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Persistent gaps in management and risk factor control among patients with atherosclerotic cardiovascular disease: All
Yakubu Bene-Alhasan1, Soad Al Osta2, Yussif Issaka3
1Baylor College of Medicine, Section of Cardiovascular Research, Houston, TX, USA.
Insights
Despite guideline recommendations, many atherosclerotic cardiovascular disease (ASCVD) patients lack optimal low-density lipoprotein cholesterol (LDL-C) control. Underused combination lipid-lowering therapy (LLT) and prevalent risk factors highlight needs for intensified management.
Area of Science:
- Cardiology
- Public Health
- Pharmacology
Background:
- Contemporary guidelines advocate for aggressive low-density lipoprotein cholesterol (LDL-C) reduction in atherosclerotic cardiovascular disease (ASCVD) patients.
- Clinical practice shows persistent gaps in achieving these LDL-C targets.
- This study examines lipid-lowering therapy (LLT) use and cardiovascular risk factor control in diverse ASCVD patient groups.
Purpose of the Study:
- To evaluate LLT utilization and LDL-C control among patients with coronary artery disease (CAD), peripheral artery disease (PAD), cerebral atherosclerosis (CAS), and polyvascular disease.
- To assess the prevalence of uncontrolled cardiovascular risk factors in these patient populations.
- To identify opportunities for improved ASCVD risk management.
Main Methods:
- Analysis of electronic health records from 26,935 ASCVD patients (2018-2023) within the All of Us Research Program.
- Assessment of baseline LLT use, LDL-C levels, and uncontrolled risk factors (hypertension, diabetes, obesity, smoking).
- Visualization of risk factor intersections using Euler diagrams for patients with LDL-C >70 mg/dL.
Main Results:
- High statin use (81-93%) did not translate to optimal LDL-C control (36-47% <70 mg/dL).
- Combination LLT was underutilized (10-21%), with PCSK9 inhibitors used in only 1-3%.
- High prevalence of uncontrolled risk factors (obesity, hypertension, diabetes, smoking) was observed, frequently co-occurring.
Conclusions:
- Significant gaps exist in achieving guideline-recommended LDL-C targets and controlling cardiovascular risk factors in a large, diverse ASCVD cohort.
- Underutilization of combination LLT and high comorbidity burden present critical opportunities for intensified treatment.
- Comprehensive risk factor management is essential for improving outcomes in ASCVD patients.
Background:
Contemporary guidelines recommend aggressive low-density lipoprotein cholesterol (LDL-C) lowering in patients with atherosclerotic cardiovascular disease (ASCVD), yet significant treatment gaps persist in clinical practice. We evaluated lipid-lowering therapy (LLT) use, LDL-C control, and prevelance of cardiovascular risk factors among patients with coronary artery disease (CAD), peripheral artery disease (PAD), cerebral atherosclerosis (CAS) and those with all three (polyvascular disease) using real-world data from the NIH-run All of Us Research Program.
Methods:
We analyzed electronic health records from 26,935 patients with ASCVD (CAD 21,573; PAD 4752; CAS 6864; and polyvascular 902) enrolled between 2018 and 2023. We assessed baseline LLT use, LDL-C levels, and prevalence of uncontrolled cardiovascular risk factors, defined as blood pressure ≥130/80 mmHg, hemoglobin A1c ≥ 7%, waist-height ratio (WHtR) ≥ 0.5, and current smoking. Among patients with LDL-C >70 mg/dL, we visualized risk factor intersections using Euler diagrams.
Results:
Despite high statin use across all cohorts (81% CAD, 82% PAD, 83% CAS, 93% Polyvascular), only 36-47% achieved LDL-C <70 mg/dL and 22-31% had LDL-C ≥100 mg/dL. Combination LLT was markedly underutilized (10-21%), with ezetimibe prescribed in 10-20% and PCSK9 inhibitors in only 1-3% of patients. Among those with LDL-C ≥70 mg/dL, central obesity was ubiquitous (86-89%), more than half had uncontrolled blood pressure (59-63%), 16-26% had hemoglobin A1c ≥ 7%, and 14-20% were active smokers. Patients with polyvascular disease had higher LLT use and LDL-C control but lower risk factor control. Uncontrolled risk factors frequently co-occurred: 29-31% had concurrent obesity and uncontrolled hypertension, and 7-9% harbored the triad of obesity, poor glycemic control, and uncontrolled hypertension.
Conclusions:
In this large, diverse cohort of patients with ASCVD, substantial gaps persist in achieving guideline-recommended LDL-C targets and controlling cardiovascular risk factors. The marked underutilization of combination LLT and the high coexistence of metabolic risk factors represent significant opportunities for treatment intensification and comprehensive risk factor management.
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