Recent Low-density Lipoprotein Cholesterol Research Articles

Lipid lowering therapy and the unmet targets in Indian patients with angiographically proven coronary artery disease: results from the OLS registry

Abstract Introduction The Lipid Association of India (LAI) 2020 guidelines classify patients with established atherosclerotic cardiovascular disease in either very high-risk or extreme-risk groups and recommend that intensive lipid-lowering therapy (LLT) should be administered to such patients to achieve a target low-density lipoprotein cholesterol (LDL-C) level below 50 mg/dl at least (preferably < 30 mg/dl in extreme risk groups). Purpose This study aimed to assess the achievement of the LAI-recommended LDL-C goals in patients with angiographically proven coronary artery disease (CAD). Methods The Optimization of LDL-C in the Stable CAD (OLS) registry started in August 2023 in 10 interventional cardiology centers across Northern India. Interventional cardiologists (ICs) were treating all enrolled patients with angiographically proven stable CAD, and data were collected at a single visit, including the most recent LDL-C and the LLT in the preceding three months of that LDL-C reading. The primary outcome was achieving the LAI-recommended LDL-C goal of <50 mg/dl. The achievement of the American College of Cardiology (ACC) recommended goal of <70 mg/dl was also assessed. Results A total of 1860 patients with angiographically proven CAD were enrolled in this ongoing registry over four months (August 2023- November 2023). The mean age of the study population was 60.2 + 9.2 years, and 79% were males. 30.3% of patients had Diabetes mellitus (DM), 36.1% had hypertension (HTN), 42.3% were obese (body mass index > 25kg/m2), and 17.8% of patients were current smokers. 74.2% of patients had a history of myocardial infarction, while 76.7% had undergone prior percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Rosuvastatin was the statin prescribed in 59.4% of patients, while atorvastatin was prescribed in 37.2%. 1270 (68.3%) of patients were taking high-intensity statin (HIS) therapy (either 20-40 mg rosuvastatin or 40-80 mg atorvastatin). Only 22 (1.2%) patients took other lipid-lowering agents, including ezetimibe, bempedoic acid, and fibrates. None of the patients were using PCSK9 Inhibitors. Only 482(25.9%) patients achieved their LAI recommended goal of LDL-C <50 mg/dl, 113(6.1%) achieved LDL-C < 30 mg/dl, while 863(46.4%) achieved ACC goal of <70 mg/dl. Notably, only 62(3.3%) patients were not taking any lipid-lowering treatment. Conclusion Results of the OLS study demonstrate the high-risk status of CAD in Indian patients with a high prevalence of DM, HTN, and obesity. Most patients were post-PCI/CABG, mainly because ICs did enrolments. More than two-thirds of patients were taking HIS and very few were not taking any treatment. Despite this, only one-fourth of patients achieved the target LDL-C goals. Greater and early utilization of combination LLT, including HIS and non-statin LLT, is likely needed to reduce these gaps for patients at the highest risk.

Low-density lipoprotein cholesterol goal attainment in Germany: Results from the DA VINCI study

Background and aimsCardiovascular mortality is high in Germany. For patients with high or very high cardiovascular risk, the European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines recommend intensive lipid lowering therapy (LLT). This study aimed to assess dyslipidaemia management and achievement of the ESC/EAS guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals. MethodsThis European 18-country, cross-sectional, observational DA VINCI study (EUPAS22075) collected data during a single visit between June 2017 and November 2018 and included LLT in the preceding 12 months and the patients' most recent LDL-C measurement. Achievement of the risk-based 2016 and 2019 ESC/EAS LDL-C goals while receiving stabilized LLT was assessed. Data from the German cohort are presented here. ResultsSeven German sites enrolled a total of 421 primary and secondary prevention patients, 327 were receiving stabilized LLT at the time of LDL-C measurement, i.e. statin monotherapy of high (16%; n = 53), moderate (49%; n = 160) or low (7%; n = 24) intensity, ezetimibe combination (18%; n = 58), proprotein convertase subtilisin/kexin type 9 antibody combination (3%; n = 9), and other LLT (7%; n = 23). The 2016 and 2019 risk-based LDL-C goals were attained by 46% (n = 149) and 28% (n = 92) of patients, respectively. ConclusionsThere is a large gap between ESC/EAS recommendations and LDL-C goal achievement in routine clinical practice in high and very high-risk patients in Germany. Low-to-moderate-intensity statin monotherapy was the most frequently used LLT; use of high-intensity statins and combination therapy was limited. In addition to optimizing statin intensity, combination with non-statin LLT may be needed in most of these patients.

Association Between Cumulative Low-Density Lipoprotein Cholesterol Exposure During Young Adulthood and Middle Age and Risk of Cardiovascular Events

Low-density lipoprotein cholesterol (LDL-C) is a major risk factor for cardiovascular disease (CVD). Most observational studies on the association between LDL-C and CVD have focused on LDL-C level at a single time point (usually in middle or older age), and few studies have characterized long-term exposures to LDL-C and their role in CVD risk. To evaluate the associations of cumulative exposure to LDL-C, time-weighted average (TWA) LDL-C, and the LDL-C slope change during young adulthood and middle age with incident CVD later in life. This cohort study analyzed pooled data from 4 prospective cohort studies in the US (Atherosclerosis Risk in Communities Study, Coronary Artery Risk Development in Young Adults Study, Framingham Heart Study Offspring Cohort, and Multi-Ethnic Study of Atherosclerosis). Participants were included if they had 2 or more LDL-C measures that were at least 2 years apart between ages 18 and 60 years, with at least 1 of the LDL-C measures occurring during middle age at 40 to 60 years. Data from 1971 to 2017 were collected and analyzed from September 25, 2020, to January 10, 2021. Cumulative exposure to LDL-C, TWA LDL-C, and LDL-C slope from age 18 to 60 years. Incident coronary heart disease (CHD), ischemic stroke, and heart failure (HF). A total of 18 288 participants were included in this study. These participants had a mean (SD) age of 56.4 (3.7) years and consisted of 10 309 women (56.4%). During a median follow-up of 16 years, 1165 CHD, 599 ischemic stroke, and 1145 HF events occurred. In multivariable Cox proportional hazards regression models that adjusted for the most recent LDL-C level measured during middle age and for other CVD risk factors, the hazard ratios for CHD were as follows: 1.57 (95% CI, 1.10-2.23; P for trend = .01) for cumulative LDL-C level, 1.69 (95% CI, 1.23-2.31; P for trend <.001) for TWA LDL-C level, and 0.88 (95% CI, 0.69-1.12; P for trend = .28) for LDL-C slope. No association was found between any of the LDL-C variables and ischemic stroke or HF. This cohort study showed that cumulative LDL-C and TWA LDL-C during young adulthood and middle age were associated with the risk of incident CHD, independent of midlife LDL-C level. These findings suggest that past levels of LDL-C may inform strategies for primary prevention of CHD and that maintaining optimal LDL-C levels at an earlier age may reduce the lifetime risk of developing atherosclerotic CVD.

Geographic variations in lipid-lowering therapy utilization, LDL-C levels, and proportion retrospectively meeting the ACC/AHA very high-risk criteria in a real-world population of patients with major atherosclerotic cardiovascular disease events in the United States

ObjectiveWe assessed national- and state-level geographic variations among patients with a history of ≥1 major atherosclerotic cardiovascular disease (ASCVD) event in: (1) the proportion of patients with retrospectively identified 2018 American College of Cardiology/American Heart Association guideline very high-risk (VHR) ASCVD criteria; (2) utilization of guideline-directed lipid-lowering therapy (LLT); and (3) the proportion of patients with persistent low-density lipoprotein cholesterol (LDL-C) elevations despite statin and/or ezetimibe use. MethodsA retrospective cohort study using the Prognos LDL-C database linked to IQVIA longitudinal medical and prescription claims databases. The study period was from January 01, 2011, to November 30, 2019 and the index period was from January 01, 2016, to November 30, 2019; the index date was defined as the most recent LDL-C test during the index period. The study included patients aged ≥18 years at index who had a measured LDL-C level during the index period and had ≥1 inpatient/outpatient claim for ASCVD during the 5-year pre-index period. ResultsOf patients with any ASCVD (N=4652,468), 1537,514 (33.1%) patients had ≥1 major ASCVD event. Among patients with ≥1 major ASCVD event, the VHR ASCVD criteria were retrospectively identified in 1139,018 (74.1%) patients; Hawaii had the highest (81.7%) and Colorado the lowest (65.0%) proportion of these patients. Nationally, 48.8% and 50.2% of patients with ≥1 major ASCVD event and retrospectively identified VHR ASCVD criteria, respectively, had current LLT use; Massachusetts and Colorado had the highest and lowest proportions, respectively. After standardizing for age and sex, 57.3% and 58.8% of patients with ≥1 major ASCVD event and retrospectively identified VHR ASCVD criteria, respectively, had LDL-C ≥70 mg/dL (≥1.8 mmol/L) despite statin and/or ezetimibe use, with substantial state-level variations observed. ConclusionsThe study highlights high rates of elevated LDL-C and pervasive underuse of LLT in health-insured patients with a history of major ASCVD events treated in the United States, with state-level geographic variations observed.

Abstract 15830: Uncontrolled and Undertreated Cholesterol in Patients With Severe Hypercholesterolemia at a Large Healthcare System

Introduction: Patients with phenotypic severe hypercholesterolemia (SH) (low-density lipoprotein-cholesterol (LDL-c) ≥ 190 mg/dL), should have at least 50% LDL-c lowering by treatment with a maximally tolerated statin to goal LDL-c&lt;100 mg/dL for primary prevention. Despite even more aggressive goals in Europe, these targets are not widely implemented. Methods: Cross-sectional study using an electronic medical record-based SH registry defined by ever having an LDL-c ≥ 190 mg/dL from 01/01/2000-01/16/2020 (n=17,925) at Essentia Health (MN, WI, and ND). Patients excluded if they had no visit at EH within the past 5 years (n=274), were &lt;20 or &gt;75 years old (n=3,171) or deceased (n=34). Results: We included 14,661 SH patients (81.1%) (mean age 59.8 ± 10.3 years; 58.9% female). A total of 40.7% were untreated for SH, 23.2% on a high-intensity statin, and 0.4% on proprotein convertase subtilisin/kexin type 9 inhibitor. Statins were prescribed in 31.8%, 47.9%, 56.1% and 65.4% of patients aged 20-39, 40-49, and 50-59, 60-75 years, respectively. There were 1,111 with a highest ever LDL-c &gt; 250 mg/dL (32.8% not currently on lipid medication (n=365) and 14.5% of this group had LDL-c&lt;100 mg/dL. Overall, 25.0% achieved at least 50% LDL-lowering (Table 1) and 19.8%, a most recent LDL-c&lt;100 mg/dL; 64.1% of men and 69.5% of women treated with any lipid medication still had an elevated LDL-c. In the no medication group, only 17.2% (n=1,025) had a statin allergy/intolerance. Females were less likely to be on a statin than males (p&lt;0.001). High-intensity statin was the strongest predictor of an LDL-c at goal, then highest ideal cardiovascular health score (adjusted RR 13.2; 95% CI: 11.1-15.6). Conclusions: Majority of patients at very high risk of CVD with SH remain untreated or undertreated with recent LDL-c levels above target. It is necessary to obtain better control of lipid levels in patients already being treated, increase the detection of SH and improve adherence to the current guidelines.

EU-Wide Cross-Sectional Observational Study of Lipid-Modifying Therapy Use in Secondary and Primary Care: the DA VINCI study.

To provide contemporary data on the implementation of European guideline recommendations for lipid-lowering therapies (LLTs) across different settings and populations and how this impacts low-density lipoprotein cholesterol (LDL-C) goal achievement. An 18 country, cross-sectional, observational study of patients prescribed LLT for primary or secondary prevention in primary or secondary care across Europe. Between June 2017 and November 2018, data were collected at a single visit, including LLT in the preceding 12 months and most recent LDL-C. Primary outcome was the achievement of risk-based 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) LDL-C goal while receiving stabilized LLT; 2019 goal achievement was also assessed. Overall, 5888 patients (3000 primary and 2888 secondary prevention patients) were enrolled; 54% [95% confidence interval (CI) 52-56] achieved their risk-based 2016 goal and 33% (95% CI 32-35) achieved their risk-based 2019 goal. High-intensity statin monotherapy was used in 20% and 38% of very high-risk primary and secondary prevention patients, respectively. Corresponding 2016 goal attainment was 22% and 45% (17% and 22% for 2019 goals) for very high-risk primary and secondary prevention patients, respectively. Use of moderate-high-intensity statins in combination with ezetimibe (9%), or any LLT with PCSK9 inhibitors (1%), was low; corresponding 2016 and 2019 goal attainment was 53% and 20% (ezetimibe combination), and 67% and 58% (PCSK9i combination). Gaps between clinical guidelines and clinical practice for lipid management across Europe persist, which will be exacerbated by the 2019 guidelines. Even with optimized statins, greater utilization of non-statin LLT is likely needed to reduce these gaps for patients at highest risk.

Abstract 377: Enhancing Adherence to Lipid-lowering Agents for Secondary Prevention After a Primary Cardiovascular Event: A Quality Improvement Initiative

Background: Targeting lower serum low-density lipoprotein cholesterol (LDL-C) levels has been a cornerstone for primary and secondary prevention of major adverse cardiovascular events (MACE), including myocardial infarction, stroke, coronary revascularization, and cardiovascular death. The most recent cholesterol guidelines advise a target serum LDL-C level of &lt;70 mg/dL using statins and other lipid-lowering agents in an escalating stepwise manner. The purpose of this quality improvement (QI) project is to encourage both physicians and patients to adhere to these new guidelines. Methods: This is a single-center QI project to be conducted at the Miami Veterans Affairs Medical Center (VAMC). When providers initiate or renew a prescription for a statin, a clinical reminder order check (CROC) will display within the electronic medical record (EMR) advising them that lipid guidelines now recommend high-intensity statin and/or additional agents as needed to target serum LDL-C level &lt;70 mg/dL. This CROC will only be activated in the charts of patients with a history of cardiac ischemic event with or without revascularization and/or do not have a recent LDL-C on file within the past year and/or the most recent LDL-C is &gt;70 mg/dL. Preliminary data from 6 months before and after CROC implementation will be collected and analyzed. The primary outcome of interest is statin prescription fill rate. Secondary outcomes include the number of patients with a serum LDL-C &gt;70 mg/dL and 30-day mortality and readmissions rate for patients admitted for acute myocardial infarction (AMI). Results/Anticipated Results: Study enrollment and data collection is ongoing. For fiscal year 2019 (FY19), the national prescription fill rate for statins within the VA health system was 90.29% in patients with history of previous cardiac ischemic event. Regionally, prescription fill rate was 92.80%. The Miami VAMC prescription fill rate was 89.77% for FY19, and 83.78% in quarter 4. National and regional prescription fill rate in quarter 4 FY19 were 90.21% and 90.20%, respectively. The average 30-day mortality rate through quarter 3 of FY19 for the Miami VAMC for patients with a diagnosis of AMI was 7.17% (50th percentile, nationally = 7.60%). The average 30-day readmission rate after AMI during the same timeframe was 15.92% (50th percentile, nationally = 15.74%). Conclusion: Statins and other lipid lowering agents, targeting a serum LDL-C &lt;70 mg/dL, have demonstrated to prevent secondary MACE in patients with a history of cardiac ischemia. By initiating this QI project to increase adherence to statins at the Miami VAMC, we expect an improvement in patient care reflected in relevant hospital quality metrics.

Abstract P179: Uncontrolled Cholesterol Levels In Patients With Severe Hypercholesterolemia

Introduction: The 2018 American Heart Association/American College of Cardiology cholesterol guidelines recommends patients who have phenotypic severe hypercholesterolemia (SH), defined as a low-density lipoprotein-cholesterol (LDL-c) &gt; 190 mg/dL, be started on maximally tolerated statin therapy without further risk stratification due to high risk for cardiovascular disease (CVD). SH patients on guideline-directed medical therapy (GDMT) should have 50% reduction in their LDL-c levels, with optimal being &lt; 100 mg/dL for primary prevention and &lt;70 mg/dL for secondary prevention. The 2019 European Society of Cardiology/European Atherosclerosis Society cholesterol guidelines recommend an optimal LDL-c level &lt; 55 mg/dL. Hypothesis: LDL-c levels vary by intensity of medication and are not at target in patients with SH in a large rural healthcare system. Methods: We used an electronic medical record-based SH registry defined by ever having an LDL-c &gt; 190 mg/dL since 01/01/2000 (n=17,925) at Essentia Health (MN, WI, and ND). In this cross-sectional study, patients were excluded if they had: no recent visit within the past 5 years (n=209), &lt;20 or &gt;75 years (n=3,153), listed as being on a statin but intensity was unavailable (n=1,934), or had no recent lab (n=998). Methods: We included 12,283 patients (68.5%)(mean age 59.4 + 10.1 years; 59.5% female) with SH and of these only 22.9% were on a high-intensity statin or proprotein convertase subtilisin/kexin type 9 inhibitor. Of the patients that were not on any lipid-lowering therapy (n=4,971; 40.5%), only 16.8% (n=837) had a statin allergy or intolerance documented. Figure 1 shows the most recent LDL-c levels; &lt;10% of patients in each group had a most-recent LDL-c &lt;70 mg/dL, and 9.4% had an LDL-c &lt;55mg/dL. Conclusions: Most SH patients remain untreated or undertreated with GDMT with recent LDL-c levels above target. More aggressive lipid-lowering therapy in patients with SH is needed to reduce risk of CVD.

Frequency of Statin Use in Patients With Low-Density Lipoprotein Cholesterol ≥190 mg/dl from the Veterans Affairs Health System

Patients with low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dl have severe hypercholesterolemia and are at markedly increased risk for adverse cardiovascular events. This study sought to examine the prevalence and treatment of patients with uncontrolled severe hypercholesterolemia in the Veterans Affairs (VA) Health System. The study population was comprised of VA outpatients ≥21 years of age without atherosclerotic disease or diabetes mellitus and an index LDL-C ≥190 mg/dl during April 2011 to March 2014. Patients needed to have filled medications at the VA within the past 6 months. Patient and facility-level predictors of statin use, high-intensity statin use, and statin intensification were analyzed using multivariate logistic regressions. There were a total of 63,576 patients meeting inclusion criteria, including 8,553 (13.5%) women and 26,879 (29.0%) nonwhite patients. The mean (±S.D.) age was 55 (±13) years and the mean of the most recent LDL-C values was 207 ± 22 mg/dl. Only 52% of all eligible patients were on any statin therapy and 9.7% received high-intensity statin therapy. High-intensity statin use increased from 8.6% in 2011 to 13.6% in 2014 (p < 0.001). In adjusted analysis, patients <35 or >75 years of age were less likely to be on a statin (p < 0.001). Women were less likely to be treated than men, odds ratio = 0.88; 95% confidence interval (0.83, 0.92). Similar patterns were observed for predictors of high-intensity statin use and statin intensification. In conclusion, only half of high-risk VA patients with uncontrolled severe hypercholesterolemia were treated with statins and a small minority was on high-intensity statin therapy.

Barriers to PCSK9 inhibitor prescriptions for patients with high cardiovascular risk: Results of a healthcare provider survey conducted by the National Lipid Association

Statin therapy is recommended for reducing atherosclerotic cardiovascular disease (ASCVD) risk. Significant risk can remain because of insufficient clinical response or statin intolerance. Proprotein convertase subtilisin/kexin type-9 (PCSK9) therapy lowers low-density lipoprotein cholesterol and has recently been shown to lower ASCVD events. The aim of the study was to assess the barriers and challenges experienced with the access and approval reimbursement process for PCSK9 inhibitor prescriptions. In 2016, the National Lipid Association conducted an online survey on PCSK9 inhibitor use and barriers to prescription among experienced healthcare workers who provide care to high-risk patients with ASCVD or familial hypercholesterolemia (FH). There were 434 respondent healthcare workers with extensive experience in treating lipid disorders. PCSK9 inhibitors are considered by 71.3% of respondent providers with statin-intolerant patients. There were high rates (>85%) of initial denial. The major barriers to approvals were insurer processes, provider documentation (inadequate documentation of maximally tolerated statin dose, diagnostic criteria for FH, number of statins failed if statin intolerant and most recent low-density lipoprotein cholesterol), and administrative burden (time, staff, paperwork, and appeals). Provider approval rates for getting ≥75% patients approved were higher for FH (43%) than for ASCVD patients (36%). Among providers with good approval rates, documentation was the most critical factor. Barriers more difficult to overcome include perceived higher threshold requirements by payers, drugs not on formulary, and drug costs. Healthcare providers encounter significant barriers to PCSK9 inhibitor prescriptions; many of these are related to documentation issues and can be overcome with checklists, staff support, and experience.

Quantifying the effect of applying the NCEP ATP III criteria in a managed care population treated with statin therapy.

Revised treatment goals suggested by the third report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP III) represent a challenge to both physicians and the health care industry. We sought to quantify the impact of these changes in a large managed care population being treated with statin therapy. Using data collected from a retrospective chart review of 1,962 managed care enrollees who received statin drug therapy between February 2001 and August 2001, we quantified the low-density lipoprotein cholesterol (LDL-C) goals and goal attainment of this population according to both the NCEP ATP II and ATP III criteria and further identified independent predictors of ATP III goal attainment using multivariable logistic regression modeling. Overall, 21.1% (n = 414) of statin patients moved to a more stringent LDL-C goal when ATP III criteria were applied over ATP II. Substituting ATP III criteria for ATP II criteria resulted in a 6.8% decrease in the percentage of participants who had their most recent LDL-C value below the suggested goal, from 59.8% under ATP II to 53.0% under ATP III. Persons with existing coronary heart disease, diabetes, obesity, and stroke or transient ischemic attack were all less likely to meet the suggested NCEP ATP III LDL-C goal. Taking into account the revised risk stratification of the ATP III guidelines and the lack of LDL-C goal attainment in patients currently taking statins, there will be an increase in the number of statin patients who require dose or agent adjustment, combination therapy, or compliance counseling to achieve their lower LDL-C goal.

Longitudinal assessment of a diabetes care management system in an integrated health network.

To describe the results of longitudinal assessment of the results of a disease management process developed in a large integrated health care system that successfully improved care for patients with diabetes. Outcome measures included rates of testing of hemoglobin A1c (HbA1c) and low-density lipoprotein (LDL), rate of annual eye exams, and LDL and HbA1c values. Intermountain Health Care (IHC) initiated the development of a Diabetes Care Management System (DCMS) in early 1998. The DCMS was developed as a comprehensive population-based disease management system. It includes provider education programs; performance feedback to physicians; clinical quality performance incentives for physicians; patient education programs; patient incentive, reminder systems to encourage compliance with best care process models; and tracking of physician behavior change and patient compliance with diabetes therapy. A multifaceted intervention and education approach was chosen because of the complexity of the diabetes treatment process. The percentage of patients with at least one annual HbA1c test increased from 78.5% in 1998 to 90.5% in 2002. During the same time period, the percentage of patients whose most recent HbA1c was less than 7.0 increased from 33.5% to 52.8%, average HbA1c decreased from 8.1 to 7.3, and the percentage of patients whose most recent HbA1c was greater than 9.5 decreased from 34.6% to 21.4%. The percentage of patients who had an LDL cholesterol screening test within the prior 2 years increased from 65.9% in 1998 to 91.7% in 2002. During the same time period, the percentage of patients whose most recent LDL cholesterol was less than 130 mg/dL increased from 39.9% to 69.8%. The percentage of diabetes patients who had an annual eye exam increased from 52% in 1998 to 62% in 2002. A multifaceted approach to improving diabetes management has led to improved performance in clinical measures related to diabetes care that have been shown to reduce the risk of patients with diabetes developing diabetes- related complications. All components of the diabetes management continuum of care, including primary care physicians, specialists, office staff, patients, diabetes educators, and others, were involved in the care improvement activities.

Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines.

To use an electronic medical record to measure rates of compliance with the National Cholesterol Education Program (NCEP) cholesterol guidelines for secondary prevention, to characterize the patterns of noncompliance, and to identify patient and physician-specific correlates of noncompliance. Cross-sectional descriptive analysis of data extracted from an electronic medical record. Nineteen primary care clinics affiliated with a tertiary academic medical center. All patients who visited their primary care physician in the preceding year who met criteria for secondary prevention of hypercholesterolemia. None. The main outcome was rate of compliance with NCEP cholesterol guidelines. Of 2,019 patients who qualified for secondary prevention, only 31% were in compliance with NCEP recommendations, although 44% were on lipid-lowering therapy. There was no low-density lipoprotein cholesterol (LDL-C) on record within the last three years for 771 (38%), and another 809 (40%) had a recent LDL-C that was above the recommended target of 100 mg/dL. Of the latter group, 374 (46%) were not on a statin, including 188 patients with an LDL-C >130 mg/dL. Compliance among secondary prevention patients with cerebrovascular or peripheral vascular disease, but not coronary disease, was even lower: 19% versus 36%, P <.0001. Most of the additional noncompliant patients never had an LDL-C checked. Patient-specific factors associated with compliance included having seen a cardiologist (45% vs 21%); having had a recent admission for myocardial infarction, unstable angina, or angina (41% vs 26%); being male (37% vs 24%); and being white (34% vs 26%). Patients over 79 and under 50 years old also were less likely to be compliant (22% vs 34% for 50-79 year olds). There were no significant differences in compliance rates based on physician-specific factors, such as level of training, gender, or panel size. We found poor compliance with nationally published and well-accepted guidelines on diagnosing and treating hypercholesterolemia in secondary prevention patients. Compliance was unrelated to physician or physician-specific characteristics, but it was especially low for women, African Americans, patients without a cardiologist, and patients with cerebrovascular and peripheral vascular disease.