Low-density Lipoprotein Cholesterol Goal Attainment Research Articles

Clinical determinants and treatment gaps in familial hypercholesterolemia: Data from a multi-ethnic regional health service.

Background Familial hypercholesterolemia is characterized by markedly increased low-density lipoprotein cholesterol and risk for premature atherosclerotic cardiovascular disease. Models of care vary and reflect differing health policies and resources. The availability of electronic databases may enable better identification and assessment of familial hypercholesterolemia in the community. Methods A regional healthcare database was utilized to identify patients with a high probability of familial hypercholesterolemia, clinically defined by age-dependent-peak low-density lipoprotein cholesterol cutoffs and exclusion of secondary causes of severe hypercholesterolemia. Clinical characteristics, low-density lipoprotein cholesterol goal attainment, and treatment gaps were investigated. Results Probable familial hypercholesterolemia was diagnosed in 1932 of 685,314 individuals (1:355; median age 47 years). Atherosclerotic cardiovascular disease was present in 16.3% of adults (38% in males aged 50-74 years). Median peak low-density lipoprotein cholesterol was 264 mg/dl (interquartile range 252-288). Statins and/or ezetimibe were prescribed to 83% of patients and high-intensity statins to 53%, whereas prescriptions were filled in 57% and 40% cases respectively over the last six months, p < 0.001. Treatment gaps were wider among ethnic minorities, younger individuals, and those without atherosclerotic cardiovascular disease. Low-density lipoprotein cholesterol < 100 mg/dl was attained in 10.1% overall and 28.7% of those with atherosclerotic cardiovascular disease. Predictors of low-density lipoprotein cholesterol goal attainment included recent issue of high-intensity statins, presence of atherosclerotic cardiovascular disease, diabetes, older age and lack of smoking. Conclusions The population with high probability for familial hypercholesterolemia was characterized by low attainment of low-density lipoprotein cholesterol treatment goals despite high prescription rates of lipid-lowering medications. Low utilization of intensified therapies, non-adherence, and ethnic disparities were contributing factors. These findings emphasize the need to improve awareness and quality of care of familial hypercholesterolemia in the community.

The efficacy and safety of co-administration of fimasartan and rosuvastatin to patients with hypertension and dyslipidemia

BackgroundHypertension and dyslipidemia are major risk factors of cardiovascular disease (CVD) events. The objective of this study was to evaluate the efficacy and safety of the co-administration of fimasartan and rosuvastatin in patients with hypertension and hypercholesterolemia.MethodsWe conducted a randomized double-blind and parallel-group trial. Patients who met eligible criteria after 4 weeks of therapeutic life change were randomly assigned to the following groups.1) co-administration of fimasartan 120 mg/rosuvastatin 20 mg (FMS/RSV), 2) fimasartan 120 mg (FMS) alone 3) rosuvastatin 20 mg (RSV) alone. Drugs were administered once daily for 8 weeks.ResultsOf 140 randomized patients, 135 for whom efficacy data were available were analyzed. After 8 weeks of treatment, the FMS/RSV treatment group showed greater reductions in sitting systolic (siSBP) and diastolic (siDBP) blood pressures than those in the group receiving RSV alone (both p < 0.001). Reductions in siSBP and siDBP were not significantly different between the FMS/RSV and FMS alone groups (p = 0.500 and p = 0.734, respectively). After 8 weeks of treatment, FMS/RSV treatment showed greater efficacy in percentage reduction of low-density lipoprotein cholesterol (LDL-C) level from baseline than that shown by FMS alone treatment (p < 0.001). The response rates of siSBP with FMS/RSV, FMS alone, and RSV alone treatments were 65.22, 55.56, and 34.09%, respectively (FMS/RSV vs. RSV, p = 0.006). The LDL-C goal attainment rates with FMS/RSV, RSV alone, and FMS alone treatments were 80.43%, 81.82%, and 15.56%, respectively (FMS/RSV vs. FMS, p < 0.001). Incidence of adverse drug reactions with FMS/RSV treatment was 8.33%, which was similar to those associated with FMS and RSV alone treatments.ConclusionThis study demonstrated that the co-administration of fimasartan and rosuvastatin to patients with both hypertension and hypercholesterolemia was efficacious and safe.Trial registrationClinicalTrials.gov Identifier: NCT02166814. 16 June 2014

Attainment of LDL Cholesterol Treatment Goals in Children and Adolescents With Familial Hypercholesterolemia. The SAFEHEART Follow-up Registry

Introduction and objectivesLittle is known about the characteristics of persons with familial hypercholesterolemia (FH) younger than 18 years, the lipid-lowering therapy used in these patients, and the lipid goals reached in real life. Our aim was to evaluate the achievement of low-density lipoprotein cholesterol (LDL-C) treatment goals in FH patients younger than 18 years enrolled in a large national registry. MethodsWe analyzed patients younger than 18 years enrolled in a large ongoing registry of molecularly-defined patients with FH in Spain. The attainment of guideline-recommended plasma LDL-C goals at entry and follow-up was analyzed in relation to the use of lipid-lowering therapy. ResultsWe enrolled 392 individuals younger than 18 years. Of these, 217 were molecularly-diagnosed FH patients and had a complete follow-up. The median follow-up time was 4.69 years (interquartile range, 2.48-6.38 years), 68.2% of FH patients were on statins, and 41.5% patients had LDL-C < 130mg/dL. Statin use was the only predictor of LDL-C goal attainment. ConclusionsThis study shows that a high proportion of FH patients younger than 18 years have high LDL-C levels and fail to achieve recommended LDL-C targets. Statin use was the only independent predictor of LDL-C goal achievement. No safety concerns were detected during follow-up. These results indicate that many FH patients are not adequately controlled and that there is still room for treatment improvement.

Clinical and economic consequences of statin intolerance in the United States: Results from an integrated health system

Although statins are considered safe and effective, they have been associated with statin intolerance (SI) in clinical and observational studies. The objective of this study was to describe the clinical and economic consequences of SI through comparison of an SI cohort of patients with matched controls. This study used data extracted from an integrated health system's electronic health records from 2008 to 2014. Adults with SI were matched to controls using a propensity score. Patients were hierarchically classified into 6 mutually exclusive cardiovascular (CV)-risk categories: recent acute coronary syndrome (ACS; ≤12months preindex), coronary heart disease, ischemic stroke, peripheral artery disease, diabetes, or primary prevention. The study endpoints, low-density lipoprotein cholesterol (LDL-C) goal attainment, medical costs, and time to first CV event were compared using conditional logistic regression, generalized linear, and Cox proportional hazards models, respectively. Patients with SI (n=5190) were matched with controls (n=15,570). Patients with SI incurred higher medical costs and were less likely to reach LDL-C goals than controls. Patients with SI were at higher risk for revascularization procedures in all CV risk categories except ACS, and those in the diabetes risk category were at higher risk for any CV event. There was a lower risk of all-cause death among patients with SI. Patients with SI were less likely to reach LDL-C goals, incurred higher health care costs, and experienced a higher risk for nonfatal CV events than patients without SI. Alternative management strategies are needed to better treat high CV risk patients.

Identification and characterization of severe familial hypercholesterolemia in patients presenting for cardiac catheterization

Patients with severe familial hypercholesterolemia (FH) are often unrecognized despite typical presentation. The introduction of PCSK9 inhibitors opens new therapeutic options and emphasizes the need for identification of severe FH patients. The objective was identification, characterization, and management of severe FH patients by screening of cardiac catheterization (CC) database. Retrospective analysis of CC database from 2002 to mid-2015 was performed for low-density lipoprotein cholesterol (LDL-C) ≥130mg/dL (n=2383). Severe FH was diagnosed if any prior LDL-C was ≥280mg/dL, excluding secondary causes. Peak/current LDL-C levels and lipid-lowering therapies were evaluated. Initial attempt was made to detect relatives with FH according to identifying data and age-dependent LDL-C cutoffs. Severe FH was identified in 54 of initial 2382 patients with CC LDL-C ≥130mg/dL. Mean age at cardiovascular disease diagnosis was 45years. Peak LDL-C was 280 to 464mg/dL (median, 322). Coronary artery bypass graft surgery was performed in 26 patients (48%) and redo coronary artery bypass graft surgery in 5 patients (9%). Risk factors included obesity (33%), hypertension (59%), smoking (33%), and diabetes (24%). LDL-C reduction ≥50% of peak value was achieved in 56%, LDL-C <130mg/dL in 32%, and LDL-C <100mg/dL in 17% of patients. High-intensity statin plus ezetimibe was prescribed for 67%, high-intensity statin alone for 24%, and other lipid-lowering therapies for 9% of patients. Treatment intensity was directly associated with attainment of LDL-C goals. Matching probands' surnames and place of residency with district health maintenance organization database has identified 161 additional individuals with possible FH; 58% were not treated with lipid-lowering drugs. A simple algorithm for identification of patients with severe FH was implemented based on large catheterization and health maintenance organization databases and revealed patients with severe FH and coronary disease at a young age, with low attainment of cholesterol treatment goals. Screening existing cardiovascular databases of populations at risk will promote identification and management of severe FH patients and their affected family members.

Status of cholesterol goal attainment for the primary and secondary prevention of atherosclerotic cardiovascular disease in dyslipidemia patients receiving lipid-lowering therapy: DYSIS-China subgroup analysis

To analyze the current status of cholesterol goal attainment for the primary and secondary prevention of cardiovascular disease in dyslipidemia patients using data from the DYSIS-China study. Based on criteria defined in the 2014 China Cholesterol Education Program (CCEP) and the 2007 Chinese guidelines for the prevention and treatment of dyslipidemia in adults, 25 317 dyslipidemia patients enrolled in the DYSIS-China study (from March 2012 to October 2012) were stratified to the atherosclerotic cardiovascular disease(ASCVD) primary prevention and secondary prevention groups. The total cholesterol (TC) target goals were <3.11, 4.14, 5.18, and 6.22 mmol/L, respectively, and the low-density lipoprotein cholesterol (LDL-C) therapeutic goals were less than 1.8, 2.6, 3.4, and 4.1 mmol/L, respectively, for the very high-risk, high-risk, moderate-risk, and low-risk patients in the primary prevention group. The TC targets for the very high-risk and high-risk patients were <3.11 and <4.14 mmol/L, respectively, and the LDL-C targets were <1.8 and <2.6 mmol/L, respectively, in the secondary prevention group. The TC and LDL-C goal attainment rates were calculated for the different risk groups according to the targets values. Totally, 71.09% (n=18 000) of the dyslipidemia patients were grouped into very high and high risk groups, 51.76% (n=13 104) and 48.24% (n=12 213) patients were stratified to primary and secondary prevention of ASCVD. The LDL-C and TC goal attainment rates for the secondary prevention group were 33.09%(4 041 cases) and 21.05% (2 571 cases), respectively. The LDL-C and TC goal attainment rates for the primary prevention group were 52.40% (6 866 cases) and 42.06% (5 511 cases), respectively. Multivariate logistic regression analysis showed that diabetes mellitus(OR=5.75, 4.15, P<0.05), coronary heart disease(OR=5.70, 3.58, P<0.001), and peripheral arterial disease(OR=2.42, 1.49, P<0.05) were risk factors for failure to achieve TC and LDL-C goals, respectively. Despite the widespread application of the 2014 CCEP and 2007 Chinese dyslipidemia guidelines, LDL-C goal attainment among secondary and primary prevention patients remains suboptimal in China. More rigorous guideline adherence is therefore required to increase the LDL-C and TC goal attainment rates and improve the long-term cardiovascular outcomes in Chinese dyslipidemia patients.

Prevalence of the American College of Cardiology/American Heart Association statin eligibility groups, statin use, and low-density lipoprotein cholesterol control in US adults using the National Health and Nutrition Examination Survey 2011–2012

The 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline identifies 4 statin-eligible groups: (1) known atherosclerotic cardiovascular disease (ASCVD) aged ≥21years, (2) low-density lipoprotein cholesterol (LDL-C) ≥ 190mg/dL (4.9mmol/L) aged ≥21years, (3) diabetes mellitus aged 40 to 75years with LDL-C 70 to 189mg/dL (1.8-4.9mmol/L), or (4) ≥7.5% 10-year ASCVD risk aged 40 to 75years with LDL-C 70 to 189mg/dL (1.8-4.9mmol/L). We examined the number of statin-eligible US adults, statin use, LDL-C goal attainment, and adherence to lifestyle management. We identified subjects from the US National Health and Nutrition Examination Survey 2011-2012 in the 4 statin-eligible groups, proportion on statin, proportion at recommended LDL-C levels using National Lipid Association goals (<70mg/dL [1.8mmol/L] for very high risk and <100mg/dL [2.6mmol/L] for others), and adherence to lifestyle measures. Of 5206 adults (representing 219 million), 1677 adults representing 62.6 million adults fit into 1 of the 4 statin-eligible groups. Statin use was 63.7% for the ASCVD, 61.4% for the LDL-C ≥ 190mg/dL (4.9mmol/L), 43.2% for the diabetes mellitus, and 27.2% for the 10-year risk ≥7.5% groups. Of those on statins with LDL-C measured, 79.7%, 98.0%, 42.3%, and 46.8% were not at LDL-C goal. Adherence to recommended <6% calories from saturated fat ranged from 3.3% to 6.4% and ≥40minutes of physical activity ≥3 times a week from 54.7% to 65.1% across statin-eligible groups. Many US adults eligible to receive statins based on American College of Cardiology/American Heart Association guidelines are not taking statins, and LDL-C levels still remain suboptimal.

Metabolic Syndrome And Low-Density Lipoprotein Cholesterol Goal Attainment In The National Health And Nutrition Examination Survey (2003–2012) †

Dr. Toth has been involved in speakers’ bureaus for Amarin, AstraZeneca, Genzyme, GSK, Kowa, and Merck and Co, and has been a consultant/advisory board member for Amgen, AstraZeneca, Kowa, Merck and Co, Novartis, Regeneron and Sanofi.

Attainment of LDL-Cholesterol Treatment Goals in Patients With Familial Hypercholesterolemia: 5-Year SAFEHEART Registry Follow-Up

BackgroundFamilial hypercholesterolemia (FH) is the most common genetic disorder associated with premature atherosclerotic cardiovascular disease (ASCVD). There are sparse data on attainment of treatment targets; large registries that reflect real-life clinical practice can uniquely provide this information. ObjectivesWe sought to evaluate the achievement of low-density lipoprotein cholesterol (LDL-C) treatment goals in FH patients enrolled in a large national registry. MethodsThe SAFEHEART study (Spanish Familial Hypercholesterolemia Cohort Study) is a large, ongoing registry of molecularly defined patients with heterozygous FH treated in Spain. The attainment of guideline-recommended plasma LDL-C goals at entry and follow-up was investigated in relation to use of lipid-lowering therapy (LLT). ResultsThe study recruited 4,132 individuals (3,745 of whom were ≥18 years of age); 2,752 of those enrolled were molecularly diagnosed FH cases. Mean follow-up was 5.1 ± 3.1 years; 71.8% of FH cases were on maximal LLT, and an LDL-C treatment target <100 mg/dl was reached by only 11.2% of patients. At follow-up, there was a significant increase in the use of ezetimibe, drug combinations with statins, and maximal LLT. The presence of type 2 diabetes mellitus, a defective allele mutation, ezetimibe use, and the absence of previous ASCVD were predictors of the attainment of LDL-C goals. ConclusionsDespite the use of intensified LLT, many FH patients continue to experience high plasma LDL-C levels and, consequently, do not achieve recommended treatment targets. Type of LDL-receptor mutation, use of ezetimibe, coexistent diabetes, and ASCVD status can bear significantly on the likelihood of attaining LDL-C treatment goals.

Reduction in total recurrent cardiovascular events in acute coronary syndrome patients with low-density lipoprotein cholesterol goal

BackgroundFor investigations into cardiovascular disease, the first problematic event (ie, nonfatal acute coronary syndrome (ACS), nonfatal stroke, or all-cause mortality) generally was considered as the primary end point; however, ACS patients often experience subsequent events, which are rarely considered. This study reports an investigation into whether achieving a low-density lipoprotein cholesterol (LDL-C) goal of <70 mg/dL (1.8 mmol/L) is associated with a reduction in total recurrent cardiovascular events in a cohort of ACS patients hospitalized in northern Thailand.MethodsThe medical charts and the electronic hospital database of ACS patients treated with statins at a tertiary hospital in Thailand between 2009 and 2012 were reviewed. Patients were checked for their LDL-C goal attainment, and then were followed for subsequent events until the last follow-up date, or to December 31, 2012. The Wei–Lin–Weissfeld method was used for multiple time-to-events data to investigate the association between achieving an LDL-C goal of <70 mg/dL and total recurrent cardiovascular events.ResultsOf 405 eligible patients, 110 patients attained an LDL-C goal of <70 mg/dL. During a median follow-up of 1.94 years, the majority of patients (88.6%) had no subsequent cardiovascular events, while 46 patients experienced at least one recurrent cardiovascular event: 36 with one event, six with two events, two with three events, one with four events, and one with seven events. Compared to patients with an LDL-C ≥100 mg/dL, patients achieving an LDL-C of <70 mg/dL were significantly less likely to experience total cardiovascular events (adjusted hazard ratio =0.29; 95% confidence interval =0.09–0.87; P-value =0.028); the result was similar to patients with an LDL-C of 70–100 mg/dL, but it was not significant (adjusted hazard ratio =0.53; 95% confidence interval =0.23–1.26; P-value =0.154).ConclusionACS patients receiving statins who attained an LDL-C <70 mg/dL experienced a reduction in total recurrent cardiovascular events compared to those with LDL-C ≥100 mg/dL.

Suboptimal Control of Lipid Levels: Results from 29 Countries Participating in the Centralized Pan-Regional Surveys on the Undertreatment of Hypercholesterolaemia (CEPHEUS).

Five multicentre, cross-sectional Centralized Pan-Regional Surveys on the Undertreatment of Hypercholesterolaemia (CEPHEUS) were conducted in 29 countries across Asia, Western Europe, Eastern Europe, the Middle East, and Africa. The surveys assessed the current use and efficacy of lipid-lowering drugs (LLDs) worldwide and identified possible patient and physician characteristics associated with failure to attain low-density lipoprotein cholesterol (LDL-C) goals. The aim of this analysis was to consolidate the global results from these surveys. The surveys involved patients aged ≥18 years who had been prescribed LLDs for at least 3 months without dose changes for at least 6 weeks. A single visit was scheduled for data collection, including fasting plasma lipid and glucose levels. Cardiovascular risk profile and LDL-C goal attainment were assessed according to the 2004 updated US National Cholesterol Education Program Adult Treatment Panel III guidelines. In total, 35 121 patients (mean age: 60.4 years) were included, and 90.3% had been prescribed statin monotherapy. Overall, only 49.4% of patients reached their recommended LDL-C level. LDL-C goals were attained in 54.8% (5084/9273) and 22.8% (3287/14 429) of patients were at high and very high cardiovascular risk, respectively. Factors associated with an increased likelihood of LDL-C goal attainment were lower baseline cardiovascular risk; presence of diabetes mellitus, hypertension, or history of cardiovascular disease; and treatment with simvastatin, atorvastatin, or rosuvastatin (vs. all other LLDs). LDL-C goal attainment in patients taking LLDs is suboptimal worldwide, particularly in patients at high and very high cardiovascular risk.

Attainment of low-density lipoprotein cholesterol goal after endovascular treatment is associated with reduced cardiovascular events in patients with peripheral arterial disease

The relationship between attainment of low-density lipoprotein cholesterol (LDL-C) levels and clinical outcomes in patients with peripheral arterial disease (PAD) has received little attention. We sought to investigate clinical outcomes in relation to attainment of LDL-C goals in patients with PAD after endovascular treatment. We reviewed 342 PAD patients treated with endovascular therapy from 2010 through 2012. We categorized patients into two groups based on the attained LDL-C levels at short-term follow-up (mean, 4.8 ± 2.8 months): group A (n = 160), with LDL-C <70 mg/dL; and group B (n = 182), with LDL-C ≥70 mg/dL. The primary end point was major adverse cardiovascular events (MACEs), a composite of all-cause death, nonfatal myocardial infarction, and stroke. Baseline characteristics were similar between group A and group B except for obstructive pulmonary disease (0% vs 7%; P = .001). More patients in group A received statin therapy than those in group B (93% vs 76%; P < .001). MACEs (4% vs 10%; P = .002) and all-cause mortality (2% vs 7%; P = .007) occurred less frequently in group A than in group B at 2 years. A Cox proportional hazards multivariate regression model identified attainment of LDL-C goal <70 mg/dL at short-term follow-up as an independent predictor of reduced MACEs (hazard ratio, 0.25; 95% confidence interval, 0.09-0.67; P = .006) along with age as a predictor of increased MACEs (hazard ratio, 1.04; 95% confidence interval, 1.00-1.08; P = .031). Attainment of LDL-C goal <70 mg/dL at short-term follow-up is an independent predictor of reduced mortality and cardiovascular events after endovascular therapy in patients with PAD.

Abstract 17156: No Major Change in Low-density Lipoprotein Cholesterol Goal Attainment in the United States From 2003 to 2012: A Time-sensitivity Analysis Using National Health and Nutrition Examination Survey Data

Introduction: Although use of lipid-lowering therapies (LLT) for treatment of dyslipidemia is increasing, there is little evidence that this has increased the percentage of patients achieving LDL-C goals of &lt;100 mg/dL, &lt;130 mg/dL, and &lt;160 mg/dL for adults at high, intermediate, and low CHD risk, respectively (based on NCEP ATP III). We used reported LDL-C levels in the National Health and Nutrition Examination Survey (NHANES) to estimate proportion of the US adult population meeting LDL-C goals as a function of time (2003-2012). Methods: Coronary heart disease risk using NCEP ATP III criteria was assessed in adult participants in 2-yearly NHANES surveys from 2003-2004 to 2011-2012. The proportion of each risk group meeting LDL-C goals and the proportion receiving LLT were calculated. Results: Estimates for the US population were based on 11,256 observations from NHANES (2003-2012). No obvious change over time was observed in the distribution of risk, with 66%, 17%, and 17% of the population estimated to be at low, intermediate and high risk in 2003-2004 and 67%, 14%, and 19%, respectively, in 2011-2012. From 2003-2012, a statistically significant increase in the use of LLT was observed in low- (p&lt;0.0001) and high-risk (p=0.008) groups (Figure). Although there was an increase in proportion of patients in the intermediate- and high-risk categories achieving LDL-C goals between 2003-2004 and 2005-2006, there was no significant improvement in LDL-C goal attainment in low- (p=0.89), intermediate- (p=0.41) or high-risk (p=0.09) groups over the entire period (Figure). Conclusion: Despite increased use of LLT, we observed no trend for improvement in LDL-C goal attainment in adults in the US population. Approximately 69 million adults (33% of the population) are at high or intermediate CHD risk, and many are not at their LDL-C goal, highlighting the need for more aggressive identification and treatment of patients at risk, objectives articulated by the ACC/AHA guideline.

Patterns of statin use and cholesterol goal attainment in a high-risk cardiovascular population: A retrospective study of primary care electronic medical records

To describe real-life patterns of statin use and cholesterol goal attainment in a retrospective cohort of patients with high cardiovascular risk. Retrospective cohort study of 21,636 individuals, 18.34% women, mean age 63.30 years (standard deviation 6.29). New statin users aged 35 to 74 years at high cardiovascular risk and with no previous cardiovascular disease in primary care electronic medical records (2006-2011). Patterns of statin use were based on statin type, potency, and 1-year statin switches. Relative mean reductions over 1 year and probability of goal attainment (<3.3 mmol/L). Natural patterns of statin use were identified using multiple correspondence analysis; general linear and logistic models were used to estimate low-density lipoprotein cholesterol (LDL-C) reductions and goal attainment probability. Three patterns of statin use were defined: low (3.82% of the population), moderate (71.94%), and high intensity (24.24%). After 1 year, potency decreased 42.74%, 64.16%, and 50.94%, respectively, and 37.41%, 29.47%, and 30.16% of the population stopped taking statins in low, moderate, and high patterns, respectively. Relative reductions in LDL-C: low intensity, 15.7% (95% confidence interval [CI]: -22.96 to 54.36); moderate intensity, 29.72% (95% CI: 29.12-30.32); and high intensity, 24.20% (95% CI: -8.08 to 40.32). There was a direct relationship between higher intensity patterns and greater probability of goal attainment. Three real-life patterns of statin use were identified. Lipid management strategies in primary care should focus on improving adherence to treatment. People starting at low potency should switch to a moderate pattern; more intensive therapies should be considered in who require a larger LDL-C reduction to reach therapeutic targets, patients with good treatment adherence who do not achieve the goal with a moderate pattern of therapy or patients at very high risk.

Unsatisfactory LDL-cholesterol Goal Attainment Rate in Type 2 Diabetic Patients

Background: Type 2 diabetic patients have a higher cardiovascular risk than people without diabetes, and tight lipid level control is recommended to reduce the cardiovascular risk. We attempted to examine the factors associated with the low-density lipoprotein-cholesterol (LDL-C) control attainment rate and the actual LDL-C control attainment rate in type 2 diabetic patients in Taiwan. Methods: This cross-sectional study of LDL-C control in type 2 diabetic patients collected data from 10,000 patients. The LDL-C goal was ＜ 100 mg/dL for all diabetic patients. Multivariate logistic regression was performed to evaluate factors associated with the attainment rate of LDL-C control. Results: 46.63% of the diabetic patients attained the LDL-C goal. Young and female patients were less successful in reaching the LDL-C goal than other participants. 51.07% of the type 2 diabetic patients with cardiovascular comorbidities attained an LDL-C ＜ 100 mg/dL, and nearly 11% of those patients attained an LDL-C ＜ 70 mg/dL. Conclusions: The LDL-C goal attainment rate in type 2 diabetic patients is unsatisfactory in clinical practice, especially in patients with cardiovascular comorbidities. Young and female patients had a lower attainment rate than other participants.

Patient and physician factors influence decision-making in hypercholesterolemia: a questionnaire-based survey.

BackgroundGoal attainment of guideline-recommended low-density lipoprotein cholesterol (LDL-C) is suboptimal. Little is known about how patient factors influence physicians’ treatment decision-making in hypercholesterolemia. We examined physicians’ treatment recommendations in high-risk patients whose LDL-C remained uncontrolled despite statin monotherapy.MethodsPhysicians completed a questionnaire prior to randomization into period I of a two-period randomized controlled trial evaluating LDL-C goal attainment in patients whose LDL-C remained ≥100 mg/dL after 5 weeks’ treatment with atorvastatin 10 mg/day (NCT01154036). Physicians’ treatment recommendations were surveyed for two hypothetical and one real scenario: (1) LDL-C presumed near goal (between 100–105 mg/dL), (2) LDL-C presumed far from goal (~120 mg/dL), and (3) observed baseline LDL-C of enrolled patients. Prognostic factors considered during decision-making were identified by regression analysis. Observed lipid outcomes at the end of period I (following 6 weeks’ treatment with ezetimibe 10 mg plus atorvastatin 10 mg, atorvastatin 20 mg, or rosuvastatin 10 mg) were compared with estimated LDL-C outcomes for physicians’ treatment recommendations after 6 weeks (based on individual patients’ pre-randomization LDL-C and expected incremental change).ResultsQuestionnaires were completed for 1,534 patients. No change in therapy, or double atorvastatin dose, were frequently recommended, even when LDL-C was far from goal (6.5% and 52.2% of patients, respectively). Double atorvastatin dose was commonly recommended in all scenarios (43–52% of patients). More intensive LDL-C-lowering regimens were recommended infrequently e.g. double atorvastatin dose and add ezetimibe only <12% in all scenarios. Overall, cardiovascular risk factors and desire to achieve a more aggressive LDL-C goal were prominent factors in decision-making for treatment. Comparison of observed and estimated LDL-C levels showed that physicians tended to overestimate the effectiveness of their recommendations.ConclusionsThis study provides insight into physicians’ perspectives on clinical management of hypercholesterolemia and highlights a gap in knowledge translation from guidelines to clinical practice. The need for lower LDL-C and cardiovascular risk were key drivers in clinical decision-making, but physicians’ treatment choices were more conservative than guideline recommendations, potentially resulting in poorer LDL-C reduction. When compared with actual outcomes, projected LDL-C control was better if physicians used more comprehensive strategies rather than simply doubling the statin dose.Trial registrationClinicaltrials.gov: NCT01154036Electronic supplementary materialThe online version of this article (doi:10.1186/s12944-015-0037-y) contains supplementary material, which is available to authorized users.

Abstract 146: Clinical and Economic Consequences of Statin Intolerance in the U.S.: Results from an Integrated Health System

Background: Low-density lipoprotein cholesterol (LDL-C) is a key therapeutic target for reducing risk of cardiovascular (CV) events. While statins are the mainstay of therapy due to efficacy and safety, observational studies indicate patients prescribed statins are unable to tolerate them to varying degrees. The study objective was to examine the clinical and economic consequences of statin intolerance (SI) comparing SI patients to non-SI patients on statin therapy. Methods: This retrospective cohort study used data from an integrated health system’s electronic health record from 2009-2014. Adult patients diagnosed as statin intolerant (identified through a custom diagnosis code), with ≥ 6 months pre- and post-index date eligibility were considered for the study. All patients were hierarchically ordered into 6 mutually exclusive CV risk categories: recent acute coronary syndrome (ACS, &lt; 12 months pre-index); coronary heart disease (CHD); ischemic stroke; peripheral artery disease (PAD); diabetes; or primary prevention. Index dates were defined as the SI diagnosis date for SI patients and a matched encounter date within ±90 days for controls. A total of 5,252 SI patients were matched to 15,756 non-SI statin users (1:3 ratio) using a propensity score that included CV risk, Charlson comorbidity index, and other clinical characteristics as covariates. Time to first myocardial infarction, unstable angina, coronary revascularization, ischemic stroke, and CV death were compared between groups using Kaplan-Meier plots and Cox proportional hazard models. Total medical costs and LDL-C goal attainment were compared using generalized linear models and conditional logistic regression, respectively. Results: The mean age of the study population was 62 years with the majority being females (61%). Three percent were categorized as recent ACS, followed by 22% for CHD, 1% ischemic stroke, 5% PVD, 17% diabetes and 52% primary prevention patients. Before matching, 5% of statin users were deemed statin intolerant by their provider; although, 86% were still able to tolerate at least asymmetric statin dosing. Compared to the matched cohort, SI patients experienced significantly higher risk of unstable angina (hazard ratio (HR)=1.55, 95% CI=1.29-1.86) and revascularization procedures (HR=1.78, 95% CI=1.47-2.17) but lower risk of CV death (HR 0.42, 95% CI=0.33-0.55). Patients with statin intolerance also experienced higher costs (cost ratio=1.21, 95% CI=1.12, 1.29) and a higher risk of not achieving LDL-C goal (odds ratio=1.84, 95% CI=1.58-2.13). All p-values were &lt;0.0001. Conclusion: While the majority of SI patients were on a statin, SI patients demonstrate a higher risk of some cardiovascular events; incur higher healthcare costs; and difficulty reaching LDL-C goals compared to patients without SI. Alternative treatment strategies are needed to better serve this at-risk patient population.

Gender differences in lipid goal attainment among Chinese patients with coronary heart disease: insights from the DYSlipidemia International Study of China

Despite great advances in lipid-lowering therapy, the gender-based disparities in lipid goal success among Chinese coronary heart disease (CHD) patients receiving lipid-lowering treatment remained uncharacterized. Furthermore, little is known about potential causes for this gender imbalance. This cross-sectional trial included 25 697 patients treated with lipid-lowering agents from 122 centres between April 2012 and October 2012; data for 9420 participants with CHD were analysed in the present study; all underwent clinical examination and had their latest fasting lipid profiles while on lipid-lowering therapy recorded. Logistic regression was used to explore possible factors associated with gender disparity in goal attainment rates, and to what extent each factor contributes. Of 9420 CHD patients (42.5% women) evaluated, women had a significantly lower overall low-density lipoprotein cholesterol (LDL-C) success rate than men (46.2 vs. 62.7%, P < 0.0001). Among CHD patients with diabetes, only 31.5% of women and 46.4% of men ( P < 0.0001) attained the optional LDL-C target of <80 mg/dL. More than half (54.0%) of female patients failed to attain their non-high-density lipoprotein cholesterol (HDL-C) goal. Approximately 7.5, 8.8, 7.5, and 6.8% of gender disparity in LDL-C goal attainment rate was attributable to the gender difference in use of an anti-diabetic, anti-hypertensive, anti-platelet treatment, and the dosage of statin treatment, respectively. Although great improvements have been made over the past decade, there is still a preventive gap in high-risk and very high-risk CHD patients regarding LDL-C and non-HDL-C levels and that this gap is apparently greater in women.

Impact of Switching From High-Efficacy Lipid-Lowering Therapies to Generic Simvastatin on LDL-C Levels and LDL-C Goal Attainment Among High-Risk Primary and Secondary Prevention Populations in the United Kingdom

PurposeHigh cholesterol, especially high low-density lipoprotein cholesterol (LDL-C), is an important risk factor for cardiovascular disease (CVD) morbidity/mortality. Switching from high-efficacy lipid-lowering therapies (HETs) to simvastatin might lead to sub-optimal control of LDL-C. Our objective was to evaluate the impact of switching from HETs to generic simvastatin on LDL-C levels and LDL-C goal attainment among the high-risk primary and secondary prevention populations in the United Kingdom. MethodsThis retrospective cohort study was conducted using Clinical Practice Research Datalink database. Included were individuals with more than 2 months of prescriptions of the following HETs between August 1, 2004 and December 31, 2008: simvastatin/ezetimibe fixed dose (S/E), simvastatin and ezetimibe co-administration (S+E), atorvastatin and ezetimibe co-administration (A+E), rosuvastatin and ezetimibe co-administration (R+E), rosuvastatin monotherapy, and atorvastatin monotherapy. For each baseline HET, we used analysis of covariance (ANCOVA) to estimate the least squares mean (LSM) difference in the percentage change from baseline in LDL-C between switchers and non-switchers, and logistic regression to estimate the odds ratio of attaining the LDL-C goal (<3 mmol/L for primary prevention and <2 mmol/L for secondary prevention, by JBS2) at follow-up. Propensity score adjusted analyses were conducted to reduce selection bias. Findings30,148 patients met the eligibility criteria with 83.8% received atorvastatin, 9.5% rosuvastatin and 2.6% S/E and S+E combined. 89.1% of patients switching from atorvastatin switched to an equivalent or higher dose of simvastatin (dose equivalency was determined by relative efficacy of one statin to other statins), while 100% of those switching from simvastatin/ezetimibe and 96.8% of those switching from rosuvastatin switched to lower than equivalent dose of simvastatin. Compared to non-switchers, the adjusted least squares mean differences in the percentage change in LDL-C levels from baseline were 18.74% (p = 0.0003), 16.73% (p < 0.0001), and −0.11% (p = 0.9044) when switching from simvastatin/ezetimibe, rosuvastatin, and atorvastatin, respectively. The odds of LDL-C goal attainment at follow-up among switchers from simvastatin/ezetimibe, rosuvastatin, and atorvastatin were 0.40 (95% CI: 0.23–0.70), 0.36 (95% CI: 0.26–0.51) and 1.03 (95% CI: 0.92–1.15) relative to non-switchers respectively. ImplicationsAmong the high risk CVD population in UK, switching to simvastatin from HET, especially rosuvastatin and simvastatin/ezetimibe, resulted in an increase in LDL-C levels and lower goal attainment. These historical data reinforce the appropriateness of the changes in the new Joint British Guideline (JBS3) which no longer recommends starting simvastatin 40 mg.

Statin therapy in patients with acute coronary syndrome: low-density lipoprotein cholesterol goal attainment and effect of statin potency.

BackgroundElevated low-density lipoprotein cholesterol (LDL-C) is associated with an increased risk of coronary artery disease. Current guidelines recommend an LDL-C target of <70 mg/dL (<1.8 mmol/L) for acute coronary syndrome (ACS) patients, and the first-line treatment to lower lipids is statin therapy. Despite current guidelines and the efficacious lipid-lowering agents available, about half of patients at very high risk, including ACS patients, fail to achieve their LDL-C goal. This study assessed LDL-C goal attainment according to use of high and low potency statins in routine practice in Thailand.MethodsA retrospective cohort study was performed by retrieving data from medical records and the electronic hospital database for a tertiary care hospital in Thailand between 2009 and 2011. Included were ACS patients treated with statins at baseline and with follow-up of LDL-C levels. Patients were divided into high or low potency statin users, and the proportion reaching the LDL-C goal of <70 mg/dL was determined. A Cox proportional hazard model was applied to determine the relationship between statin potency and LDL-C goal attainment. Propensity score adjustment was used to control for confounding by indication.ResultsOf 396 ACS patients (60% males, mean age 64.3±11.6 years), 229 (58%) were treated with high potency statins and 167 (42%) with low potency statins. A quarter reached their target LDL-C goal (25% for patients on high potency statins and 23% on low potency statins). High potency statins were not associated with increased LDL-C goal attainment (adjusted hazards ratio 1.22, 95% confidence interval 0.79–1.88; P=0.363).ConclusionThere was no significant effect of high potency statins on LDL-C goal attainment. Moreover, this study showed low LDL-C goal attainment for patients on either low or high potency statins. The reasons for the low LDL-C goal attainment rate warrants further investigation.