Prescription Of High-intensity Statins Research Articles

Statin prescriptions and progression of advanced fibrosis risk in primary care patients with MASLD

ObjectiveWe aimed to determine the association of statins with progression to a high risk for advanced fibrosis in primary care patients with metabolic dysfunction-associated steatotic liver disease (MASLD).DesignThis retrospective cohort...

Prescription of lipid-lowering therapy, LDLc control, and risk of MACE in patients after ST-elevation myocardial infarction in Mexico

Abstract Funding Acknowledgements None. Background/Introduction Optimal control of low-density lipoprotein cholesterol (LDLc) has been demonstrated to reduce cardiovascular event rates after ST-elevation myocardial infarction (STEMI). However, real-world data shows that a low proportion of patients achieve LDLc targets. Furthermore, the association of LDLc levels and major cardiovascular adverse events (MACE) in post-STEMI patients is limited in developing countries. Purpose In this study, we aimed to assess the prescription patterns of lipid-lowering therapies, LDLc control, and their impact on the risk of MACE after STEMI in Mexico. Methods We conducted a prospective observational study of patients with STEMI. LDLc levels and prescriptions of lipid-lowering therapy were assessed during the first scheduled visit following STEMI hospital discharge. LDLc control was determined in accordance with the 2023 European Society of Cardiology Acute Coronary Syndrome Guidelines, which recommend achieving LDLc levels below 55 mg/dL for secondary prevention. Patients were categorized as controlled (if LDLc <55 mg/dL) and not controlled (if LDLc >55 mg/dL) and were followed for a median of 4.5 years to evaluate the rate of MACE, including cardiovascular death, cardiogenic shock, recurrent MI, and heart failure. Results We included 447 patients with a mean age of 57.87 (± 10.5 years), predominantly male (84.5%). Hypertension (43.8%), smoking (41.1%), type 2 diabetes mellitus (33.5%), obesity (26.6%), and dyslipidemia (21.4%) were highly prevalent. The median LDLc level in the total population was 65.4 mg/dL (IQR 49.2- 87.7). Among these, 34% (152) were considered controlled, while 66% (295) were not. Baseline clinical characteristics did not significantly differ among the groups. Prescription of high-intensity statins reached 94.7%, and ezetimibe and PCSK-9i were used in 1.8% and 0.4% of cases, respectively. We observed no statistically significant difference (Hazard ratio: 1.03, 95% confidence interval 0.74-1.73) in the rate of MACE based on LDLc control (Fig.1). The risk of MACE was also not different based on the use of high-intensity statins. Conclusions In this real-world study of patients post-STEMI, LDLc control was achieved in just one-third of the population. While the prescription of high-intensity statins was high, combination therapy was low. We did not observe a statistically significant association with an increased long-term risk of MACE; however, we noted a higher rate of events compared with other series.

Quality control to improve LDL-cholesterol management in patients with acute coronary syndromes based on the ACS EuroPath IV project.

We performed quality control of lipid-lowering therapy (LLT) in patients with acute coronary syndrome (ACS), with a view to proposing corrective actions. Using a Define Measure Analysis Improve Control (DMAIC) approach applied to data from the ACS EuroPath IV survey, we measured attainment of two quality indicators (QIs) related to lipid-lowering treatment: (i) prescription of high-intensity statins (or equipotent treatment) before discharge, and (ii) proportion with LDL-cholesterol <55 mg/dL (1.4 mmol/L) during follow-up. A total of 530 European cardiologists responded and provided data for up to 5 patients from their centre, for acute and follow-up phases. Corrective measures are proposed to increase the rate of attainment of both QIs. Attainment of the first QI was measured in 929 acute-phase patients, 99% had LLT prescribed at discharge and 75% of patients fulfilled the first QI. Attainment of the second QI was assessed in 1721 patients with follow-up. The second QI was reached in 31% of patients. The DMAIC approach yielded 10 potential changes in prescription, 3 for the first and 7 for the second QI. The overall strategy is 'Fire to Target', i.e. early intensification of the LLT using statins, ezetimibe, bempedoic acid, and proprotein convertase subtilisin/kexin type-9 inhibitors, and is presented as an algorithm for routine application. Quality control for LLT, based on the ACS EuroPath IV survey, detected 10 potential changes in prescription that could enhance attainment of 2 QIs. Whether the Fire to Target strategy will be adopted and effective needs to be assessed in further steps of the EuroPath Quality programme.

Projected Outcomes of Optimized Statin and Ezetimibe Therapy in US Military Veterans with Coronary Artery Disease

Many patients with coronary artery disease (CAD) do not achieve the guideline-directed goals for low-density lipoprotein cholesterol (LDL-C) levels. To estimate reductions in the rates of adverse events associated with CAD in a large US military veteran population that may be achieved through use of optimized statin therapy alone or with ezetimibe compared with the prevailing lipid-lowering therapy (LLT). In this observational cohort study, US military veterans with CAD were identified by coronary angiography between June 2015 and September 2020 across 82 US Department of Veterans Affairs health care facilities. The exposures were observed LLT, LLT with an optimized statin regimen, and LLT with optimized statin and ezetimibe. Observed rates of death, myocardial infarction, stroke, and coronary revascularization, and potential reductions in those outcomes with optimized LLT based on expected further reductions in LDL-C levels and application of formulas from The Cholesterol Treatment Trialists' Collaboration. The analysis cohort comprised 111 954 veterans (mean [SD] age, 68.4 [8.8] years; 109 390 men [97.7%]; 91 589 White patients [81.8%]; 17 592 Black patients [15.7%]). The median (IQR) observation period for this study was 3.4 (2.1-4.0) years. At the time of index angiography, 66 877 patients (59.7%) were treated with statin therapy, and 623 patients (0.6%) were treated with ezetimibe. At 6 months, the number of patients with statin prescriptions increased to 74 400 (68.7%), but the number of patients with high-intensity statin prescriptions was only 57 297 (52.9%). At 6 months, ezetimibe use remained low (n = 1168 [1.1%]), and LDL-C levels were 70 mg/dL or more in 56 405 patients (52.1%). At 4 years, observed incidences of death, myocardial infarction, stroke, and coronary revascularization were 21.6% (95% CI, 21.3%-21.8%), 5.0% (95% CI, 4.9%-5.2%), 2.2% (95% CI, 2.1%-2.3%), and 15.4% (95% CI, 15.2%-15.7%), respectively. With optimized statin treatment, projected absolute reductions in these incidences were 1.3% (95% CI, 0.9%-1.7%), 0.8% (95% CI, 0.7%-1.0%), 0.2% (95% CI, 0.1%-0.3%), and 2.3% (95% CI, 2.0%-2.7%), respectively. With optimized statin and ezetimibe treatment, projected absolute reductions were 1.8% (95% CI, 1.2%-2.4%), 1.1% (95% CI, 0.9%-1.3%), 0.3% (95% CI, 0.2%-0.4%), and 3.1% (95% CI, 2.6%-3.6%), respectively. In this cohort study of veterans with CAD, suboptimal LLT was prevalent in the clinical setting. Optimization of statin therapy was projected to produce clinically relevant reductions in the risks of death and cardiovascular events. Despite a lesser lipid-lowering efficacy of ezetimibe, its widespread use on a population level in conjunction with optimized statin therapy may be associated with further meaningful reductions in cardiovascular risk.

Statin Use in Older Adults for Primary Cardiovascular Disease Prevention Across a Spectrum of Cardiovascular Risk.

There remains uncertainty regarding optimal primary atherosclerotic cardiovascular disease (ASCVD) prevention practices for older adults. To assess statin treatment patterns and incident ASCVD among older patients for primary prevention across the spectrum of ASCVD risk. Retrospective cohort study of participants without ASCVD aged 65-79 years. Patients were stratified by age (65-69, 70-75, > 75 years) and 10-year ASCVD risk category (low/borderline, intermediate, high) based on the Pooled Cohort Equations. Multivariable logistic regressions were used to identify predictors of moderate- or high-intensity statin prescriptions. Cox proportional models were used to estimate hazard ratios (HRs) for incident ASCVD. Patients aged 65-79 years without ASCVD from a Northern California health system. Statin prescriptions and incident ASCVD events. There were 54,066 patients, with 10,288 (19%) aged > 75 years and 57% women. Compared with younger groups, adults > 75 years were less likely to be prescribed moderate- or high-intensity statin prescriptions across ASCVD risk groups (all p < 0.001); this persisted after multivariable adjustment including for ASCVD risk (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74-0.86). Adults > 75 years were more likely to experience incident ASCVD (HR 1.42, 95% CI 1.23-1.63). Women (OR 0.85, 95% CI 0.81-0.89) and underweight older adults (OR 0.45, 95% CI 0.33-0.61) were also less likely to receive moderate- or high-intensity statins. Among older adults aged 65-79 years without prior ASCVD, those > 75 years of age were less likely to receive moderate- or high-intensity statins regardless of ASCVD risk compared with their younger counterparts, while experiencing more incident ASCVD. Efforts are warranted to study the reasons for age-based differences in statin use in older adults, particularly those at highest ASCVD risk.

Prevalence of poor lipid control in patients with premature coronary artery disease

Background and aimsLipid goals have become more stringent in high risk patients. However, no studies have analyzed lipid control defined as the composite achievement of goals in low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (Non-HDL-C) and apolipoproteinB-100 (ApoB-100), in patients with premature coronary artery disease (CAD). We aimed to analyze lipid control rates, and the associated factors with its poor achievement in patients with premature CAD. Methods and resultsThe study included 1196 patients with CAD diagnosed before 55 and 65 years old in men and women, respectively. The American Heart Association/American College of Cardiology (non-strict) and the American Association of Clinical Endocrinologists (strict) criteria were used to analyze lipid control rates. Sociodemographic, dietary-healthy and clinical characteristics of the patients were collected. Participants were 54 ± 8 years old, 19.7% were women, and median CAD evolution was 2.4 years. Non-strict and strict lipid control was achieved in 23.0% and 8.9% of the patients, respectively. Moreover, 46.5% and 62.8% of the patients did not achieve any lipid goal using both criteria. Sociodemographic data were not different among patients who achieved or not lipid control. Treatment adherence<85%, prescription of low- and moderate-intensity statins, and obesity were consistently associated with poor lipid control. ConclusionsLipid control is suboptimal in patients with premature CAD. Low lipid-lowering treatment adherence, low prescription of high-intensity statins, and obesity were independently associated with poor lipid control. Novel preventive programs and more aggressive pharmacological intervention should be implemented in order to reduce the burden of premature CAD.

Abstract P103: Atherosclerotic Cardiovascular Disease Risk Reduction in High Risk Populations: A Resident Driven Quality Improvement Initiative

Background: Current guidelines recommend statins for patients with clinical ASCVD and more specifically, to target LDL-C levels &lt;70mg/dL. However, recent studies suggest that overall statin usage in ASCVD patients is suboptimal (58%), with less than one-third of these individuals on a high-intensity dose. Our goal was to assess LDL-C levels amongst patients with known ASCVD within a large safety-net academic medical center, while identifying factors leading to suboptimal cholesterol control, to determine potential targeted interventions to improve patient outcomes and guideline compliance. Methods: We obtained data from the medical record data warehouse of a primary care outpatient medicine clinic that is predominantly staffed by internal medicine residents with attending physician guidance. Patients with a diagnosis of ASCVD who were evaluated from Jan-Dec 2016 were reviewed. Medical record abstraction was performed and bivariate analyses were conducted to identify potential factors affecting high-intensity statin prescriptions rates and resultant LDL-C levels. Results: Our patient population was predominantly African American (93%; 1015/1091). Statins were prescribed for 82% of these patients (897/1091), of which, only 69% (615/897) were on a high-intensity statin. However, LDL-C levels &lt;70 mg/dL were seen in only 41% and 34% of patients on a high-intensity vs non-high-intensity statin respectively. Younger age, female sex, lack of insurance, PHQ scores &gt;4 (indicative of mild depression or greater), and the presence of ≥4 comorbidities were all associated with a lower likelihood of being prescribed a high-intensity statin and/or having controlled LDL-C levels (p&lt;0.05 for all variables). Conclusion: LDL-C control appears suboptimal among ASCVD patients within our safety-net patient population. This may reflect the inherent complexity of our patient population, which is predominantly low income, uninsured, and African American. Our future goals are to develop resident driven interventions to properly monitor LDL-C levels, escalate guideline based therapies, and manage comorbid conditions such as depression, hypertension, and diabetes, to decrease ASCVD risk and improve guideline compliance.

Implementing simple algorithms to improve glucose and lipid management in people with diabetes and acute coronary syndrome.

Diabetes mellitus is associated with increased risk of adverse outcomes following acute coronary syndrome. Translating evidence-based recommendations into practice is necessary to improve outcomes. We evaluated whether implementing algorithms to guide inpatient care improved glycaemic control, and increased use of sodium-glucose co-transporter 2 (SGLT2) inhibitors and lipid-lowering medication in a tertiary cardiac unit. A 3-month audit (phase 1) was conducted to evaluate hyperglycaemia and dyslipidaemia management, and medication prescriptions. Consecutive people with diabetes admitted for acute coronary syndrome were prospectively identified. Target blood glucose level was defined as 5-10mmol/l. A multidisciplinary committee designed and implemented decision-support algorithms plus education. A 3-month post-implementation audit (phase 2) was conducted. There were 104 people in phase 1 and 101 in phase 2, with similar characteristics [HbA1c 64±20mmol/mol vs. 61±21mmol/mol (8.0±1.8% vs. 7.8±1.9%]. Post implementation, the incidence of blood glucose levels >10mmol/l was lower [phase 1: 46.4% vs. phase 2: 31.8%, rate ratio(RR)=0.77, 95% confidence intervals (CI) 0.60-0.98; P=0.031], without a difference in blood glucose levels <5mmol/l (phase 1: 4.9% vs. phase 2: 4.5%, RR=1.20, 95% CI 0.70-2.08; P=0.506). SGLT2 inhibitor prescriptions increased significantly (baseline to discharge: 12.5% to 15.4% vs. 7.9% to 24.8%; P=0.007) but high-intensity statin prescriptions did not (baseline to discharge: 35.6% to 72.1% vs. 40.6% to 85.1%; P=0.074). Prescription rates of non-statin lipid-lowering medications were not significantly increased. Implementing decision-support algorithms was associated with improved inpatient glycaemic control and increased use of cardioprotective therapies at discharge in people with diabetes and acute coronary syndrome.

Lipid-Lowering Prescription Patterns in Patients With Diabetes Mellitus or Cardiovascular Disease

The purpose of this study is to describe lipid-lowering therapy (LLT) prescriptions and low-density lipoprotein cholesterol (LDL-C) monitoring in patients with diabetes mellitus (DM) with or without concomitant cardiovascular disease (CVD). Olmsted County, Minnesota residents with a first-ever diagnosis of DM or CVD (ischemic stroke/transient ischemic attack, myocardial infarction, unstable angina pectoris, or revascularization procedure) between 2005 and 2012 were classified as having DM only, CVD only, or CVD + DM. All LLT prescriptions and LDL-C measurements were obtained for 2 years after diagnosis. A total of 4,186, 2,368, and 724 patients had DM, CVD, and CVD + DM, respectively. Rates of LDL-C measurement were 1.31, 1.66, and 1.88 per person-year and 14%, 32%, and 42% of LDL-C measurements were <70 mg/dl in those with DM, CVD, and CVD + DM. Within 3 months after diagnosis, 47%, 71%, and 78% of patients with DM, CVD, and CVD + DM were prescribed LLT. Most prescriptions were for moderate-intensity statins. Under one-fifth of patients with CVD and CVD + DM were prescribed high-intensity statins. Predictors of high-intensity statin prescriptions included male sex, having CVD or CVD + DM, increasing LDL-C, and LDL-C measured more recently (2012 to 2014 vs before 2012). In conclusion, a large proportion of patients at high CVD risk are not adequately treated with LLT. Despite often being considered a risk equivalent, patients with DM have substantially lower rates of LLT prescriptions and lesser controlled LDL-C than those with CVD or CVD + DM.

Attainment of Guideline-Directed Medical Treatment in Stable Ischemic Heart Disease Patients With and Without Chronic Kidney Disease

Stable ischemic heart disease (SIHD) is prevalent in patients with chronic kidney disease (CKD); however, whether guideline-directed medical therapy (GDMT) is adequately implemented in patients with SIHD and CKD is unknown. Use of GDMT and achievement of treatment targets would be higher in SIHD patients without CKD than in patients with CKD. This was a retrospective study of 563 consecutive patients with SIHD (mean age 67.8years, 84% Caucasians, 40% females). CKD was defined as an estimated glomerular filtration rate (eGFR) of < 60mL/min/1.73m2 using the four-variable MDRD Study equation. We examined the likelihood of achieving GDMT targets (prescription of high-intensity statins, antiplatelet agents, renin-angiotensin-aldosterone system inhibitors (RAASi), and low-density lipoprotein cholesterol levels < 70mg/dL, blood pressure < 140/90mmHg, and hemoglobin A1C < 7% if diabetes) in patients with (n = 166) and without CKD (n = 397). Compared with the non-CKD group, CKD patients were significantly older (72 vs 66years; p < 0.001), more commonly female (49 vs 36%; p = 0.002), had a higher prevalence of diabetes (46 vs 34%; p = 0.004), and left ventricular systolic ejection fraction (LVEF) < 40% (23 vs. 10%, p < 0.001). All GDMT goals were achieved in 26% and 24% of patients with and without CKD, respectively (p = 0.712). There were no between-group differences in achieving individual GDMT goals with the exception of RAASi (CKD vs non-CKD: adjusted risk ratio 0.73, 95% CI 0.62-0.87; p < 0.001). Attainment of GDMT goals in SIHD patients with CKD was similar to patients without CKD, with the exception of lower rates of RAASi use in the CKD group.

Temporal trends, determinants, and impact of high-intensity statin prescriptions after percutaneous coronary intervention: Results from a large single-center prospective registry

High-intensity statins (HIS) are recommended for secondary prevention following percutaneous coronary intervention (PCI). We aimed to describe temporal trends and determinants of HIS prescriptions after PCI in a usual-care setting. All patients with age ≤75 years undergoing PCI between January 2011 and May 2016 at an urban, tertiary care center and discharged with available statin dosage data were included. HIS were defined as atorvastatin 40 or 80 mg, rosuvastatin 20 or 40 mg, and simvastatin 80 mg. A total of 10,495 consecutive patients were included. Prevalence of HIS prescriptions nearly doubled from 36.6% in 2011 to 60.9% in 2016 (P < .001), with a stepwise increase each year after 2013. Predictors of HIS prescriptions included ST-segment elevation myocardial infarction/non-ST-segment elevation myocardial infarction (odds ratio [OR] 4.60, 95% CI 3.98-5.32, P < .001) and unstable angina (OR 1.31, 95% CI 1.19-1.45, P < .001) as index event, prior myocardial infarction (OR 1.48, 95% CI 1.34-1.65, P < .001), and co-prescription of β-blocker (OR 1.26, 95% CI 1.12-1.43, P < .001). Conversely, statin treatment at baseline (OR 0.86, 95% CI 0.77-0.96, P = .006), Asian races (OR 0.73, 95% CI 0.65-0.83, P < .001), and older age (OR 0.90, 95% CI 0.88-0.92, P < .001) were associated with reduced HIS prescriptions. There was no significant association between HIS prescriptions and 1-year rates of death, myocardial infarction, or target-vessel revascularization (adjusted hazard ratio 0.98, 95% CI 0.84-1.15, P = .84), although there was a trend toward reduced mortality (adjusted hazard ratio 0.71, 95% CI 0.50-1.00, P = .05). Although the rate of HIS prescriptions after PCI has increased in recent years, important heterogeneity remains and should be addressed to improve practices in patients undergoing PCI.

Temporal changes in statin prescription and intensity at discharge and impact on outcomes in patients with newly diagnosed atherosclerotic cardiovascular disease—Real-world experience within a large integrated health care system: The IMPRES study

Statins are indicated for secondary atherosclerotic cardiovascular disease (ASCVD) prevention; however, multiple surveys have found treatment gaps in clinical application. To determine trends over 15years in the prevalence and impact of a statin prescription and dose intensity at discharge after a first ASCVD event. The Intermountain Enterprise Data Warehouse was searched to identify all adults with a first encounter for ASCVD between January 1, 1999 and December 31, 2013, including coronary artery disease, cerebrovascular disease, and peripheral arterial disease, who survived the index event and were followed for ≥3years or until death. Major adverse cardiovascular events (MACE) were assessed overall and in 5-year increments. A total of 62,070 patients met inclusion criteria. Mean age was 65.9±13.7years, and most of them were male (64.7%). Increases in any statin (59.3% to 72.6% to 80.8%) and high-intensity prescription (3.1% to 14.2% to 28.1%) occurred over consecutive 5-year intervals and were greatest in coronary artery disease patients. Statin therapy was associated with a reduced risk of 3-year MACE (multivariable hazard ratio=0.75 [0.72, 0.78], P<.0001), with a significant linear trend across dose intensities. In a real-world experience within a large, integrated health care system, significant reductions in MACE were found in association with both any and high-intensity statin prescriptions following an ASCVD event. Temporal trends indicated progressive improvement in guideline-recommended prescriptions. However, treatment gaps remain in receipt of both any statin and, especially, a high-intensity statin prescription, and these represent prime opportunities for further improvement in secondary ASCVD prevention.

Statin prescription rates and their facility-level variation in patients with peripheral artery disease and ischemic cerebrovascular disease: Insights from the Department of Veterans Affairs.

The 2013 American College of Cardiology/American Heart Association cholesterol guideline recommends moderate to high-intensity statin therapy in patients with peripheral artery disease (PAD) and ischemic cerebrovascular disease (ICVD). We examined frequency and facility-level variation in any statin prescription and in guideline-concordant statin prescriptions in patients with PAD and ICVD receiving primary care in 130 facilities across the Veterans Affairs (VA) health care system between October 2013 and September 2014. Guideline-concordant statin intensity was defined as the prescription of high-intensity statins in patients with PAD or ICVD ≤75 years and at least moderate-intensity statins in those >75 years. We calculated median rate ratios (MRR) after adjusting for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns independent of patient characteristics. Among 194,151 PAD patients, 153,438 patients (79.0%) were prescribed any statin and 79,435 (40.9%) were prescribed a guideline-concordant intensity of statin. PAD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin therapy less frequently (69.1% and 28.9%, respectively). Among 339,771 ICVD patients, 265,491 (78.1%) were prescribed any statin and 136,430 (40.2%) were prescribed a guideline-concordant intensity of statin. ICVD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin less frequently (70.9% and 30.5%, respectively). MRRs for both PAD and ICVD patients demonstrated a 20% and 28% variation among two facilities in treating two identical patients with statin therapy and guideline-concordant intensity of statin therapy, respectively. The prescription of statins, especially guideline-recommended intensity of statin therapy, is suboptimal in PAD and ICVD patients, with significant facility-level variation not explained by patient-level factors.

Trends in Use of High-Intensity Statin Therapy After Myocardial Infarction, 2011 to 2014

BackgroundData prior to 2011 suggest that a low percentage of patients hospitalized for acute coronary syndromes filled high-intensity statin prescriptions upon discharge. Black-box warnings, generic availability of atorvastatin, and updated guidelines may have resulted in a change in high-intensity statin use. ObjectivesThe aim of this study was to examine trends and predictors of high-intensity statin use following hospital discharge for myocardial infarction (MI) between 2011 and 2014. MethodsSecular trends in high-intensity statin use following hospital discharge for MI were analyzed among patients 19 to 64 years of age with commercial health insurance in the MarketScan database (n = 42,893) and 66 to 75 years of age with U.S. government health insurance through Medicare (n = 75,096). Patients filling statin prescriptions within 30 days of discharge were included. High-intensity statins included atorvastatin 40 or 80 mg and rosuvastatin 20 or 40 mg. ResultsThe percentage of beneficiaries whose first statin prescriptions filled following hospital discharge for MI were for high-intensity doses increased from 33.5% in January through March 2011 to 71.7% in October through November 2014 in MarketScan and from 24.8% to 57.5% in Medicare. Increases in high-intensity statin use following hospital discharge occurred over this period among patients initiating treatment (30.6% to 72.0% in MarketScan and 21.1% to 58.8% in Medicare) and those taking low- or moderate-intensity statins prior to hospitalization (from 27.8% to 62.3% in MarketScan and from 12.6% to 45.1% in Medicare). In 2014, factors associated with filling high-intensity statin prescriptions included male sex, filling beta-blocker and antiplatelet agent prescriptions, and attending cardiac rehabilitation within 30 days following discharge. ConclusionsThe use of high-intensity statins following hospitalization for MI increased progressively from 2011 through 2014.

Abstract P123: Lipid-lowering Therapy Prescription Patterns and Predictors of High Intensity Statin Prescriptions in Patients With Diabetes or Atherosclerotic Cardiovascular Disease

Background: Many patients with atherosclerotic cardiovascular disease (ASCVD) or diabetes mellitus (DM) do not receive guideline-recommended lipid lowering therapy (LLT). We characterized LLT treatment patterns and identified predictors of high intensity statin prescriptions (Rx) in patients with ASCVD and DM. Methods: Olmsted County, MN residents with DM or ASCVD (MI, unstable angina, revascularization, ischemic stroke/TIA) from 2005-2012 were followed for 2 years capturing all LDL-C and LLT Rx. Cox regression examined predictors of high intensity statin Rx, modeling LDL-C as a time-dependent variable. Results: 8408 patients with DM (n=4881) or ASCVD (n=3527) were identified (mean age 63.1, 55.1% male). Over 2 years, mean (SD) number of LDL-C measurements was 2.7 (1.9); 12.1% had none. Among those with ≥1 LDL-C, the first was ≥100 mg/dL in 46.2%. LLT Rx increased within 30 days after the first LDL-C. (Table). However, among those with LDL-C ≥100, 40.1% were not prescribed LLT; these patients were younger (mean age 56.9 vs 60.8), more likely female (52.7% vs 45.6%) and more likely to have DM vs ASCVD (84.5% vs 54.6%) than those prescribed LLT. High intensity statin Rx increased more for those with LDL-C ≥100 than those with LDL-C &lt;100. Men [HR 1.29 (CI 1.13-1.48)] and patients with ASCVD vs DM [6.12 (5.25-7.12)] were more likely to be prescribed high intensity statins. Higher LDL-C was associated with greater high intensity statin Rx, although associations differed between ASCVD and DM (p-interaction=0.004). Compared to DM, ASCVD patients were more likely prescribed high intensity statins at every level of LDL-C [2.73 (1.70-4.37), 6.47 (4.94-8.47), 5.68 (4.45-7.25), and 7.88 (5.89-10.53) for LDL-C &lt;70, 70-99, 100-130, and ≥130]. Conclusions: Although high intensity statin Rx increased in response to increasing LDL-C, a large proportion of patients do not receive guideline-concordant care. Efforts should be made to encourage more aggressive treatment of elevated LDL-C and to understand why treatment is neglected or delayed.

Abstract 188: Hospital and Regional Variation in Use of High-intensity Statins Following Myocardial Infarction Among Medicare Beneficiaries

Background: American College of Cardiology/American Heart Association guidelines published in 2013 recommend high-intensity statins (atorvastatin 40 or 80 mg or rosuvastatin 20 or 40 mg) for most adults ≤75 years of age with atherosclerotic cardiovascular disease (ASCVD). For adults &gt;75 years of age with ASCVD, the guidelines recommend continuation of tolerated statins or initiation of moderate intensity statins for most patients. Objective: To examine whether guideline concordant use of high-intensity statins following myocardial infarction (MI) among Medicare beneficiaries differed by hospital size, medical school affiliation, and region of the US in 2014 (after publication of the guidelines). Methods: We identified 28,086 Medicare beneficiaries with fee-for-service and pharmacy coverage who filled a statin within 30 days following hospital discharge for MI in 2014. The analyses were restricted to 731 hospitals with at least 20 beneficiaries discharged for MI in 2014. Hospital size and medical school affiliation were determined from the American Hospital Association survey. In subgroups ≤75 and &gt;75 years of age, we calculated the proportion of beneficiaries whose first statin fill after MI was a high-intensity statin by hospital, hospital size, medical school affiliation, and region. Results: Among statin users ≤75 years of age, 10,696 (55%) beneficiaries filled a prescription for a high-intensity statin following MI. The percentage filling high-intensity statins range from 0-100% (25 th percentile 39%, 75 th percentile 69%) across hospitals. High-intensity statin use was more common following hospitalization at larger hospitals, hospitals with medical school affiliations, and those in New England ( Figure ). A lower percentage of Medicare beneficiaries &gt;75 years of age filled high-intensity statins (n = 8,441, 44%), but patterns were similar across hospital characteristics and region. Conclusions: Similar patterns of high-intensity statin use were present among individuals ≤75 years of age, in whom high-intensity statin use is guideline concordant, and individuals &gt;75 years of age, in whom high-intensity statin use is not necessarily guideline concordant, suggesting that variation in high-intensity statin prescriptions may not be directly related to close adherence to guidelines.

A consensus statement on lipid management after acute coronary syndrome.

In patients admitted for acute coronary syndrome (ACS), the guidelines of the European Society of Cardiology give a Class I, Level A recommendation for the prescription of high-intensity statins to be initiated as early as possible, regardless of the low-density lipoprotein cholesterol (LDL-C) level. Although statins are widely prescribed after ACS, the intensity of therapy and the proportion of patients achieving target LDL-C values are often not in line with recommendations due to a lack of compliance with guidelines by the physicians, a lack of compliance with treatment or poor tolerance by patients, and poor dose adaptation. In this context, a group of French physicians came together to define strategies to facilitate and improve the management of lipid-lowering therapy after ACS. This paper outlines the scientific rationale for the use of statins at the acute phase of ACS, the utility of ezetimibe, the measurement of LDL-C during the course of ACS, the opportunities for detecting familial hypercholesterolaemia and the results of the consensus for the management of lipid-lowering therapy, illustrated in two decision-making algorithms.

Impact of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines on the prescription of high-intensity statins in patients hospitalized for acute coronary syndrome or stroke

The 2013 American College of Cardiology/American Heart Association cholesterol management guidelines represented a paradigm shift from the National Cholesterol Education Program Adult Treatment Panel III guidelines, replacing low-density lipoprotein cholesterol targets with a risk assessment model to guide statin therapy. Our objectives are to compare provider prescription of high-intensity statin therapy in patients hospitalized with acute coronary syndrome (ACS) or cerebrovascular accident (CVA) before and after the publication of the 2013 cholesterol guidelines, determine potential predictors of high-intensity statin utilization, and identify targets for improvement in cardiovascular risk reduction among these high-risk populations. A single-center retrospective cohort study of 695 patients discharged with a diagnosis of ACS or CVA in the 6months before (n=359) and after (n=336) the release of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines. Patient characteristics were compared using analysis of variance and χ2 tests. Multivariable logistic regression models were used to assess clinical predictors of provider utilization of high-intensity statins. After the 2013 cholesterol guidelines, the rate of prescribing high-intensity statins was greater for statin-naïve patients compared with those already on statin therapy (odds ratio [OR]0.51, P=.02). Prescription of high-intensity statins was higher for patients with ACS compared with CVA (OR 8.4, P<.001-pre-2013 guidelines; OR 4.5, P<.001-post-2013 guidelines). Prescription of high-intensity statins steadily improved over the study period, significantly among patients with CVA (P<.001). Physicians were more likely to prescribe high-intensity statins in statin-naïve patients as compared with intensifying existing statin therapy, and their prescription pattern was lower after CVA vs ACS.

Abstract 142: Patterns and Predictors of Intensive Statin Therapy among Patients with Type 2 Diabetes Mellitus after an Acute Myocardial Infarction

Background: Patients with diabetes mellitus (DM) and acute myocardial infarction (AMI) are at increased risk for death and recurrent AMIs. Intensive statin therapy, a key component of aggressive risk factor management, has been shown to improve AMI outcomes especially in such a high risk population. However the frequency and predictors of intensive statin therapy among patients with DM after an AMI has not yet been described. Methods: We examined patterns of intensive statin therapy at discharge among AMI patients with prevalent DM enrolled in a 24-site US registry (TRIUMPH). Intensive statin therapy was defined as discharge on a statin with an expected LDL lowering of &gt;50% (i.e., 80mg of atorvastatin or ≥20mg of rosuvastatin). We investigated the association of patient characteristics (including DM duration, DM treatment type and HbA1c levels) with intensive statin therapy at discharge using hierarchical modified Poisson models. Results: The analysis cohort was comprised of 1,319 patients with DM who were discharged alive after an AMI; mean age was 60 years, 41% women, 42% nonwhite and mean HbA1c of 8.3. At hospital discharge, only 21% were prescribed intensive statin therapy. In the multivariable model, ST-elevations on arrival, statin use on admission and higher LDL levels were independent predictors of intensive statin therapy. DM duration, HbA1C, and DM treatment type were not associated with intensive statin therapy (Figure). Conclusion: In a large, multicenter registry, only 1 in 5 patients with DM were prescribed intensive statin therapy at discharge after an AMI. While type of AMI, and LDL levels did correlate with intensive statin therapy upon discharge, neither DM duration nor severity was significantly associated with intensive statin therapy. These observations suggest an under-recognition of the high-risk nature of these patients and represent an opportunity for systems improvement to optimize prescription of high-intensity statins, in accordance with evidence-base.