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Routine lipid testing confers greater adherence to optimal therapy, lower LDL levels
Patients who undergo testing of LDL levels appear to be more likely to adhere to the 2013 American College of Cardiology/American Heart Association cholesterol guidelines, including treatment with a statin medication, a high-intensity statin and nonstatin lipid-lowering therapy, according to a study published in the Journal of the American Heart Association.
Patients who had routine lipid testing also had lower LDL levels compared with those who did not.
Misinterpretation of guidelines
“Prior studies demonstrated a misconception that clinicians following the 2013 ACC/AHA guidelines no longer needed to measure lipid levels given the shift away from LDL-C treatment targets,” Angela M. Lowenstern, MD, of the department of medicine at Duke University School of Medicine, and colleagues wrote. “Our study showed that many primary and secondary prevention patients were managed without recent LDL-C testing, which may be a reflection of misinterpretation of the 2013 ACC/AHA guidelines. ... Clinicians who reported primarily following the 2013 ACC/AHA guidelines were more likely to test LDL-C levels.”
To evaluate LDL testing patterns across the United States, researchers analyzed data from the 2015 PALM registry, resulting in a study population of 7,627 primary and secondary adult patients at high risk or with a documented history of atherosclerotic CVD from 140 cardiology, endocrinology and primary care offices. The registry included demographic data, whether lipid testing had been performed and the most recent and highest LDL measurement in the past 2 years. Patients were also asked if they knew their cholesterol level. On the day of enrollment, patients underwent phlebotomy, which analyzed total cholesterol, direct LDL, HDL and triglyceride levels.
High- or moderate-intensity statin dosing was defined by recommendations from the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.
Researchers categorized patients based on whether they had medically documented lipid testing with at least one LDL value and the highest LDL value in the 2 years before study enrollment.
Also, the association between documented LDL and statin use was assessed.
Researchers found that 63.5% of the study population had a documented measurement of LDL in the medical record in the 2 years before enrollment and that primary prevention patients had a testing rate of 61.8% vs. 65.6% for secondary prevention patients (P < .001).
Patients without LDL measurements were more likely to be women, nonwhite, uninsured and noncollege graduates than those who had documented measurements (P < .01 for all).
In addition, patients who had been tested were more likely to have chronic kidney disease (10.8% vs. 7.1%; P < .001) and less likely to have other CV risk factors such as diabetes (37.7% vs. 40%; P = .04), hypertension (76.3% vs. 79.3%; P = .002) and habitual smoking (10.6% vs. 18.3%; P < .001) than those who were not tested.
Patients with LDL testing were also more likely to report knowing their cholesterol level than those not tested (77% vs. 64.2%; P < .001).
As for findings related to providers, 74.4% of patients seen by endocrinologists, 67.2% of patients seen by cardiologists and 64.7% of patients seen by primary care physicians had undergone recent lipid testing (P for trend = .008).
Furthermore, 65.5% of patients seen at urban locations had undergone lipid testing vs. 44.5% of patients at practices in rural locations (P < .001).
Patients seen by providers who reported using the 2013 ACC/AHA lipid management guidelines were more likely to have been tested than those seen by providers who did not (68.2% vs. 60.6%; P < .001).
Greater adherence
Researchers also found that 5,909 patients had a guideline indication for statin treatment and 76% of those who had LDL testing within the past 2 years were taking a statin at the time of their visit vs. 72.6% of those who had not been tested in the past 2 years (P = .0034). After multivariable adjustment, this association continued (OR = 1.23; 95% CI, 1.01-1.5).
Patients who had been tested for LDL were also more likely to be treated with a high-intensity statin (24.3% vs. 21.5%; P = .016) or a nonstatin lipid-lowering therapy (27.3% vs. 24.8%; P = .037) than those who had not been tested.
Patients who had a guideline indication for statin therapy and chart-documented LDL testing in the previous 2 years had lower core laboratory LDL levels at the time of enrollment than those who did not have documented LDL levels (median, 92 mg/dL vs. 97 mg/dL; P < .001).
When researchers looked at only patients on statin therapy, those with documented LDL testing had lower core laboratory LDL, non-HDL and triglyceride levels at enrollment than those who had no previous lipid testing.
“Clinicians can use this information to further educate on the importance of statin adherence and tolerance for minor side effects, as well as encourage improvement in nonpharmacologic therapies such as diet and exercise,” the researchers wrote. “Lipid testing may help to optimize adherence to guideline-recommended statin use and dosing, as well as identify patients who are nonadherent to treatment or who need more intense lipid-lowering therapy.” – by Melissa J. Webb
Disclosures: The study was supported by Sanofi and Regeneron. Lowenstern reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.