Lipid-lowering therapy intensification low among veterans after MI, revascularization
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Fewer than half of veterans, most of whom were not on lipid-lowering therapy before an event, received intensified lipid-lowering therapies after an MI or elective revascularization, researchers reported.
The prevalence of lipid-lowering therapy intensification remained low despite more than half of patients having LDL of 70 mg/dL or more at 1 year, exceeding guideline recommendations for this population, according to research published in Circulation: Cardiovascular Quality and Outcomes.
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“Intensification of lipid-lowering therapy is often helpful to reduce the risk of recurrent atherosclerotic CVD events. However, many patients are undertreated following an ASCVD event, despite the high risk of a recurrent events,” Alexander R. Zheutlin, MD, MS, resident in internal medicine at the University of Utah School of Medicine, and colleagues wrote. “The current analysis highlights the underutilization of lipid-lowering therapy for secondary prevention of ASCVD and the need for better implementation of guideline-directed medical therapy.”
For the analysis, researchers utilized data from Veterans Health Administration Corporate Data Warehouse from more than 140 VA hospitals and 1,200 VA outpatient clinics to evaluate changes in intensification of lipid-lowering therapies after 81,372 MIs or elective coronary revascularizations within 1 year after hospital discharge (mean age, 69 years; 2% women; mean baseline LDL, 89.6 mg/dL; 33.8% with LDL < 70 mg/dL at baseline).
Intensification, defined as increased statin dose or initiation of a statin, ezetimibe or PCSK9 inhibitor, was assessed in the overall cohort and among patients with LDL between 70 mg/dL and 100 mg/dL.
At baseline, before MI and/or coronary revascularization, 39.7% of patients were not taking any lipid-lowering therapies, 22% were taking a low- to moderate-intensity statin, 37.2% were taking a high-intensity statin and 0.6% were taking ezetimibe.
Lipid-lowering therapy intensification at 1 year
After 14 days, 33.3% of patients received intensified lipid-lowering therapy, and at 1 year, intensification had occurred in 47.3% of patients. Intensification was most common among patients not already taking lipid-lowering therapy (82.5%) before MI and/or coronary revascularization, according to the study. In addition, 60.3% of patients already taking a low- to moderate-intensity statin at baseline, 57% of those taking ezetimibe and 2.5% of those taking a high-intensity statin received intensification within 1 year.
Among patients with at least one lipid test within 3 months (37%) after hospital discharge following MI or elective coronary revascularization, 49.8% had an LDL of at least 70 mg/ dL. At 1 year, among the 81.7% of the cohort who had at least one lipid test, 58.4% had LDL of at least 70 mg/ dL and 26.3% had an LDL of at least 100 mg/dL, according to the researchers.
Moreover, higher LDL at baseline, having a lipid test and attending a cardiology visit were each associated with increased odds of intensification of lipid-lowering therapy at 1 year, whereas older age ( 75 years vs. < 65 years) was associated with decreased odds of intensification, according to the study; however, no one factor was associated with lower odds of intensification across every study timepoint.
Therapeutic inertia a ‘barrier’ to intensification
“Therapeutic inertia ... has been identified as a barrier to statin and PCSK9 inhibitor use. Lipid testing and outpatient follow-up visits after an MI or coronary revascularization are important in reducing therapeutic inertia and maintaining medication adherence. A structured care pathway, an organized and well-defined approach to disease management, may reduce therapeutic inertia in lipid-lowering therapy,” the researchers wrote. “Some providers may not intensify due to patient nonacceptance of taking additional medication, drug-drug interactions, or clinical uncertainty around the true etiology of event (eg, plaque rupture vs. sepsis-induced MI). Pragmatic and implementation studies are needed to address therapeutic inertia in lipid-lowering therapy.”
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Zheutlin AR, et al. Circ Cardiovasc Qual Outcomes. 2022;doi:10.1161/CIRCOUTCOMES.121.008861.
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