Most patients at high CV risk are not achieving LDL goals
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Key takeaways:
- The patients at highest CV risk generally do not achieve guideline-recommended LDL goals.
- Most clinicians do not prescribe combination lipid-lowering therapies to their patients at highest CV risk.
NEW ORLEANS — Most patients at high or very high CV risk do not achieve guideline-recommended LDL goals, according to data from the Family Heart Database presented at the American College of Cardiology Scientific Session.
“We know that individuals living with familial hypercholesterolemia (FH) are too often undiagnosed and undertreated, and our goal is to change this,” Mary P. McGowan, MD, FNLA, assistant professor of medicine at the Geisel School of Medicine at Dartmouth, lipid researcher at Dartmouth Hitchcock Medical Center and chief medical officer at The Family Heart Foundation in Pasadena, California, told Healio. “For this analysis, we decided to look more broadly at individuals at high risk because of very elevated LDL-C levels (this would include many people with FH) and also a larger group of individuals with underlying atherosclerotic cardiovascular disease. We wanted to quantify the degree of undertreatment (including no treatment) in this very large group of Americans. The findings ... are very disturbing given that elevated LDL-C is such a strong risk factor for ASCVD.”
McGowan and colleagues conducted an analysis of the Family Heart Database, which includes diagnostic, procedural and prescription data from claims and/or laboratory data for more than 324 million individuals in the U.S. from 2012 to 2021.
The cohort included more than 38 million Americans defined as at high or very high risk for CVD. Those who had severe primary hypercholesterolemia (LDL 190 mg/dL) and those who had ASCVD were defined as high risk, and those with multiple major ASCVD events or one major ASCVD event plus multiple high-risk conditions were defined as very high risk.
The researchers assessed whether high- or very high-risk patients achieved LDL goals as outlined in the 2018 Multidisciplinary Guideline on the Management of Blood Cholesterol: 70 mg/dL or less for those at very high risk or at high risk because of ASCVD, and 100 mg/dL or less for those at high risk because of severe primary hypercholesterolemia.
Only 27.8% of high- or very high-risk patients ever achieved their LDL goal, and for those who did achieve it, the mean duration of achievement was 158.8 days, according to the researchers.
“I can’t stress enough the importance of lowering LDL-C, especially in high-risk individuals,” McGowan told Healio. “We know from randomized controlled clinical trials that for every 40 mg LDL-C falls, and stays down, cardiac risk is reduced by about 20%. These are studies that lasted about 5 years, so keeping the LDL down over a prolonged period is crucial. The longer the LDL stays low, the greater the benefit.”
In addition, McGowan and colleagues found, 79.5% of clinicians never prescribed combination lipid-lowering therapy to high- or very high-risk patients despite guideline recommendations, and only 2.2% of high-risk patients received combination lipid-lowering therapy.
“When it comes to high- and very high-risk patients, we are failing,” McGowan told Healio. “Clinicians need to follow the guidelines — this is an easy thing to say, but to be honest, our health system isn’t set up to allow clinicians to practice the kind of medicine they went to school to practice. When you have a patient with ASCVD, diabetes, hypertension, hyperlipidemia and, maybe, knee pain sitting in your office and you have 20 minutes to educate and solve all this patient’s problems, something is going to fall by the wayside. And all too often, it is LDL-C that is cast aside. Often clinicians feel that if a person is at least on a statin, they have done their job. But we could be doing so much better.”
Education and reevaluation of performance metrics are key to improving the situation, McGowan said.
“Patients who are educated regarding their own LDL-C goals can push their clinicians to prescribe combination lipid-lowering therapy when needed,” she told Healio. “In short, educating clinicians and patients is important, but we also need to motivate clinicians by reactivating LDL-C as both a quality and performance measure.”
Reference:
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Wilemon KA, et al. Abstract 1310-172. Presented at: American College of Cardiology Scientific Session; March 4-6, 2023; New Orleans (hybrid meeting).
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