PAD; and LDL-C < 100 mg/dL in patients with DM and AAD). Statin use was observed in relatively low proportions of subjects (21.5% [known high-risk], 34.4% [newly defined high-risk]). LDL-C goal attainment from 2009 to 2015 steadily increased but the goal-achiever proportion of newly defined high-risk patients with ACS remained reasonably constant (38.7% in 2009; 38.1% in 2015).ConclusionsLDL-C goal attainment rates in high-risk patients with CVD and DM in Korea demonstrate unmet medical needs. Proactive management is necessary to bridge the gap between the recommendations of clinical guidelines and actual clinical practice.

PCSK9 Monoclonal Antibodies: An Overview.

PCSK9 monoclonal antibodies are novel lipid-lowering therapy that have been extensively studied in patients with hypercholesterolemia either as monotherapy or as an add-on to other LLTs. PCSK9 monoclonal antibodies have significantly reduced the low-density lipoprotein cholesterol (LDL-C) plasma level resulting in a better LDL-C goal attainment. The commercially available PCSK9 monoclonal antibodies, alirocumab and evolocumab, have demonstrated reductions in major adverse cardiovascular events such as myocardial infarction, stroke, unstable angina, and the need for coronary revascularization but not mortality. PCSK9 monoclonal antibodies have demonstrated a favorable safety profile. The most reported side effects are mild injection site with no causal relationship proven between the inhibition of PCSK9 and neurocognitive or glycemic adverse events. In this overview, the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of primary and familial hypercholesterolemia will be discussed.

Impact of lipoprotein(a) on long-term outcomes after percutaneous coronary intervention in patients with reduced low-density lipoprotein cholesterol.

The purpose of this study is to investigate the effect of lipoprotein(a) level on long-range prognosis after Percutaneous Coronary Intervention (PCI) in patients with low-density lipoprotein cholesterol (LDL-C) goal attainment. In this retrospective study, 350 patients in Coronary artery disease (CAD) with LDL-C less than 1.8 mmol/L were enrolled in the Guangdong Institute of Cardiovascular Diseases from January 2011 to December 2013. Follow-up was 1 year after PCI. According to the median value of the study population based on Lp(a), the patients were assigned to the high-level group and low-level group. The clinical data of the 2 groups were collected. We compared the baseline data between the 2 groups and the incidence rate of major cardiovascular events. After statistical analysis, the gender composition, hypertension, diabetes, and age of the patients between the 2 groups were similar, and the distinction was not significant. There was no significant distinction in cardio-vascular death, ischemic stroke, and recurrent myocardial infarction between the 2 groups, but the incidence of revascularization was higher in the high-level group (P < 0.05). High Lp(a) level predicts an increased incidence of revascularization of patients in CAD with LDL-C less than 1.8 mmol/L after PCI.

Adherence to Statin Therapy and Attainment of LDL Cholesterol Goal Among Patients with Type 2 Diabetes and Dyslipidemia.

BackgroundStatins are widely utilized antidyslipidemics with a proven track record of safety and efficacy. However, the efficacy of these therapeutic agents hinges on patients’ adherence to their prescribed statins.ObjectiveThe primary objectives of this study were to examine the relationship between adherence to prescribed statins and its impact on the low-density lipoprotein (LDL) level, and to explore the factors that influence patient adherence to statins among patients with diabetes and dyslipidemia.MethodsThis was a retrospective, cross-sectional study using the electronic health records data of adults (≥18 years) with type 2 diabetes and dyslipidemia visiting outpatient clinics at a university-affiliated tertiary care center. Adherence to statin therapy was estimated using the proportion of days covered (PDC). Patients with diabetes were considered adherent to statins if they had a PDC of ≥80%. Treatment success was considered if the LDL level of < 2.6 mmol/L.ResultsOut of 10,226 of patients with diabetes, 1532 met the inclusion criteria and were included in the study. Seventy-nine percent of the patients with diabetes were on atorvastatin and 21% were on simvastatin. The vast majority of the patients with diabetes (77%) were considered adherent and about 42% achieved LDL-cholesterol goal < 2.6 mmol/L. No association between adherence to statin therapy and LDL goal attainment was observed. Women had lower odds of being adherent to statin therapy (AOR=0.66, 95% CI: 0.49–0.87) compared to men. Further, young adults (18–44 years) had lower odds of being adherent to statin therapy (AOR=0.58, 95% CI: 0.32–0.97) compared to older adults (age>65 years).ConclusionThe findings of this study highlight the need to examine the impact of adherence to statins on healthcare services utilization due to different complications of uncontrolled dyslipidemia.

Baseline Predictors of Low-Density Lipoprotein Cholesterol and Systolic Blood Pressure Goal Attainment After 1 Year in the ISCHEMIA Trial.

Risk factor control is the cornerstone of managing stable ischemic heart disease but is often not achieved. Predictors of risk factor control in a randomized clinical trial have not been described. The ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) randomized individuals with at least moderate inducible ischemia and obstructive coronary artery disease to an initial invasive or conservative strategy in addition to optimal medical therapy. The primary aim of this analysis was to determine predictors of meeting trial goals for LDL-C (low-density lipoprotein cholesterol, goal <70 mg/dL) or systolic blood pressure (SBP, goal <140 mm Hg) at 1 year post-randomization. We included all randomized participants in the ISCHEMIA trial with baseline and 1-year LDL-C and SBP values by January 28, 2019. Among the 3984 ISCHEMIA participants (78% of 5179 randomized) with available data, 35% were at goal for LDL-C, and 65% were at goal for SBP at baseline. At 1 year, the percent at goal increased to 52% for LDL-C and 75% for SBP. Adjusted odds of 1-year LDL-C goal attainment were greater with older age (odds ratio [OR], 1.11 [95% CI, 1.03-1.20] per 10 years), lower baseline LDL-C (OR, 1.19 [95% CI, 1.17-1.22] per 10 mg/dL), high-intensity statin use (OR, 1.30 [95% CI, 1.12-1.51]), nonwhite race (OR, 1.32 [95% CI, 1.07-1.63]), and North American enrollment compared with other regions (OR, 1.32 [95% CI, 1.06-1.66]). Women were less likely than men to achieve 1-year LDL-C goal (OR, 0.68 [95% CI, 0.58-0.80]). Adjusted odds of 1-year SBP goal attainment were greater with lower baseline SBP (OR, 1.27 [95% CI, 1.22-1.33] per 10 mm Hg) and with North American enrollment (OR, 1.35 [95% CI, 1.04-1.76]). In ISCHEMIA, older age, male sex, high-intensity statin use, lower baseline LDL-C, and North American location predicted 1-year LDL-C goal attainment, whereas lower baseline SBP and North American location predicted 1-year SBP goal attainment. Future studies should examine the effects of sex disparities, international practice patterns, and provider behavior on risk factor control.

P944Comparing therapeutic gap in lipid-lowering management between high-risk cardiovascular patients after acute coronary syndrome, stroke and critical limb ischemia

Abstract Background Guidelines recommend intensive low-density-lipoprotein cholesterol (LDL-C) lowering in high cardiovascular (CV) risk patients with acute coronary syndrome (ACS), stroke and critical limb ischemia (CLI). Purpose We evaluated LDL-C goal attainment and lipid-lowering treatment (LLT) in a Chinese population with ACS, stroke and CLI patients. Methods We retrospectively evaluated consecutive high CV risk patients discharged between 2013 and 2017 from 3 hospitals in Hong Kong. Lipid profile and LLT were compared among 3 patient groups: ACS, Stroke and CLI. Results Of 10,168 high-CV risk patients (mean age 70.6±13.7 years; 62.4% male), 64.0% were ACS, 33.6% stroke and 2.5% CLI. Between baseline and 12-month, mean LDL-C reduced from 2.7±1.1 to 2.0±0.8 mmol/L in ACS patients, 2.7±1.0 to 2.0±0.7 mmol/L in stroke patients and 2.5±1.0 to 2.2±0.9 mmol/L in CLI patients (p&lt;0.01). Proportion of CLI patients (29.9%) who achieved target LDL-C &lt;1.8mmol/L at month 12 was significantly lower than stroke (45.6%) and ACS (48.2%) patients (p&lt;0.01). The mean residual distance to target LDL-C was greatest in CLI (0.8±0.8 mmol/L) compared to stroke (0.6±0.6 mmol/L) and ACS (0.7±0.7 mmol/L) patients (p&lt;0.01). Use of statin therapy on discharge was highest in ACS (88.4%) compared to stroke (78.3%) and CLI (52.6%) patients (p&lt;0.01). But use of high-potency statin (rosuvastatin ≥20mg, atorvastatin ≥40mg or simvastatin ≥80mg) on discharge was very low in stroke (3.0%) and CLI (2.0%) compared to ACS (21.4%, p&lt;0.01) patients. At 12 months 28.8% ACS, 34.3% stroke and 51.4% CLI patients were on no LLT (p&lt;0.01) and the use of high-potency statin did not change significantly (3.0% in stroke, p=0.99; and 1.2% in CLI, p=0.48). Despite the poor achievement in LDL-C target in CLI patients, the proportion of CLI patients switching to high-potency statin (0.8%) was significantly lower than stroke (1.3%) and ACS (5.2%) patients (p&lt;0.01). Conclusion This study demonstrated significant therapeutic gaps in lipid-lowering management in high CV risk patients. In particular, CLI patients were less aggressively treated with LLT and hence larger proportion of patient not achieving LDL-C target compared to ACS and stroke patients.

PCSK9 inhibition in patients with and without prior myocardial infarction or ischemic stroke: A pooled analysis of nine randomized-controlled studies of alirocumab

Patients with prior cardiovascular events are at very high risk of recurrent events and may benefit from low-density lipoprotein cholesterol (LDL-C) lowering beyond that achieved with maximally tolerated statins. To assess potential differences between the efficacy and safety of the proprotein convertase subtilisin/kexin type 9 inhibitor, alirocumab, in patients with vs without prior myocardial infarction (MI)/ischemic stroke. Data (n=4880) were pooled from nine ODYSSEY phase 3 trials of alirocumab 75/150mg or 150mg every 2weeks, mostly on background statins±other lipid-lowering therapies. Analyses were performed according to statin status, alirocumab dose, and control (placebo or ezetimibe). Baseline LDL-C, non-high-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and apolipoprotein B levels were lower and lipoprotein(a) higher in patients with than without prior MI/ischemic stroke. LDL-C levels were reduced from baseline to week 24 in patients with (51.1%-62.9%) and without (43.6%-58.3%) prior MI/ischemic stroke, with no significant interaction between prior MI/ischemic stroke status and LDL-C-lowering efficacy of alirocumab vs controls. Alirocumab significantly reduced other lipid/lipoproteins (including lipoprotein[a]) similarly in patients with/without MI/ischemic stroke. Week 24 LDL-C goal attainment rates for subgroups with/without prior MI/ischemic stroke on background statins were 74.1%-84.8% and 63.7%-74.7%, respectively. The safety profile of alirocumab was generally similar regardless of prior MI/ischemic stroke status. Alirocumab significantly reduced LDL-C and other atherogenic lipids/lipoproteins in patients with prior MI/ischemic stroke, and the majority of this very high cardiovascular risk population achieved LDL-C goals; efficacy and safety results were similar in patients without prior MI/ischemic stroke.

Achievement of low density lipoprotein (LDL) cholesterol targets in primary and secondary prevention: Analysis of a large real practice database in Italy

Background and aimsTarget and intensity of low-density lipoprotein cholesterol (LDL-C) lowering therapy should be tailored according to the individual global cardiovascular (CV) risk. We aimed at retrospectively evaluating real-life LDL-C goal attainment and predictive factors for predefined LDL-C therapeutic goals both in primary and secondary prevention. MethodsWe collected data from a large cohort of outpatients aged 40–65 years, followed by general practitioners, cardiologists and diabetologists in Italy. All data were centrally analysed for global CV risk assessment and rates of control of major CV risk factors, including LDL-C. Study population was stratified according to the presence or absence of previous CV events, including coronary artery disease (CAD), peripheral artery disease (PAD) or stroke/TIA. CV risk profile characterization was based on the European SCORE. Predefined therapeutic goals were set according to the European guidelines on dyslipidaemia: LDL-C levels <70 mg/dl for very high CV risk patients in primary prevention and for those in secondary prevention; <100 mg/dl LDL-C levels for high CV risk patients in primary prevention. Logistic regression analysis with clinical covariates was used to identify predictive factors for achieving these goals; lipid lowering therapy entered in the analysis as continuous (model 1) or categorical variable (model 2). ResultsWe included 4,142 outpatients (43,7% female, age 58.0 ± 5.2 years, BMI 28.5 ± 5.0 kg/m2) among whom 2,964 (71.6%) in primary and 1,178 (28.4%) in secondary prevention. In primary prevention, none of the patients at very high CV risk had LDL-C <70 mg/dl and 8.9% of patients at high CV risk showed LDL-C <100 mg/dl. Only 5.8% of patients in secondary prevention had LDL-C levels <70 mg/dl, specifically 6.5% of patients with CAD, 2.6% of patients with PAD and 4.7% of patients with CVD (p < 0.001). Beyond diabetes and lipid lowering therapy, high risk SCORE estimation resulted a strong and independent predictor for the lack of achieving all predefined therapeutic targets, including LDL-C <100 mg/dl [OR: 0.806 (0.751–0.865)); p < 0.001], and LDL-C <70 mg/dl [OR: 0.712 (0-576-0.880); p = 0.002], in primary prevention. ConclusionsDespite high or very high SCORE risk and use of lipid lowering therapies, we observed poor achievement of LDL-C targets in this large cohort of outpatients followed in a setting of real practice in Italy.

Abstract P128: Statin Prescribing, Switching, and Low-density Lipoprotein Cholesterol Goal Attainment Across Racial/Ethnic Groups With Atherosclerotic Cardiovascular Disease

Introduction: Statins are effective in reducing low-density lipoprotein cholesterol (LDL-C) and preventing cardiovascular (CV) events in patients with a history of atherosclerotic CV disease (ASCVD), irrespective of race/ethnicity (R/E). Differences in statin utilization, including prescribing and switching, in relationship to LDL-C goal attainment by R/E has not been well studied. Hypothesis: We expect differences in attaining LDL-C &lt;70 mg/dL (goal) by R/E and that differences in goal attainment are associated with patterns in statin utilization. Methods: We selected patients ≥40 years of age in the Sutter Health electronic health records (EHR) with ASCVD based on International Classification of Diseases 9/10 diagnoses (2006-2016), with a new statin prescription (defined as no evidence of a statin in the year prior) and LDL-C values. Patient demographics and clinical characteristics at statin initiation (index) were extracted. We examined differences in LDL-C goal attainment after 1-year follow-up (mean ~16 months) from index date by R/E and initial statin intensity (low/moderate [L/MIS] vs. high [HIS]) using logistic regression. Differences in rates of statin intensity increases or decreases were estimated during follow-up by R/E using negative binominal regression. Incident rate ratios (IRR) were calculated. All models were adjusted for demographic and clinical characteristics. Results: From a database of 3.1 million patients, 241,912 had ASCVD and 11,499 met inclusion criteria (66% non-Hispanic white [NHW], 9% Asian, 3% black, 8% Hispanic, 14% other/unknown). About 18% of patients initiated treatment on HIS and 82% on L/MIS statin, with no significant differences by R/E. LDL-C goal was attained by 33% of patients, overall, and 42% and 30% on HIS and L/MIS, respectively. Of those on HIS, Asians were more likely to have statin intensity decreases than NHWs (IRR:1.89) but were also more likely to attain LDL-C goal than NHWs (58% vs. 39%). Among those on L/MIS, intensity increases were not different by R/E, yet Asians were still more likely to attain goal than NHWs (38% vs. 30%), whereas black patients were less likely (24%). Hispanics on L/MIS were more likely to have intensity decreases (IRR: 1.44), yet similarly met goal (33%) as compared with NHWs. When included in statistical models, statin intensity increases and decreases were independent predictors of higher and lower odds of goal attainment, respectively, but did not alter relationships between R/E and goal attainment. Conclusions: In this ASCVD cohort receiving statins, LDL-C goal attainment differed by R/E, and was highest among Asians and lowest among black patients, however this difference in goal attainment does not appear to be related to differences in statin utilization. Other modifiable factors, such as adherence or access to care, need to be investigated further to improve goal attainment across all R/E groups.

Blood pressure and low-density lipoprotein cholesterol control status in Chinese hypertensive dyslipidemia patients during lipid-lowering therapy

ᅟThe present study comprised 17,096 Chinese hypertensive dyslipidemia patients who received lipid-lowering treatment for > 3 months in order to investigate blood pressure (BP) as well as low-density lipoprotein cholesterol (LDL-C) goal attainment rates in Chinese hypertensive dyslipidemia patients on antidyslipidemia drugs. The factors that interfered with BP, or BP and LDL-C goal attainment rates and antihypertensive treatment patterns, were analyzed. In total, 89.9% of the 17,096 hypertensive dyslipidemia patients received antihypertensive medications mainly consisting of a calcium channel blocker (CCB) (48.7%), an angiotensin receptor antagonist (ARB) (25.4%) and an angiotensin-converting enzyme inhibitor (ACEI) (15.1%). In cardiology departments, usage rates of β-blockers (19.2%) were unusually high compared to other departments (4.0–8.3%), whereas thiazide diuretics were prescribed at the lowest rate (0.3% vs 1.2–3.6%). The overall goal attainment rates for combined BP and LDL-C as well as BP or LDL-C targets were 22.9, 31.9 and 60.1%, respectively. The lowest BP, LDL-C and BP combined with LDL-C goal attainment rates were achieved in endocrine departments (19.9, 48.9 and 12.4%, respectively). Combination therapies showed no benefit particularly for BP goal achievement. A multivariate logistic regression analysis showed that age < 65 years, alcohol consumption, diabetes, coronary heart disease (CHD), cerebrovascular disease (CVD), chronic kidney disease (CKD), body mass index (BMI) ≥ 28 kg/m2 and not achieving total cholesterol goals were independent predictors for achieving BP, LDL-C or combined BP and LDL-C goals. In summary, the BP and LDL-C goal achievement rates in Chinese dyslipidemia outpatients with hypertension were low, especially in endocrine departments. Combination therapies were not associated with improvement of the goal achievement rates.Trial registrationClinical trial registration number NCT01732952