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Effectiveness of Blood Lipid Management in Patients With Peripheral Artery Disease
Connie N Hess1, Christopher P Cannon2, Joshua A Beckman3
1Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; CPC Clinical Research, Aurora, Colorado, USA.
Insights
Lipid-lowering therapy use in peripheral artery disease (PAD) is suboptimal, with many patients not achieving target low-density lipoprotein cholesterol (LDL-C) levels. This indicates missed opportunities for effective cardiovascular risk reduction in PAD patients.
Area of Science:
- Cardiovascular Medicine
- Vascular Surgery
- Pharmacology
Background:
- Low-density lipoprotein cholesterol (LDL-C) significantly increases the risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in peripheral artery disease (PAD).
- Lipid-lowering therapies (LLT) are crucial for reducing LDL-C and mitigating these risks in PAD patients.
Purpose of the Study:
- To evaluate the patterns of LLT utilization and the actual achieved LDL-C levels in patients diagnosed with PAD.
- To identify factors associated with achieving target LDL-C levels (<70 mg/dl) in this patient population.
Main Methods:
- Analysis of MarketScan data from 2014-2018 for patients with PAD.
- Categorization of LLT into high-intensity (HI), low-intensity, or no therapy.
- Assessment of follow-up LDL-C levels and identification of factors associated with LDL-C <70 mg/dl using multivariable logistic regression.
Main Results:
- Among 250,103 PAD patients, 40% received no LLT at baseline, and only 20.5% were on HI LLT.
- At follow-up, despite increased HI LLT use, median LDL-C remained elevated at 87 mg/dl, with only 28.6% of patients achieving LDL-C <70 mg/dl.
- HI LLT use and achieving LDL-C <70 mg/dl were more common after MACE or MALE events, suggesting a reactive rather than proactive treatment approach.
Conclusions:
- LLT use in PAD patients is suboptimal, leading to persistently elevated LDL-C levels.
- The intensity of LLT prescribed is an unreliable indicator of achieved LDL-C, highlighting a gap in treatment efficacy.
- Lipid management in PAD appears less aggressive compared to general cardiovascular disease, indicating significant opportunities for improved therapeutic strategies.
Background:
Low-density lipoprotein cholesterol (LDL-C) is associated with heightened risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in peripheral artery disease (PAD). Lipid-lowering therapies (LLT) that reduce LDL-C decrease this risk.
Objectives:
The authors examined LLT use and actual achieved LDL-C in PAD.
Methods:
PAD patients in MarketScan from 2014 to 2018 were identified. Outcomes included LLT use, defined as high-intensity (HI) (high-intensity statin, statin plus ezetimibe, or PCSK9 inhibitor), low-intensity (any other lipid regimen), or no therapy, and follow-up LDL-C. Factors associated with LDL-C <70 mg/dl were identified with multivariable logistic regression.
Results:
Among 250,103 PAD patients, 20.5% and 39.5% were treated at baseline with HI and low-intensity LLT, respectively; 40.0% were on no LLT. Over a 15-month median follow-up period, HI LLT use increased by 1.5%. Among 18,747 patients with LDL-C data, at baseline, 25.1% were on HI LLT, median LDL-C was 91 mg/dl, and 24.5% had LDL-C <70 mg/dl. Within the HI LLT subgroup, median LDL-C was 81 mg/dl, and 64% had LDL-C ≥70 mg/dl. At follow-up, HI LLT use increased by 3.7%, median LDL-C decreased by 4.0 mg/dl, and an additional 4.1% of patients had LDL-C <70 mg/dl. HI LLT use was greater after follow-up MACE (55.0%) or MALE (41.0%) versus no ischemic event (26.1%). After MACE or MALE, LDL-C was <70 mg/dl in 41.5% and 36.1% of patients, respectively, versus 27.1% in those without an event. Factors associated with follow-up LDL-C <70 mg/dl included smoking, hypertension, diabetes, prior lower extremity revascularization, and prior myocardial infarction but not prior acute or critical limb ischemia.
Conclusions:
In PAD, LLT use is suboptimal, LDL-C remains elevated, and LLT intensity is a poor surrogate for achieved LDL-C. Less aggressive lipid management was observed in PAD versus cardiovascular disease, highlighting missed opportunities for implementation of proven therapies in PAD.
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