Right on Target? Analysis of LDL Levels and Medication Use in a Very High-Risk ASCVD Population

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2024-03-21

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Purpose: The American College of Cardiology (ACC) released an expert consensus pathway in 2022, introducing a new low-density lipoprotein (LDL) goal < 55 for very high-risk individuals with atherosclerotic vascular disease (ASCVD) and highlighting the need for additional non-statin therapies to achieve that goal and reduce the risk of recurrent cardiovascular (CV) events, hospitalization, and death. This study seeks to investigate whether this LDL target is being achieved and the antihyperlipidemic medications used in a very high-risk ASCVD primary care population at the UNTHSC Family Medicine Clinic.

Methods: This is a retrospective chart review using the NextGen electronic record to evaluate patients at the UNTHSC Family Medicine Clinic. Living adults with very high-risk ASCVD were included. Very high-risk was defined as multiple major ASCVD events (myocardial infarction [I25.2, I22] or stroke [I63, Z86.73]) or one major ASCVD event and multiple high-risk conditions (heart failure [I50], diabetes [E10-E13], hypertension [I10-16], chronic kidney disease [N18], age > 65 years old, and current tobacco use). Demographics such as gender, race/ethnicity, insurance, and medications were also collected. Very high-risk ASCVD patients were then stratified based on LDL goal achievement and analyzed using Chi-square analysis, independent sample T-test, and descriptive statistics using SPSS.

Results: Of the identified very high-risk ASCVD patients (n = 199), 60 (30.2%) had achieved an LDL goal < 55 mg/dL. The average LDL achieved in this group was 44.2 + 10.8 mg/dL vs. 98.6 + 44.0 mg/dL for non-achievers. All those who achieved an LDL goal < 55 mg/dL were on at least one antihyperlipidemic medication. Of those who achieved an LDL goal < 55 mg/dL, 49 (81.7%) were on a high-intensity statin, 8 (13.33%) were on ezetimibe, 6 (10%) were on fish oil, and 3 (5%) were on a PCSK9 inhibitor. No patients were prescribed bempedoic acid or inclisirin. For non-achievers, 81 (58.2%) were on a high-intensity statin, 10 (7.2%) were on ezetimibe, 14 (10.1%) were on fish oil, and only one (0.72%) patient was on a PCSK9 inhibitor. Twenty (14.4%) of the non-achievers were not on any antihyperlipidemic agents. This subset of patients had a much higher average LDL (108.1 + 33.3 mg/dL), and 20% had a history of multiple ASCVD events. LDL goal achievers were slightly older (average age 68.2 + 9.9 years vs. 65.5 + 10.5 years), male (60% vs. 33.6%), and commercially insured compared to non-achievers.

Conclusions: A majority of very high-risk ASCVD patients at the UNTHSC Family Medicine Clinic are not currently achieving the LDL goal < 55 mg/dL. Additionally, non-statin therapies are not being widely used to augment statin therapy. Further investigation is needed to determine potential barriers and limitations to achieving this lower LDL target.

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