In the JournalsPerspective

Patients with atherosclerotic CVD face ‘remarkable treatment gap’

Among a cohort of more than a quarter million patients with atherosclerotic CVD in Canada, only about two-thirds were prescribed lipid-lowering therapy and of those, more than a third did not reach recommended LDL cholesterol levels, according to findings recently published in the Canadian Journal of Cardiology.

“Despite diagnostic advances and established treatment guidelines, atherosclerotic CVD remains a leading cause of morbidity and mortality in Canada and worldwide,” Guanmin Chen, MD, a senior biostatistician at the Libin Cardiovascular Institute of Alberta at the University of Calgary, told Healio Primary Care.

Although there is an abundance of research showing the benefits of statins and lowering LDL cholesterol levels in patients with atherosclerotic CVD, there is little information to help clinicians understand how these patients are treated, according to researchers.

To fill in this research gap, they examined clinical characteristics, treatments and LDL cholesterol assessments of 281,665 patients with atherosclerotic CVD in Alberta, Canada.

Chen and colleagues found that 77.9% of the patients had an index LDL cholesterol test, 55.1% were prescribed lipid-lowering therapy before the test and 65.9% were prescribed lipid-lowering therapy after it.

In addition, 60.6% of the patients who received any lipid-lowering therapy were receiving moderate-/high-intensity statins. Among the 32.6% of the cohort who underwent two LDL cholesterol tests, 48.5% of patients who received lipid-lowering therapy did not achieve LDL cholesterol levels consistent with the 2016 Canadian Cardiovascular Society guideline of less than 2 mmol/L or a reduction of 50% or more, and 36.6% of patients did not reach that target at the follow-up test.

Chen explained how primary care physicians can help close what he and his co-authors described as a “remarkable treatment gap.”

“This may include using risk stratification tools and current guidelines for recommended lipid-lowering therapy. In addition, routine follow-up of lipid profiles and adjustments of treatments as needed would also benefit these patients,” he said in the interview.

“In addition, for patients with established atherosclerotic CVD, physicians should redouble their effort to get patients back on their statins with a goal of treating to new lower [dyslipidemia] targets,” Chen continued, adding that new strategies are also needed to improve the management of, and reduce the burden of disease among, patients with atherosclerotic CVD.

In a related editorial, Robert T. Sparrow, MD, faculty of medical science at the Schulich School of Medicine and Dentistry, Western University in London, Ontario, Canada and colleagues wrote that there is no “magic bullet approach to improving statin compliance.”

However, they noted that previous studies have identified patient-focused and physician-focused approaches to improve statin prescribing, which have had varying levels of success in improving the lives of patients with atherosclerotic CVD. – by Janel Miller

Disclosures: Chen reports being a consultant for Medlior and receiving research funding from the Canadian Institutes for Health Research. Sparrow reports no relevant financial disclosures. Please see the study and editorial for all other relevant financial disclosures.

Among a cohort of more than a quarter million patients with atherosclerotic CVD in Canada, only about two-thirds were prescribed lipid-lowering therapy and of those, more than a third did not reach recommended LDL cholesterol levels, according to findings recently published in the Canadian Journal of Cardiology.

“Despite diagnostic advances and established treatment guidelines, atherosclerotic CVD remains a leading cause of morbidity and mortality in Canada and worldwide,” Guanmin Chen, MD, a senior biostatistician at the Libin Cardiovascular Institute of Alberta at the University of Calgary, told Healio Primary Care.

Although there is an abundance of research showing the benefits of statins and lowering LDL cholesterol levels in patients with atherosclerotic CVD, there is little information to help clinicians understand how these patients are treated, according to researchers.

To fill in this research gap, they examined clinical characteristics, treatments and LDL cholesterol assessments of 281,665 patients with atherosclerotic CVD in Alberta, Canada.

Chen and colleagues found that 77.9% of the patients had an index LDL cholesterol test, 55.1% were prescribed lipid-lowering therapy before the test and 65.9% were prescribed lipid-lowering therapy after it.

In addition, 60.6% of the patients who received any lipid-lowering therapy were receiving moderate-/high-intensity statins. Among the 32.6% of the cohort who underwent two LDL cholesterol tests, 48.5% of patients who received lipid-lowering therapy did not achieve LDL cholesterol levels consistent with the 2016 Canadian Cardiovascular Society guideline of less than 2 mmol/L or a reduction of 50% or more, and 36.6% of patients did not reach that target at the follow-up test.

Chen explained how primary care physicians can help close what he and his co-authors described as a “remarkable treatment gap.”

“This may include using risk stratification tools and current guidelines for recommended lipid-lowering therapy. In addition, routine follow-up of lipid profiles and adjustments of treatments as needed would also benefit these patients,” he said in the interview.

“In addition, for patients with established atherosclerotic CVD, physicians should redouble their effort to get patients back on their statins with a goal of treating to new lower [dyslipidemia] targets,” Chen continued, adding that new strategies are also needed to improve the management of, and reduce the burden of disease among, patients with atherosclerotic CVD.

In a related editorial, Robert T. Sparrow, MD, faculty of medical science at the Schulich School of Medicine and Dentistry, Western University in London, Ontario, Canada and colleagues wrote that there is no “magic bullet approach to improving statin compliance.”

However, they noted that previous studies have identified patient-focused and physician-focused approaches to improve statin prescribing, which have had varying levels of success in improving the lives of patients with atherosclerotic CVD. – by Janel Miller

Disclosures: Chen reports being a consultant for Medlior and receiving research funding from the Canadian Institutes for Health Research. Sparrow reports no relevant financial disclosures. Please see the study and editorial for all other relevant financial disclosures.

    Perspective
    Jossef Amirian

    Jossef Amirian

    Chen and colleagues’ multi-centered retrospective observational study highlights the underutilization of statin therapy in patients with established atherosclerotic CVD. Based on this study, approximately two-thirds of the patients receiving low-intensity statin therapy failed to achieve recommended LDL cholesterol levels based on the 2016 Canadian Cardiovascular Society guideline recommendations. Even more alarming, more than one-third of patients with atherosclerotic CVD were not prescribed lipid-lowering drugs. If these trends were to hold true in the United States, we as physicians would have to make drastic changes in our treatment of the patients who would benefit most from lipid-lowering agents.

    In order to see an improvement over time, we must first direct our attention to the definition of atherosclerotic CVD, which not only includes patients with established coronary artery disease, but also individuals with neurovascular and peripheral vascular disease. Once we establish a patient has clinical atherosclerotic CVD, then we must emphasize the recommendations noted in the American College of Cardiology 2018 Guideline on the Management of Blood Cholesterol, which recommends that we initiate high-intensity or maximally tolerated statin therapy. The guideline notes that the greater the LDL cholesterol reduction on statin therapy, the greater the subsequent risk reduction.

    The 2018 guidelines go even further and categorize patients into another category called “very high-risk ASCVD,” which includes patients who have had a history of multiple major atherosclerotic CVD events (acute coronary syndrome within the past 12 months, history of myocardial infarction, history of ischemic stroke, symptomatic peripheral arterial disease) or one major atherosclerotic CVD event and multiple high-risk conditions.

    In these “very high-risk ASCVD” patients, the treatment should not be limited to statin therapy alone. If LDL cholesterol levels remain 70 mg/dL (1.8 mmol/L) or higher despite maximally tolerated statin therapy, it is reasonable to add ezetimibe. Another medication which has shown favorable LDL reduction especially in this subset of patients are proprotein convertase subtilisin/kexin type 9 protease (PCSK9) inhibitors, which play an important role in cholesterol metabolism by regulating LDL receptor degradation.

    Chen and colleagues’ study sheds light on an area within our field that requires a great amount of attention. I am confident that putting emphasis on the use of guidelines to assist providers in making treatment strategies for their patient will lead to excellent patient care and overcome the underutilization of lipid-lowering agents over time.

    • Jossef Amirian, MD, FACC, FASE, CBNC, RPVI
    • Board-certified cardiologist
      Manhattan Cardiology, New York

    Disclosures: Amirian reports no relevant financial disclosures.