Prescription Of Lipid-lowering Therapy Research Articles

#1212 Trends in real-world lipid lowering therapy use among adult patients with chronic kidney disease: 5-year single center experience in the Philippines

Abstract Background and Aims Patients with chronic kidney disease (CKD) carry an extremely high burden for atherosclerotic cardiovascular disease (ASCVD), which worsens as CKD progresses. Several international guidelines, including the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, have recommended the use of lipid-lowering therapy (LLT) in this high-risk population. To evaluate the implementation of these recommendations in real-world practice, we assessed patterns of dyslipidemia management among patients with CKD. Specific objectives include describing the prevalence and intensity of LLT prescription [stratified by estimated glomerular filtration rate (GFR) and whether requiring renal replacement therapy or not] as well as adherence to guideline recommendations on LLT use. Method We conducted a single-center, cross-sectional study covering the period of January 2019 to December 2023. A review of inpatient and outpatient medical records of the Department of Medicine, University of the Philippine—Philippine General Hospital was done. Eligible patients were at least 18 years of age, and diagnosed with CKD. Exclusion criteria included having a concomitant diagnosis of Acute Kidney Injury, and being pregnant or breastfeeding at any point in the study period. Sociodemographic, clinical, and laboratory data were based off the latest entry in each patient's medical record. No clinical data were collected beyond those that were available on the records. Classification of statin intensity was based on the 2019 American Heart Association/American College of Cardiology Guidelines on the Management of Blood Cholesterol as well as the 2020 Philippine Clinical Practice Guidelines on the Management of Dyslipidemia. All analyses were descriptive and done using STATA 18. Categorical variables were summarized as frequencies and percentages. Continuous variables were reported as measures of central tendency [i.e. mean (SD) or median (IQR), as appropriate]. Results Of the 3845 patients included in the study, 2922 (76%) were prescribed LLT. The most common LLT were statins (92%), followed by statin/ezetimibe combinations (6%), then statin/fibrate combinations (2%). None were prescribed PCKS9 inhibitors, niacin, omega-3 fatty acids, or bile acid sequestrants. Among non-dialytic patients, the distribution of LLT use was as follows: a) eGFR ≥ 60 ml/min/1.73 m2: 40% (173/431) b) eGFR 30-60 ml/min/1.73 m2: 76% (1198/1576) c) eGFR <30 ml/min/1.73 m2: 84% (1551/1838). Among dialytic patients, 68% (601/884) were already on LLT prior to initiation of dialysis while 35% (283/884) were started on LLT after dialysis initiation. Notably, 89% (786/884) of these dialytic patients were still on moderate-to-high-intensity statin doses. Based on recommendations from the 2013 KDIGO guidelines, only 78% (2610/3334) of eligible patients were prescribed on LLT, while 61% (312/511) of ineligible patients were prescribed on LLT. Similar rates of adherence were seen to other international guideline recommendations on the management of dyslipidemia in CKD (e.g. 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol, 2019 European Society of Cardiology/European Atherosclerosis Society guidelines for the management of dyslipidaemias, 2020 Clinical Practice Guidelines for the management of dyslipidemia in the Philippines). Conclusion Real-world LLT use among CKD patients remains high, even at lower eGFRs. More importantly, a large proportion of patients remain under- and over-treated, highlighting significant gaps between guideline recommendations and real-world clinical practice. Further investigation regarding the underlying reasons for these practice variations is necessary to improve quality of care, and safely reduce the burden of dyslipidemia and ASCVD among CKD patients.

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.

Association of Use and Dose of Lipid-Lowering Therapy Post Acute Myocardial Infarction With 5-Year Survival in Older Adults.

Older people are underrepresented in randomized trials. The association between lipid-lowering therapy (LLT) and its intensity after acute myocardial infarction and long-term mortality in this population deserves to be assessed. The FAST-MI (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) program consists of nationwide French surveys including all patients admitted for acute myocardial infarction ≤48 hours from onset over a 1- to 2-month period in 2005, 2010, and 2015, with long-term follow-up. Numerous data were collected and a centralized 10-year follow-up was organized. The present analysis focused on the association between prescription of LLT (atorvastatin ≥40 mg or equivalent, or any combination of statin and ezetimibe) and 5-year mortality in patients aged ≥80 years discharged alive. Cox multivariable analysis and propensity score matching were used to adjust for baseline differences. Among the 2258 patients aged ≥80 years (mean age, 85±4 years; 51% women; 39% ST-segment elevation myocardial infarction; 58% with percutaneous coronary intervention), 415 were discharged without LLT (18%), 866 with conventional doses (38%), and 977 with high-dose LLT (43%). Five-year survival was 36%, 47.5%, and 58%, respectively. Compared with patients without LLT, high-dose LLT was significantly associated with lower 5-year mortality (adjusted hazard ratio, 0.78 [95% CI, 0.66-0.92]), whereas conventional-intensity LLT was not (adjusted hazard ratio, 0.93 [95% CI, 0.80-1.09]). In propensity score-matched cohorts (n=278 receiving high-intensity LLT and n=278 receiving no statins), 5-year survival was 52% with high-intensity LLT at discharge and 42% without statins (hazard ratio, 0.78 [95% CI, 0.62-0.98]). In these observational cohorts, high-intensity LLT at discharge after acute myocardial infarction was associated with reduced all-cause mortality at 5 years in an older adult population. These results suggest that high-intensity LLT should not be denied to patients on the basis of old age. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT00673036, NCT01237418, and NCT02566200.

Short-Course High-Intensity Statin Treatment during Admission for Myocardial Infarction and LDL-Cholesterol Reduction-Impact on Tailored Lipid-Lowering Therapy at Discharge.

We hypothesized that a short-course high-intensity statin treatment during admission for myocardial infarction (MI) could rapidly reduce LDL-C and thus impact the choice of lipid-lowering therapy (LLT) at discharge. Our cohort comprised 133 MI patients (62.71 ± 11.3 years, 82% male) treated with atorvastatin 80 mg o.d. during admission. Basal LDL-C levels before admission were analyzed. We compared lipid profile variables before and during admission, and LLT at discharge was registered. Achieved theoretical LDL-C levels were estimated using LDL-C during admission and basal LDL-C as references and compared to LDL-C on first blood sample 4-6 weeks after discharge. A significant reduction in cholesterol from basal levels was noted during admission, including total cholesterol, triglycerides, HDL-C, non-HDL-C, and LDL-C (-39.23 ± 34.89 mg/dL, p < 0.001). LDL-C levels were reduced by 30% in days 1-2 and 40-45% in subsequent days (R2 0.766, p < 0.001). Using LDL-C during admission as a reference, most patients (88.7%) would theoretically achieve an LDL-C < 55 mg/dL with discharge LLT. However, if basal LDL-C levels were considered as a reference, only a small proportion of patients (30.1%) would achieve this lipid target, aligned with the proportion of patients with LDL-C < 55 mg/dL 4-6 weeks after discharge (36.8%). We conclude that statin treatment during admission for MI can induce a significant reduction in LDL-C and LLT at discharge is usually prescribed using LDL-C during admission as the reference, which leads to insufficient LDL-C reduction after discharge. Basal LDL-C before admission should be considered as the reference value for tailored LLT prescription.

Therapeutic gaps in low-density lipoprotein cholesterol management have narrowed over time but remain wide: a wide study of 40,141 acute coronary syndrome patients from 2016 to 2021

Abstract Background There are significant therapeutic gaps in ‘real-word’ low-density lipoprotein cholesterol (LDL-C) management in very-high risk patients. Understanding these gaps is important for developing strategies to bridge these gaps. Purpose We aimed to evaluate trends and identify therapeutic gaps in LDL-C management in very-high risk patients. Methods We retrospectively analyzed consecutive patients admitted with a diagnosis of acute coronary syndrome (ACS) to 16 public hospitals in between 2016 and 2021. Baseline and 12-month lipid-lowering therapy (LLT) including statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor and LDL-C levels were recorded. We evaluated trends-over-time in percentage achievement of guideline Class I recommendations including (i) in-hospital initiation of high-intensity LLT; (ii) lipid-profile at follow-up post discharge; (iii) achieve at least 50% reduction in LDL-C from baseline with a goal of (iv) LDL-C &amp;lt;1.4 mmol/L. Results Of 40,141 ACS patients (mean age 71, male 66.5%), 61.2% were statin-naïve on admission. Baseline average LDL-C was 2.35 mmol/L (IQR 1.74 to 3.13 mmol/L). LLT prescription on discharge increased over time from 63.8% in 2016 to 96.2% in 2021. The use of high-intensity statins on discharge also increased over time from 24.7% to 53.7% but still suboptimal. The use of high-intensity statins increased significantly at 12-months (29.4% in 2016 and 59% in 2021) compared to on discharge (44.1% vs. 40.9% overall, p&amp;lt;0.001). The use of combination LLT was very low (1.3%-3.8%). Up to 22% of patients did not have repeated lipid profile after discharge. Of patients who had follow-up lipid profile, the median LDL-C was 1.74 mmol/L with a median LDL-C reduction of 29%. Only 27.5% reached the LDL-C goal of &amp;lt;1.4 mmol/L and 22.5% achieved at least 50% of LDL-C reduction. LDL-C reduction improved over time from 25.8% in 2016 to 31% in 2021, proportion of patients who reached LDL-C goal of &amp;lt;1.4 mmol/L improved over time from 20.8% in 2016 to 28.7% in 2021, and proportion of patients who achieved at least 50% of LDL-C reduction improved over time from 18.5% in 2016 to 24.6% in 2021, respectively. Conclusion Despite an increasing trend in the use of high-intensity statins and combination LLT over time, most patients did not reach guideline-recommended LDL-C target. Early up-titration of statin and addition of non-statin LLT may be required in the majority of patients.

Low-density-lipoprotein cholesterol target attainment in high-risk patients with history of diabetes or major adverse cardiac and cerebrovascular event: an (un)expected gender bias

Abstract Background Lowering low-density lipoprotein cholesterol (LDL-C) is the cornerstone of cardiovascular disease prevention, especially after the occurrence of a major adverse cardiac and cerebrovascular event (MACCE). Collection of epidemiological data is crucial for monitoring healthcare appropriateness and the fulfillment of guidelines recommendations. Purpose This analysis aimed to evaluate the proportion of high-risk patients who achieved LDL-C goal as suggested by the international guidelines by analyzing regional administrative data and to explore the predictors of therapeutic failure, with a focus on the role of gender. Methods By linking health administrative and laboratory data, we collected data from seven Local Health Districts on residents aged ≥45 years. Inclusion criteria were: 1) at least one LDL-C measurement in the year; 2) a history of MACCE (defined as myocardial infarction and/or stroke and/or revascularization of the coronary, carotid, or peripheral arteries) and/or type 2 diabetes mellitus (T2DM). Cohorts were defined at 1st January 2019 and 1st January 2020. Lipid lowering therapy use (defined as ≥2 prescription fillings or ≥75% coverage of treatment days) over the past 6 months if LDL-C data were available or over the past year if no LDL-C data were available was monitored. The outcome was the number of patients with on-treatment LDL-C optimal levels, as defined by levels &amp;lt;55 mg/dl for patients with MACCE and &amp;lt;70 mg/dl for patients with T2DM without MACCE. Results A cohort of 174,200 individuals was analyzed (55% males). As regards subjects on lipid-lowering therapies, we found that female gender was associated with a significantly lower probability to have LDL-C levels at target (OR: 0.58±0.01; p&amp;lt;0.0001) in patients with MACCE with or without T2DM, in a model adjusted for age, district area, and the presence of cardiovascular risk factors and comorbidities (renal failure, heart failure, atrial fibrillation). This result was confirmed also in the analysis conducted in subjects without lipid-lowering therapies (OR: 0.56±0.01; p&amp;lt;0.0001). No significant differences were documented by stratifying for the presence of clinical pathways aimed to the active call of the patients by clinicians ("Initiative Health"). Conclusions These results demonstrated that females have a significantly lower probability to reach LDL-C levels recommended targets. This datum is confirmed even in the absence of lipid-lowering therapies. These results call for action aimed to: 1) education for general population and for patients with MACCE with a specific target on females; 2) information for clinicians for the need of assessing adequate lipid-lowering therapy prescription and adherence irrespectively of gender; 3) organization of clinical pathways - from admission to recovery and follow-up - with a specific focus on secondary prevention target attainment.

1071 Examining Blood Lipid Profiles and Lipid Lowering Therapy in Carotid Surgery Patients in a 1-Year Follow-Up Study

Abstract Aim Stroke patients are at a high risk of future major adverse cardiovascular events. Focusing on lipid lowering therapy (LLT), current ESVS and NICE guidelines advise high intensity statin (HIS) treatment with a target LDL-C of less than 1.8mmol/L. Method This is a retrospective cohort study on 205 patients who underwent carotid endarterectomy or stenting from 01/01/18 to 31/12/20 at Leeds Vascular Institute. Prescriptions and lipid profiles prior to intervention, at discharge, and 1-year post-intervention were recorded. Differences between time points were assessed using the McNemar test. Results There were 137 men, the median age was 73, and 175 patients underwent carotid endarterectomy. Increases in prescriptions of statins (65%vs93%, p&amp;lt;0.001) and HIS (47%vs83%, p&amp;lt;0.001) were observed at discharge compared to pre-intervention but no differences were seen at 1 year. At 1 year, 8 patients were not on statin therapy; 6 were intolerant and 3 were prescribed Ezetimibe. At 1 year, there was a significant improvement in median LDL-C (2.4mmol/L IQR (1.9-3.3) vs. 1.6mmol/L (1.2-2.0)), and proportion of patients reaching target LDL-C of &amp;lt;1.8mmol/L (21%vs59%,p = 0.003) compared to pre-admission. In patients with LDL-C≥1.8mmol/L, 92% had scope for LLT up-titration. No significant differences were noted in the proportion of patients who underwent lipid profile monitoring prior to admission and at 1 year. Conclusions Admission to our local vascular unit is associated with an increase in the guideline-directed prescription of LLT, and subsequently attainment of target LDL-C. Reasons for suboptimal lipid monitoring in the community need to be understood to allow for optimal risk reduction.

Impact of Patient Visualization of Cardiovascular Images on Modification of Cardiovascular Risk Factors: Systematic Review and Meta-Analysis

BackgroundIt is unclear whether detection and patient visualization of cardiovascular (CV) images using computed tomography to assess coronary artery calcium or carotid ultrasound (CU) to identify plaque and intima-medial thickness merely prompts prescription of lipid-lowering therapy or whether it motivates lifestyle change among patients. ObjectivesThis systematic review and meta-analysis sought to investigate whether patient visualization of CV images (computed tomography or CU) has a beneficial impact on improving overall absolute CV risk as well as lipid and nonlipid CV risk factors in asymptomatic individuals. MethodsThe key words “CV imaging,” “CV risk,” “asymptomatic persons,” “no known or diagnosed CV disease,” and “atherosclerotic plaque” were searched in PubMed, Cochrane, and Embase in November 2021. Randomized trials that assessed the role of CV imaging in reducing CV risk in asymptomatic persons with no known CV disease were eligible for study inclusion. The primary outcome was a change in 10-year Framingham risk score from the trial commencement to the end of the follow-up following patient visualization of CV images. ResultsSix randomized controlled trials (7,083 participants) were included; 4 studies used coronary artery calcium and 2 used CU to detect subclinical atherosclerosis. All studies used image visualization in the intervention group to communicate CV risk. Imaging-guidance was associated with a 0.91% improvement in 10-year Framingham risk score (95% CI: 0.24%-1.58%; P = 0.01). Significant reductions in low-density-lipoprotein, total cholesterol, and systolic blood pressure were observed (all P < 0.05). ConclusionsPatient visualization of CV imaging is associated with overall CV risk reduction and improvement of individual risk factors: cholesterol and systolic blood pressure.

Outpatient Practice of Lipid-Lowering Therapy Prescription (According to the ARGO-3 Study)

Aim. To study the frequency of prescriptions of various types of lipid-lowering therapy and their effectiveness in outpatient clinical practice based on the results of a questionnaire of primary care physicians.Material and methods. The study was performed in 2022 in 75 constituent entities of the Russian Federation with the participation of 1117 doctors working in outpatient clinics. Most of the doctors had work experience of 10-20 years or more. Doctors of polyclinics (therapists and cardiologists, etc.) before the start of the study received instructions, questionnaires for filling out, developed by the National Atherosclerosis Society. The frequency of prescriptions by primary care physicians of various types of lipid-lowering therapy and their effectiveness in terms of the frequency of achieving target levels of low-density lipoprotein cholesterol (LDL-C) was studied based on the results of a questionnaire.Results. Monotherapy with statins was prescribed in 55.2% of cases, free combination of rosuvastatin with ezetimibe – in 17.2%, single pill combination of rosuvastatin with ezetimibe – in 23.2%, combination therapy with PCSK9 inhibitors – in 4.1% of cases. Target levels of LDL-C ˂ 1.8 mmol/l and ˂ 1.4 mmol/l were achieved with statin monotherapy in 42.6% and 28.2% of cases, respectively, free combination of rosuvastatin with ezetimibe – in 61.7% and 39 .5%, a fixed combination of rosuvastatin with ezetimibe – in 67.8% and 48.5%, combination therapy with PCSK9 inhibitors – in 96.8% and 92.8% of cases.Conclusion. The single pill combination of rosuvastatin with ezetimibe is more effective in achieving target levels of LDL-C compared with statin monotherapy and therapy with free combination of statin with ezetimibe. Despite the fact that the target values of LDL-C when prescribing a combination with PCSK9 inhibitors were achieved in 96.8% and 92.8% of cases, they were used quite rarely at the outpatient stage of treatment in the Russian Federation.

Analysis of the frequency of detection of hypercholesterolemia, carotid atherosclerosis and lipid-lowering therapy prescription in young adults under 45 years old according to the Duplex registry database

Aim of the study to analyze the detection of hypercholesterolemia (HCHL) and carotid atherosclerosis (CAS), verified by duplex scanning of the carotid arteries (DSCA) in young adults (YA), and to evaluate the lipid-lowering therapy (LLT) prescription among them according to the local registry database.&#x0D; Material and Methods: The Duplex registry database was used for this study (n=2548). YA up to 45 years old were selected for the final analysis (n=351).&#x0D; Results: HCHL (&gt; 5 mmol/L) was detected in 68.9% of patients (n=241), and only 9.5% of them received LLT (n=23). CAS was detected in 12.8% (n=45), only 17.8% of them had received LLT (n=8). Men and women differed 1.5 times by the incidence of CAS in this age range: 15.7% (30 out of 191) vs 9.4% (15 out of 160), p=0.05. Men also generally have a higher prevalence of other risk factors/diseases: HCHL (78.0% (n=149) vs 58.1% (n=93) in women, p=0.00004), hypertension (AH) (15.7% (n=30) vs 9.4% (n=15) in women, p=0,05), history of myocardial infarction (MI) (1,6% (n=3) vs 0% (n=0) in women, ns). Signs that had a significant impact on LLT intake were the following: CAS (OR 2.8 [1.09;6.6] p=0.036); AH (OR 3.1 [1.32; 7.16] p=0.009); HCHL (&gt; 5 mmol/L) (OR 4.2 [1.12; 26.83] p=0.06); HCHL (ICD-10 code E78) (OR 5.4 [2.04; 13.7] p=0.0003); MI history (OR 22.3 [1.65;675.5] p=0.009).&#x0D; Conclusion: The insufficient LLT prescription in young adults with HCHL and CAS was ascertained in the present study. The use of imaging methods to clarify the degree of cardiovascular risk is advisable for low and intermediate risk patients, which include young adults. DSСA is the main method for subclinical atherosclerosis verification. LLT should be prescribed to all YA patients with CAS (in the absence of contraindications).&#x0D; Graphical Abstract

Analyzing Sex Differences in Intensity of Cardiovascular Disease Prevention Medications in Patients With Abdominal Aortic Aneurysms—A Single-Center Cross-Sectional Study

Patients with abdominal aortic aneurysm (AAA) are at a significant risk of cardiovascular events, similar to that of patients who have already experienced a major cardiac event. The European Society for Vascular Society AAA guidelines suggest that antiplatelet therapy and lipid-lowering therapy (LLT) should be considered in all patients with AAA. This study explores the overall prevalence and intensity of antithrombotic therapy and LLT, and lipid profile monitoring in a single center AAA surveillance cohort alongside any sex differences. This was a retrospective, single center, cross-sectional study of 614 patients enrolled in the AAA surveillance program of a tertiary vascular surgery unit. All patients undergoing at least 1 surveillance scan from January 1, 2018, to December 31, 2020, were assessed. Electronic hospital records linked to real-time primary care records were interrogated for data on demographics, comorbidities, antiplatelet and LLT prescriptions, and serum cholesterol laboratory results. An analysis of covariance test was used to account for the effects of confounding comorbidities. Twenty-one percent of patients were not on antithrombotic therapy, and 20% of patients were not on LLT which reflects a group of patients receiving sub-optimal clinical care. In total, 47% of the cohort were on low/moderate intensity statin therapy which reflects a group of patients where care can be improved upon. Female sex was independently associated with a reduced likelihood of being prescribed LLT (P=0.008, eta squared (ηp2)=0.012, small effect size) but not antithrombotic therapy (P=0.202). Fewer women underwent low-density lipoprotein cholesterol (LDL-C) monitoring (mean difference 9%, P=0.040) and achieved the European Society of Cardiology-European Atherosclerosis Society- LDL-C target of <1.4mmol/L (mean difference 9%, P=0.040). Overall, there is room for improvement in these aspects of cardiovascular risk prevention for both sexes. Sex differences in the prescription of LLT, the prevalence of lipid profile monitoring, and likelihood of achieving LDL-C targets exist among patients with AAA, with a lower prevalence in women.

Cardiovascular Risk Profile and Lipid Management in the Population-Based Cohort Study LATINO: 20 Years of Real-World Data.

The rising prevalence of cardiovascular (CV) risk factors in Portugal has translated into more than 35,000 annual deaths due to CV diseases. We performed a multicenter observational cohort study encompassing clinical activities performed between 2000 and 2019 to characterize the CV risk profile and LDL-C management of patients in every CV risk category using electronic health records of a regional population in Portugal. We analyzed data from 14 health centers and 1 central hospital in the north of Portugal of patients between 40 and 80 years that had at least 1 family medicine appointment at these institutions. Living patients were characterized on 31 December 2019. CV risk assessment was computed according to the 2019 ESC/EAS Guidelines. Lipid-lowering therapy (LLT) and achievement of LDL-C targets were assessed. In total, the analysis included 78,459 patients. Patient proportions were 33%, 29%, 22%, and 17% for low, intermediate, high, and very high CV risk, respectively. Moderate-intensity statins were the most frequently used medication across all CV risk categories. High-intensity statins were used in 5% and 10% of high and very high CV risk patients, respectively. Ezetimibe was used in 6% and 10% of high and very high CV risk patients, respectively. LDL-C targets were achieved in 44%, 27%, 7%, and 3% of low, intermediate, high, and very high CV risk patients, respectively. For uncontrolled patients in the high and very high CV risk categories, a median LDL-C reduction of 44% and 53%, respectively, would be required to meet LDL-C targets. There are clear opportunities to optimize LDL-C management in routine clinical practice. The prescription of LLT according to CV risk represents an important missed treatment opportunity.

Exploring Contemporary Data on Lipid-Lowering Therapy Prescribing in Patients Following Discharge for Atherosclerotic Cardiovascular Disease in the South of Italy.

Current international guidelines strongly recommend the use of high-intensity lipid-lowering therapy (LLT) after hospitalization for atherosclerotic cardiovascular disease (ASCVD) events. With this study, our aim was to evaluate LLT prescribing in a large Italian cohort of patients after discharge for an ASCVD event, exploring factors associated with a lower likelihood of receiving any LLT and high-intensity LLT. Individuals aged 18 years and older discharged for an ASCVD event in 2019–2020 were identified using hospital discharge abstracts from two local health units of the Campania region. LLT treatment patterns were analyzed in the 6 months after the index event. Logistic regression models were developed for estimating patient predictors of any LLT prescription and to compare high-intensity and low-to-moderate-intensity LLT. Results: A total of 8705 subjects were identified. In the 6 months post-discharge, 56.7% of patients were prescribed LLT and, of those, 48.7% were high-intensity LLT. Female sex, older age, and stroke/TIA or PAD conditions were associated with a higher likelihood of not receiving high-intensity LLT. Similar predictors were found for LLT prescriptions. LLT utilization and the specific use of high-intensity LLT remain low in patients with ASCVD, suggesting a substantial unmet need among these patients in the contemporary real-world setting.

Lipid-lowering treatment intensity, persistence, adherence and goal attainment in patients with coronary heart disease

BackgroundTo examine patterns of lipid-lowering therapy (LLT) use, and persistence and adherence among patients with coronary heart disease and their associations with lipoprotein cholesterol (LDL-C) goal attainment. MethodsObservational study among 26,768 patients who had suffered a myocardial infarction or had been revascularized in Stockholm during 2012 to 2018, and followed up through 2019. Outcomes included initiation of LLT, discontinuation, re-initiation, adherence to treatment and LDL-C goal attainment according to the European dyslipidaemia guidelines from 2011 and 2016 (mainly LDL-C <1.8 mmol/L). Results82% of patients commenced or continued LLT within 90 days after discharge. Of those, 71% were dispensed an LLT prescription within 30 days (62% of them for high-intensity LLT). High-intensity LLT prescribing increased over time, from 12% in 2012 to 78% in 2018. During a median follow-up of 3 (IQR 2-5) years 73% continued to fill prescriptions for a statin, 26.3% temporarily or permanently discontinued, and 0.5% changed to non-statin LLT. Only 1.3% discontinued statin treatment permanently. Throughout observation, about 80% of patients showed good statin adherence (proportion of days covered ≥80%). LDL-C target attainment was 52% the first year and <50% during subsequent years. LDL-C goal attainment was highest among patients receiving high-intensity statin treatment and showing good treatment adherence. ConclusionIn secondary prevention for patients with established coronary heart disease, the proportion of LDL-C target attainment was low throughout the time period of the study, despite increasing use of high-intensity LLT and good treatment persistence and adherence.

Compliance with Cardiovascular Prevention Guidelines in Type 2 Diabetes Individuals in a Middle-Income Region: A Cross-Sectional Analysis.

Stricter control of risk factors has been pursued as a compelling strategy to mitigate cardiovascular events (CVE) in type 2 diabetes (T2D) individuals. However, the achievement rate of the recommended goals has remained low in clinical practice. This study investigated the 2019 ESC guideline recommendation attainment among T2D individuals enrolled in a national cohort held in Brazil. Data from 1030 individuals (mean age: 58 years old; 54% male; mean T2D duration: 9.7 years) were analyzed. The control rates were 30.6% for SBP, 18.8% for LDL-C, and 41% for A1c, and only 3.2% of the study participants met all three targets. Statins and high-intensity lipid-lowering therapy prescription rates were 45% and 8.2%, respectively. Longer T2D duration and those at higher CV risk were less likely to be controlled. Longer diabetes duration and higher CV risk were inversely related to the chance of achieving the recommended targets. Treatment escalation using conventional therapies would be sufficient to gain optimal control in most of the study sample. In conclusion, a minimal proportion of T2D individuals comply with guidelines-oriented CV prevention targets. Given the significant burden of the disease, and the substantial effect size predicted for these therapies, bridging this gap between guidelines and clinical practice should be considered an urgent call to public health managers.

Organization of lipid centers operation in the Russian Federation — new opportunities

Project of the Russian National Atherosclerosis SocietyIn 2016, Guidelines on the medical care organization to the patients with hereditary atherogenic lipid disorders in the regions of Russia were published, which described and presented the principles of routing patients with hereditary dyslipidemia and the organization of medical care for them within the current regulatory documents. In December 2018, the Russian Ministry of Health approved clinical guidelines for the diagnosis and treatment of familial hypercholesterolemia. Thus, persons with a severe hereditary dyslipidemia were able to get free medication with expensive lipid-lowering drugs and receive apheresis. Following the European ones, the Russian guidelines on the management of lipid metabolism disorders were updated: lower target low density lipoprotein cholesterol levels were adopted. In the Russian population, there is a high prevalence of hypercholesterolemia, including familial monogenic and polygenic types. Therefore, timely detection and routing to a lipid center or an office to a specialist (cardiologist, lipidologist), adequate and modern prescription of lipid-lowering therapy will make an important contribution not only to secondary, but also to primary prevention of atherosclerotic cardiovascular complications.

Temporal trends of lipid control in very high cardiovascular risk patients

IntroductionSince 2011, the European guidelines have included a specific low-density lipoprotein cholesterol (LDL-C) target, <70 mg/dl, for very high cardiovascular risk (CVR) patients. However, registries have shown unsatisfactory results in obtaining this level of adequate lipid control. ObjectivesTo assess temporal trends in the use of lipid-lowering therapy (LLT) and attainment of adequate control in very high CVR patients since 2011. MethodsWe performed a retrospective observational study including very high CVR patients admitted in two periods: the first two years since the 2011 guidelines (2011/2012) and five years later (2016/2017). Lipid values, LLT, clinical variables and adequate lipid control rates were analyzed. ResultsA total of 1314 patients were reviewed (2011/2012: 638; 2016/2017: 676). Overall, 443 patients (33.7%) were not under LLT and only a slight improvement in drug prescription was observed from 2011/2012 to 2016/2017. In LLT users, the proportion of high-intensity LLT increased significantly in the later years (6.4% vs. 24.0%; p<0.001), but this was not associated with adequate lipid control. Overall, mean LDL-C was 95.4±37.2 mg/dl and adequate control was achieved in 320 patients (24.4%), without significant differences between 2011/2012 and 2016/2017 (p=0.282). Independent predictors of adequate control were male gender, older age, diabetes, chronic kidney disease, prior acute coronary syndrome, prior stroke and LLT, while stable coronary artery disease was associated with higher risk of failure. ConclusionEven after the introduction of specific LDL-C targets, these are still not reached in most patients. Over a five-year period, LLT prescription only improved slightly, while adequate lipid control rates remained unchanged.

Lipid-lowering therapy in outpatients of different ages with coronary artery disease

Aim. To conduct a pharmacoepidemiologic analysis of lipid-lowering therapy (LLT) in outpatients of different ages with coronary artery disease (CAD).Material and methods. A total of 805 medical records of outpatients with CAD were analyzed in this pharmacoepidemiologic, cross-sectional study conducted at primary care facility of Moscow. The total sample of patients was divided into 3 age groups: group 1 — &lt;65 years (n=267; 33,2%), group 2 — 65-74 years (n=305; 37,9%), group 3 — ≥75 years (n=233; 28,9%). Data on LLT (prescription rates, structure, intensity), prevalence of irrational drug combinations, lipid profile were collected. Statistical analysis was performed using SciPy 1.4.1, NumPy 1.18.4 for Python 3.73. Differences were considered significant at p&lt;0,05.Results. LLT prescription rates were equally high in all ages — 92,9%, 85,9%, and 81,6% in groups 1, 2, and 3 respectively (p&gt;0,05). Dual LLT was prescribed rarely (4,9%, 3,9%, 0,9%, respectively), especially in patients ≥75 years (p&lt;0,05 for groups 1 and 3, p»0,05 for groups 2 and 3). Atorvastatin prevailed in all ages (p&gt;0,05); patients ≥75 received rosuvastatin less often (p&lt;0,05 for groups 1 and 3); simvastatin was more frequently prescribed to patients ≥65 years (p&lt;0,05 for groups 1 and 2, 1 and 3). Prescription rate of high-intensity LLT was higher in group 1 (57,3%) compared with group 2 (40,1%; p&lt;0,05) and group 3 (30,0%; p&lt;0,01). Prevalence of polypharmacy (50,2%, 56,5%, 60,4%) and irrational drug combinations (34,0%, 38,1%, 43,3%) was comparable in all groups (p&gt;0,05), as well as the proportion of patients not achieved target LDL-C &lt;1,8 mmol/l (72,9%, 73,9%, 84,3%; p&gt;0,05).Conclusion. The study demonstrated no significant influence of patient age on LLT prescription rates, LDL-C control, and prevalence of irrational drug combinations in outpatients with CAD. Rates of dual LLT, structure and intensity of statin therapies differed depending on age groups.

Modern principles of atherogenic dyslipidemia management in special groups of patients

Aim.To provide modern view on atherogenic disorders in the blood lipid spectrum, the principles of lipid-lowering therapy prescription in certain groups of patients, the safety issues of statin therapy in patients with chronic liver diseases.&#x0D; Materials and methods.The data of 55 scientific sources published in the Russian and foreign press in 19882020 were analyzed.&#x0D; Results.It is known that atherogenic dyslipidemia is a key factor in pathogenesis of atherosclerotic cardiovascular diseases. Various disorders in blood lipids and lipoproteins are identified. In this regard, there are certain recommendations for the analysis of lipids and lipoproteins in certain situations. The issues of interpreting extreme deviations from normal values of the blood lipid spectrum are discussed. Patient groups with different levels of the cardiovascular risk, which determines prescription of lipid-lowering therapy, are presented. Statins are the first line of lipid-lowering therapy for both the correction of dyslipidemia and the prevention of cardiovascular complications. The article discusses the tactics of prescribing statins in special groups of patients, their safety issues. It considers promising ways for increasing statins tolerability in patients with chronic liver diseases, primarily with non-alcoholic fatty liver disease, by adding of combined hepatoprotector.&#x0D; Conclusions.Generally, modern tactics of statins prescription are based on dyslipidemia characteristics and the patients cardiovascular risk level. Moreover, statins are clinically effective in special patient groups and have a good tolerability profile.

Lipid-lowering therapy in patients with coronary artery disease in primary care practices: what has changed over 7 years?

Aim. To analyze changes in the pattern of lipid-lowering therapy (LLT) in outpatients with stable coronary artery disease (SCAD) over the 7-year period.Material and methods. This pharmacoepidemiological, retrospective, cross-sectional, two-stage study was conducted on the basis of primary care facility of Moscow. We analyzed 1,834 and 805 medical records of patients with SCAD at the first (2011) and second (2018) stages, respectively. Data on demography, medical history, lipid profile, and administrated LLT were collected. Statistical analysis was performed using SPSS Statistics V16.0 and MS Excel. Differences were considered significant at p&lt;0,05.Results. Overall LLT prescription rate in outpatients with SCAD increased from 48,5 up to 86,4% (p&lt;0,05) over the 7-year period. Statin monotherapy continued to prevail in the structure of LLT: its prescription rate increased from 48,2 up to 82,3% (p&lt;0,05) in total sample. Use of statin/ezetimibe combination was registered only in 2018 (2,4% in LLT structure). Atorvastatin was the most frequently recommended medication at both study stages (51,5 vs 66,3%; p&lt;0,05); prescription rate of simvastatin decreased from 44,5 to 3,9% (p&lt;0,05), rosuvastatin — increased from 1,7 to 29,5% (p&lt;0,05). Over the study period, the proportion of patients receiving high-intensity LLT increased (2,0 vs 41,8%; p&lt;0,05). We also revealed a significant increase of patients who reached target levels of low-density lipoprotein cholesterol (11,1 vs 23,3%; p&lt;0,05) and total cholesterol (17,0 vs 33,0%; p&lt;0,05).Conclusion. The results demonstrated significant improvements in the LLT pattern over the 7-year period in outpatients with SCAD. Number of patients receiving statins doubled, and the cases of prescribing lowintensity LLT have become very rare. However, control of blood lipids in the target group remained inadequate.