Statin therapy underused for treating severe hypercholesterolemia
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The number of adults with severe hypercholesterolemia prescribed general and high-intensity statins in a Kentucky health system falls below recommended guidelines, according to a study published in The American Journal of Cardiology.
“Individuals with severe hypercholesterolemia have a fivefold higher long-term risk for coronary heart disease and atherosclerotic cardiovascular disease compared with individuals with average LDL-C levels,” Wael Eid, MD, an endocrinologist and lipid specialist at St. Elizabeth Physicians Regional Diabetes Center in Covington, Kentucky, the University of Kentucky College of Medicine in Lexington, the University of South Dakota Sanford School of Medicine in Sioux Falls and Alexandria University in Egypt, told Healio. “There are distinct rigorous guidelines to support aggressive treatment for severe hypercholesterolemia with high-intensity statins and other lipid-lowering therapies, if needed. However, there is a general feeling that these guidelines are not yet fully implemented. The value of this study was to assess the extent of use of these guidelines in the population we serve, to identify potential areas of gaps in care, and to be able to identify these individual patients and optimize their treatment.”
Eid and colleagues conducted a cross-sectional study of every patient who had LDL cholesterol measured in the St. Elizabeth Health Care system from 2009 to April 2020. Severe hypercholesterolemia was defined as having LDL cholesterol levels of at least 190 mg/dL. Those with severe hypercholesterolemia were placed in one group (n = 19,695) while those without severe hypercholesterolemia were placed into a second group (n = 245,525).
The severe hypercholesterolemia group had a higher prevalence of hypertension and higher mean blood pressure, systolic BP, diastolic BP and cholesterol values than those with nonsevere hypercholesterolemia.
Most patients with no comorbidities in the severe hypercholesterolemia group were treated by primary care providers (43.2% to 45.7%) — who mostly prescribed low- or moderate-intensity statin therapy — whereas 3.4% to 4.4% were treated by an endocrinologist and 2.5% to 3.3% by a cardiologist.
In the severe hypercholesterolemia group, 77% were prescribed general statins and 27% high-intensity statin therapy. Of the severe hypercholesterolemia group, 83% had persistently elevated LDL cholesterol levels, and 22% of these were prescribed a high-intensity statin.
Patients with comorbidities were more likely to be prescribed statins, regardless of hypercholesterolemia severity. Adults with severe hypercholesterolemia aged 40 to 75 years (74% to 76.3%) and those older than 75 years (65.6% to 73.6%) were more likely to receive a statin prescription than those younger than 40 years (50% to 58.3%).
“There was evidence of treatment paradox where those with highest risk for CVD are not treated as aggressively as they should,” Eid said. “Less than one-third of patients with severe hypercholesterolemia are treated by high-intensity statins. Younger patients with severe hypercholesterolemia are being less aggressively treated than those who are middle-aged, even though both have high risk for CVD. Most of these patients are being cared for at primary care offices rather than specialty medicine, and that is where most of the efforts in optimizing care should be targeted.”
Eid said support is needed from quality improvement and clinical utilization departments to have initiatives for optimizing risk for patients with severe hypercholesterolemia. He added that greater awareness of severe hypercholesterolemia in primary care practices and identifying barriers for statin therapy optimization are other important issues to address.
For more information:
Wael Eid, MD, can be reached at wael.eid@usd.edu.
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