Lipid-lowering therapy use low, LDL elevated in patients with PAD
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Among patients with peripheral artery disease, use of lipid-lowering therapies was low and LDL remained elevated, according to findings published in the Journal of the American College of Cardiology.
“Randomized clinical trials of lipid-lowering therapies have shown that reducing LDL cholesterol decreases the risk of these ischemic events and observational data have shown an association between high-intensity statin use and reduction in lower extremity amputation and mortality in PAD,” Connie N. Hess, MD, MHS, an interventional cardiologist and associate professor of medicine in the division of cardiology at the University of Colorado School of Medicine in Aurora, Colorado, and colleagues wrote.
Researchers identified 250,103 patients with PAD (mean age, 74 years; 49% women) in the MarketScan database from 2014 to 2018. Using multivariable logistic regression, researchers also identified factors associated with LDL levels less than 70 mg/dL.
The primary outcomes included lipid-lowering therapy use, defined as high intensity, low intensity or no therapy, and follow-up LDL.
Lipid-lowering therapy
In the cohort, 20.5% of patients were treated at baseline with high-intensity lipid-lowering therapies, 39.5% were treated with low-intensity lipid-lowering therapies and 40% were not treated with any lipid-lowering therapies. During 15-month follow-up, there was a 1.5% increase in high-intensity lipid-lowering therapy use in the cohort.
At baseline, among the 18,747 patients with data on LDL, 25% were treated with high-intensity lipid-lowering therapies. The median LDL level was 91 mg/dL and 24.5% of patients had LDL levels less than 70 mg/dL. Median LDL level was 81 mg/dL in the high-intensity lipid-lowering therapy group and 64% of those patients had at least 70 mg/dL.
During follow-up, there was an increase of 3.7% for use of high-intensity lipid-lowering therapies, whereas median LDL decreased 4 mg/dL, and there was a 4.1% increase in patients with LDL levels less than 70 mg/dL.
At the end of follow-up, high-intensity lipid-lowering therapy was used in 55% of those who had a major adverse CV event, 41% of those who had a major adverse limb event, 38.5% of those who had critical limb ischemia and 26.1% of those who had no ischemic events, according to the researchers.
LDL level was less than 70 mg/dL in 41.5% of patients after a major adverse CV event and in 36.1% of patients after a major adverse limb event compared with 27.1% of patients without any events.
In addition, researchers observed factors such as smoking, hypertension, diabetes, prior lower-extremity revascularization and prior MI were associated with a follow-up LDL level of less than 70 mg/dL; prior acute or critical limb ischemia was not associated with LDL levels.
Forward progress essential
According to an accompanying editorial, the health care system has failed to optimize lipid management in patients with PAD and to emphasize the importance of nonstatin therapies for maximizing lipid lowering.
“Novel strategies and additional resources for expanding PAD care are desperately needed to effectively treat these patients,” Eric A. Secemsky, MD, MSc, director of vascular intervention and an interventional cardiologist and associate professor of medicine at the Cardiovascular Institute at Beth Israel Deaconess Medical Center, and colleagues wrote. “The effort to change the trajectory of care for PAD will require confrontation of some our most challenging frontiers in medicine: behavioral change, large-scale physician and patient education and reduction of disparities in health care. Such efforts are essential to making forward progress, as opposed to moving in circles, in delivering evidence-based medicines to patients with PAD.”
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