Underuse of cholesterol-lowering medications creates ‘missed opportunities’
ATLANTA — Despite the improvements that have been made in cholesterol reduction, more efforts are needed to improve usage rates of cholesterol-lowering medications in patients, including those with familial hypercholesterolemia, according to a presentation at the FH Foundation’s FH Global Summit.
Rear Admiral Betsy L. Thompson, MD, MSPH, DrPH, assistant surgeon of the U.S. Public Health Service and director of the division for heart disease and stroke prevention at the National Center for Chronic Disease Prevention and Health Promotion at the CDC, said the division has several goals: reduce the risk for hypertension and hypercholesterolemia, improve management and control of hypertension and hypercholesterolemia and to reduce the burden of stroke and heart disease.
“This really covers the spectrum from prevention to detection and treatment to control,” she said. “I hope it’s apparent to you that our goals are inextricably linked with your own. Reducing the risk for and improving management of hypercholesterolemia is central to our work at the CDC, and I know it’s central to your work as well.”
The CDC’s goal to improve the CV health of patients is driven by addressing health equity — focusing on priority populations — and strategically engaging partners, she said.
Some progress has been made with regards to the prevalence of hypercholesterolemia, as shown with 1999-2000 and 2015-2016 NHANES data. During that time, the prevalence of high total cholesterol declined from 18.3% to 12.4%, and the rate of low HDL declined from 22.2% to 18.4%, but despite the improvements, disparities still exist according to sex, race, ethnicity and geographic locations, Thompson said.
“That still leaves over 90 million adults with total cholesterols of 200 mg/dL or more and over 28 million with levels greater than or equal to 240 mg/dL,” Thompson said during the presentation. “In fact, nearly one in three adults has high LDL cholesterol while 18% have a low HDL.”
One in five children also have high total cholesterol and low HDL, according to the presentation.
“The bottom line is that clearly there is still much work to be done in terms of decreasing the prevalence of dyslipidemia,” Thompson said during the presentation.
Dyslipidemia often results from several factors including modifiable risk factors, high-risk populations and consequences. Even with these factors, lipid management can still be achieved with both lifestyle modifications and treatments, particularly in patients with familial hypercholesterolemia, Thompson added.
The 2018 American College of Cardiology/American Heart Association Guideline on the Management of Blood Cholesterol had a variety of treatment options across risk groups with an emphasis on a heart-healthy lifestyle. She said the most effective first-line medication is statins, noting that high-intensity statin therapy has the potential to lower LDL by more than 50%. Nonstatin therapies such as ezetimibe, bile acid sequestrants and PCSK9 inhibitors can also be used, she said.
“You’ve heard about these already and will hear more during this summit, but how well are we doing with the use of statins as a first-line therapy overall,” Thompson said during the presentation.
The use of all cholesterol-lowering medications has increased from 19.9% in 2003 to 27.9% in 2012. The use of statins also increased during this time from 16.3% to 23.2%. Not much has changed during this time with regards to statins and nonstatins together and nonstatins alone, according to the presentation.
In an assessment of 2013-2014 NHANES data, an estimated 39.1 million of patients are not using statins when indicated.
“This represents millions of missed opportunities to help people live longer and healthier lives,” Thompson said.
Although there has been an increase in the use of cholesterol-lowering medications for patients with CVD, not as many patients with hypercholesterolemia receive these medications.
“This may be because they simply don’t understand their cardiovascular disease risk or understand the importance of starting medications to prevent events,” Thompson said.
The steps to cholesterol management in adults should include prevention, screening, treatment eligibility, awareness, treatment and control, according to the presentation. Assessing these as individual components allows clinicians to see where patients may be lost, according to the presentation.
“This also means that we can make improvements at each step along the way if we identify those steps most at play in the population we serve and implement evidence-based strategies to improve cholesterol management,” Thompson said. – by Darlene Dobkowski
Thompson BL. Heart Disease Prevention: A Public Health Perspective. Presented at: The FH Foundation’s FH Global Summit; Oct. 20-21, 2019; Atlanta.
Disclosure: Thompson is an employee of the CDC.