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Disparities in PCSK9 Initiation Among US Veterans with Peripheral Arterial Disease or Cerebrovascular Disease
Salil V Deo1,2,3, David McAllister4, Sharon LaForest5
1Surgical Services, Louis Stokes Cleveland VA Medical Center, 10701 E Boulevard, Cleveland, OH, 44106, USA. svd14@case.edu.
Insights
Peripheral arterial disease (PAD) and cerebrovascular disease (CeVD) patients are less likely to receive proprotein convertase subtilsin/kexin type 9 inhibitors (PCSK9i). Household income and community deprivation influence PCSK9i use in US Veterans.
Area of Science:
- Cardiovascular Medicine
- Pharmacotherapy
- Health Services Research
Background:
- Effective lipid lowering is crucial for patients with peripheral arterial disease (PAD) and cerebrovascular disease (CeVD).
- Proprotein convertase subtilsin/kexin type 9 inhibitors (PCSK9i) are potent LDL-lowering agents, but their utilization in PAD and CeVD populations remains limited.
- This study investigates PCSK9i use patterns among US Veterans, comparing initiation rates across PAD, CeVD, and coronary artery disease (CAD) cohorts.
Purpose of the Study:
- To evaluate the initiation rates of PCSK9 inhibitors (PCSK9i) in US Veterans diagnosed with atherosclerotic vascular disease.
- To compare PCSK9i utilization among patients with coronary artery disease (CAD), peripheral arterial disease (PAD), and cerebrovascular disease (CeVD).
- To identify patient and socioeconomic factors associated with PCSK9i initiation in the Veterans Affairs healthcare system.
Main Methods:
- A retrospective analysis of PCSK9i initiation between 2016-2019 was conducted across 124 Veterans Affairs hospitals.
- Hierarchical logistic regression modeled the association between primary diagnosis (CAD, PAD, CeVD), baseline LDL-C, socioeconomic indicators, and PCSK9i initiation.
- The study included 519,566 patients with atherosclerotic vascular disease.
Main Results:
- Of 519,566 patients, 0.4% initiated PCSK9i therapy; 84.3% had CAD, while only 7.2% had PAD and 8.5% had CeVD.
- PAD and CeVD patients were significantly less likely to receive PCSK9i compared to CAD patients (OR 0.50 and 0.24, respectively).
- Higher household income and lower community deprivation were associated with increased PCSK9i initiation.
Conclusions:
- Patients with PAD and CeVD are significantly underrepresented in PCSK9i therapy initiation, even after adjusting for LDL-C levels.
- Nationwide PCSK9i initiation rates among US Veterans are low, despite a low co-pay structure.
- Socioeconomic factors, including household income and community deprivation, play a significant role in predicting PCSK9i utilization.
Background:
Effective lipid lowering is essential in patients with peripheral arterial disease (PAD) and cerebrovascular disease (CeVD). Proprotein convertase subtilsin/kexin type 9 inhibitors (PCSK9i) efficiently lower low-density lipoprotein (LDL) levels; however, use in PAD and CeVD patients is limited. Therefore, our aim was to evaluate the use of PCSK9i among US Veterans and compare rates between patients with PAD, CeVD, and coronary artery disease (CAD).
Methods:
We evaluated PCSK9i initiation (2016-2019) in US Veterans with CAD, PAD, or CeVD treated at 124 Veterans Affairs (VA) hospitals. We fit a hierarchical logistic regression model to evaluate the association of the patient's primary diagnosis, baseline low-density lipoprotein cholesterol (LDL-C) levels, socioeconomic indicators, and the Department of Veterans Affairs medical center enrollment with PCSK9i initiation.
Results:
Of 519,566 patients with atherosclerotic vascular disease, 337,766 (65%), 79,926 (15%) and 101,874 (20%) had CAD, PAD, and CeVD, respectively. Among 2115/519,566 (0.4%) initiated on PCSK9i therapy, 84.3% had CAD, while only 7.2% and 8.5% had PAD and CeVD, respectively. Compared with CAD patients, PAD {odds ratio [OR] 0.50 (0.36-0.70)} and CeVD [OR 0.24 (0.15-0.37)] patients were less likely to receive PCSK9i. Relative to under $40K per year, PCSK9i initiation was higher if earning $40,000-$80,000 [OR 1.13 (1.01-1.27)] or > $80,000 [OR 1.41 (1.14-1.75)]. Even moderate community deprivation [OR 0.87 (0.77-0.97)] was associated with lower PCSK9i therapy.
Conclusions:
Adjusted for LDL-C levels, PAD and CeVD patients are much less likely to receive PCSK9i therapy. Despite low co-pay, PCSK9i initiation rates among US veterans, nationwide, is low, with household income and community deprivation appearing to predict PCSK9i use.
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