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Missed Opportunities to Intensify Lipid-Lowering Therapy in Patients With Atherosclerotic Cardiovascular Disease: A
Hannah Ayers1, Vicki Groo1,2, Robert J DiDomenico1,3
1Department of Pharmacy Practice, University of Illinois Chicago, Chicago, Illinois, USA.
Insights
Most patients with atherosclerotic cardiovascular disease (ASCVD) after revascularization do not achieve target low-density lipoprotein cholesterol (LDL-C) levels despite recommendations for intensive lipid-lowering therapy (LLT). This highlights significant missed opportunities for optimizing LLT and improving patient outcomes.
Area of Science:
- Cardiology
- Vascular Medicine
- Pharmacotherapy
Background:
- Intensive lipid-lowering therapy (LLT) is recommended post-revascularization to reduce atherosclerotic cardiovascular disease (ASCVD) events by achieving low-density lipoprotein cholesterol (LDL-C) < 70 mg/dL.
- However, a majority of patients exhibit elevated LDL-C levels, and LLT intensification is infrequently implemented.
Purpose of the Study:
- To evaluate the post-revascularization management of LLT in patients with various forms of ASCVD.
- To assess the rates of LDL-C goal achievement and LLT intensification in patients following revascularization procedures.
Main Methods:
- Retrospective cohort study of adults with ASCVD undergoing coronary, cerebrovascular, or peripheral revascularization (July 2021-July 2022).
- Evaluated LDL-C levels, LLT prescribing patterns, and follow-up care over 15 months.
- Compared patient characteristics and LLT practices between those achieving LDL-C < 70 mg/dL (goal) and those with LDL-C ≥ 70 mg/dL (not-at-goal).
Main Results:
- Only 47.9% of patients had a follow-up lipid panel, and 47.7% of those were at goal (LDL-C < 70 mg/dL).
- LLT intensification occurred in only 19.3% of the entire cohort.
- Patients with follow-up lipid panels showed higher rates of LLT intensification (28.1% vs. 11.3%) and more ambulatory care visits.
Conclusions:
- Most revascularized ASCVD patients do not achieve target LDL-C levels due to infrequent follow-up lipid panels and LLT intensification.
- Significant opportunities exist to improve LLT management and enhance ASCVD event risk reduction in this population.
Background:
Intensive lipid-lowering therapy (LLT) to achieve low-density lipoprotein cholesterol (LDL-C) levels < 70 mg/dL is recommended to lower the risk of atherosclerotic cardiovascular disease (ASCVD) events following revascularization. However, LDL-C remains elevated in most patients and LLT intensification is infrequent. To evaluate post-revascularization management of LLT in patients with various forms of ASCVD.
Methods:
This retrospective cohort study evaluated LLT intensification in adults with ASCVD after coronary, cerebrovascular, or peripheral revascularization between July 2021 and July 2022. Patients were identified from procedure lists. Exclusion criteria included no baseline LDL-C, baseline LDL-C < 70 mg/dL, triglycerides > 500 mg/dL, end-stage renal disease, and no documented follow-up care. The last documented LDL-C, LLT prescribing patterns, and all follow-up visits with primary care providers and ASCVD specialists were evaluated during post-revascularization follow-up (15 months). We compared patient characteristics and LLT practice patterns between patients achieving LDL-C < 70 mg/dL (goal) and those with LDL-C ≥ 70 mg/dL (not-at-goal) during a 15-month follow-up period.
Results:
119 patients were included. Within 15 months, 57 (47.9%) patients had a follow-up lipid panel for evaluation, 27 (47.7%) of whom were at goal. Only 23 (19.3% of the entire cohort) patients had LLT intensified. Patient characteristics were similar between those at goal and not-at-goal except for race (fewer non-White patients, p < 0.01) and revascularization type (more coronary revascularization, p < 0.05) in those at goal. Patients with follow-up lipid panel(s) had significantly more ambulatory care visits (6 [4-10] vs. 3 [1-6], p < 0.001) and had higher rates of LLT intensification (28.1% vs. 11.3%, p < 0.001) than those without. Among patients without follow-up lipid panels, there were 269 missed opportunities to reassess lipids and/or intensify LLT.
Conclusion:
In this study, most revascularized ASCVD patients did not have follow-up lipid panels, LLT intensification, and did not achieve an LDL-C < 70 mg/dL, suggesting numerous opportunities for improvement.
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