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Anderson JL, Knowlton KU, May HT, Le VT, Lappe’ DL, Cripps ST, Schwab LH, Winslow T, Bair TL, Muhlestein JB. Impact of Active vs Passive Statin Selection for Primary Prevention: The CorCal Vanguard Trial. JACC. ADVANCES 2023; 2:100676. [PMID: 38938499 PMCID: PMC11198348 DOI: 10.1016/j.jacadv.2023.100676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 06/29/2024]
Abstract
Background Statins can improve outcomes in high-risk primary prevention populations. However, application in clinical practice has lagged. Objectives The objective of this study was to compare an active vs a passive strategy (ie, usual care) to statin prescription for primary prevention of atherosclerotic cardiovascular disease (ASCVD). Methods A total of 3,770 patients ≥50 years of age without a history of ASCVD or statin use were invited to enroll in CorCal, with 601 consenting to participate. These patients were randomized 1:1 to statin initiation guided by the pooled cohort equation or by coronary artery calcium scoring (CACS). Outcomes (2.8-year follow-up) compared patients managed actively vs passively (randomly invited but declined or did not respond). Results Patient demographics were well matched. Statin recommendation was common among enrolled patients (41.7%). During follow-up, 25.3% of active patients were taking a statin vs 9.8% managed passively (P < 0.0001). Active patients had more lipid panels (median 2.0 vs 1.0), lower low-density lipoprotein cholesterol (109 vs 117 mg/dL) (both P < 0.0001), and a low rate of major adverse cardiovascular events during follow-up (0.6% vs 1.0%, P = 0.47). Statistical comparisons included t-tests, chi-squared tests, nonparametric tests, and time-to-event tests as appropriate. Conclusions An active approach to statin selection for primary ASCVD prevention identified a large treatment opportunity and led to over twice as many patients on statins compared to passive (usual care) management. A large CorCal Outcomes Trial is underway to more definitively assess the impact on outcomes of active management of statins for primary prevention.
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Affiliation(s)
- Jeffrey L. Anderson
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
- The University of Utah School of Medicine, Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Kirk U. Knowlton
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
- The University of Utah School of Medicine, Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Heidi T. May
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
| | - Viet T. Le
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
- The Rocky Mountain University of Health Professions Master of PA Studies, Provo, Utah, USA
| | - Donald L. Lappe’
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
- The University of Utah School of Medicine, Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Shanelle T. Cripps
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
| | - Lesley H. Schwab
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
| | - Tyler Winslow
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
| | - Tami L. Bair
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
| | - Joseph B. Muhlestein
- Intermountain Medical Center Heart and Vascular Clinical Program, Murray, Utah, USA
- The University of Utah School of Medicine, Department of Internal Medicine, Salt Lake City, Utah, USA
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Makhmudova U, Wolf M, Willfeld K, Beier L, Weingärtner O. [Primary and secondary prevention in hypercholesterolemia: differences relevant to patient care in the PROCYON trial]. Dtsch Med Wochenschr 2023; 148:e101-e110. [PMID: 37604168 PMCID: PMC10946085 DOI: 10.1055/a-2117-6504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
BACKGROUND Cardiovascular disease accounts for one third of deaths in Germany. Elevated levels of low-density lipoprotein cholesterol (LDL-C) are considered a major risk factor. Lowering LDL-C levels is therefore an integral part of the prevention of cardiovascular events. METHODS The aim of this work is to identify potential differences between primary prevention (PP) and secondary prevention (SP) by means of a post-hoc comparison of cross-sectional data from the PROCYON survey. Medical history, concomitant diseases, adherence, and disease awareness in relation to hypercholesterolemia were queried. RESULTS 5,494 patients had participated in the survey (PP: 3,798; SP: 1,696). Comparison of the results showed a numerically higher proportion of women (PP 70.7% vs. SP 42.5%) as well as more frequent comorbidities such as hypertension (PP 45.6% vs. SP 61.0%), obesity (PP 20.9% vs. SP 27.4%), and type 2 diabetes mellitus (PP 14.1% vs. SP 23.8%). In primary prevention, hypercholesterolemia was most often diagnosed during screening (PP 74.6%), and in secondary prevention, the diagnosis was most often made during cardiovascular-related hospitalization (SP 58.0%). A cardiologist was consulted by 16.3% (PP) and 54.0% (SP) of patients, respectively. At least semiannual LDL-C checks (PP 46.8% vs. SP 77.9%) and drug intervention (PP 43.0% vs. SP 87.0%) were more frequent in the secondary prevention group. In addition, differences in the implementation of lifestyle changes, improvement of LDL-C levels, adjustment of therapy as well as adherence, treatment satisfaction and patient knowledge were observed. CONCLUSION The comparison of primary and secondary prevention from the PROCYON survey shows overall better utilization of treatment options and higher intensity of care in the secondary prevention group. However, there is still great potential for improvement in both groups to ensure efficient prevention of cardiovascular events.
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Affiliation(s)
| | - Michaela Wolf
- Cholesterin & Co e. V.: Patientenorganisation für Patienten mit Familiärer Hypercholesterinämie oder anderen schweren genetischen Fettstoffwechselstörungen (CholCo e. V.), Frankfurt/M
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Kopp K, Motloch L, Berezin A, Maringgele V, Ostapenko H, Mirna M, Schmutzler L, Dieplinger A, Hoppe UC, Lichtenauer M. Missed Opportunities in Implementation and Optimization of Lipid-Lowering Therapies in Very-High-Risk Patients Presenting with ST-Segment Elevation Myocardial Infarction. J Clin Med 2023; 12:5685. [PMID: 37685752 PMCID: PMC10488884 DOI: 10.3390/jcm12175685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
The aim of this retrospective study was to provide real-world data on lipid-lowering therapy (LLT) implementation and low-density lipoprotein cholesterol (LDL-C) target achievement in an ST-segment elevation myocardial infarction (STEMI) population, with a focus on very-high-risk patients according to European guidelines criteria. METHODS Included were all STEMI patients with available LDL-C and total cholesterol treated at a large tertiary center in Salzburg, Austria, 2018-2020 (n = 910), with stratification into very-high-risk cohorts. Analysis was descriptive, with variables reported as number, percentages, median, and interquartile range. RESULTS Among patients with prior LLT use, statin monotherapy predominated, 5.3% were using high-intensity statins, 1.2% were using combined ezetimibe therapy, and none were taking PCSK9 inhibitors at the time of STEMI. In very-high-risk secondary prevention cohorts, LLT optimization was alarmingly low: 8-22% of patients were taking high-intensity statins, just 0-6% combined with ezetimibe. Depending on the very-high-risk cohort, 27-45% of secondary prevention patients and 58-73% of primary prevention patients were not taking any LLTs, although 19-60% were actively taking/prescribed medications for hypertension and/or diabetes mellitus. Corresponding LDL-C target achievement in all very-high-risk cohorts was poor: <22% of patients had LDL-C values < 55 mg/dL at the time of STEMI. CONCLUSION Severe shortcomings in LLT implementation and optimization, and LDL-C target achievement, were observed in the total STEMI population and across all very-high-risk cohorts, attributable in part to deficits in care delivery.
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Affiliation(s)
- Kristen Kopp
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, 5020 Salzburg, Austria; (L.M.)
| | - Lukas Motloch
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, 5020 Salzburg, Austria; (L.M.)
- Department of Internal Medicine II, Salzkammergut Klinikum, 4840 Vöcklabruck, Austria
| | - Alexander Berezin
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, 5020 Salzburg, Austria; (L.M.)
- Internal Medicine Department, State Medical University of Zaporozhye, 69061 Zaporozhye, Ukraine
| | - Victoria Maringgele
- Department of Psychiatry, Psychotherapy and Psychosomatics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Halyna Ostapenko
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, 5020 Salzburg, Austria; (L.M.)
| | - Moritz Mirna
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, 5020 Salzburg, Austria; (L.M.)
| | - Lukas Schmutzler
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, 5020 Salzburg, Austria; (L.M.)
| | - Anna Dieplinger
- Institute for Nursing and Practice, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, 5020 Salzburg, Austria; (L.M.)
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, 5020 Salzburg, Austria; (L.M.)
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Makhmudova U, Wolf M, Willfeld K, Beier L, Weingärtner O. Different Perspectives of Patients and Physicians on LDL-C Target Achievement in the Treatment of Hypercholesterolemia: Results on Secondary Prevention from the German PROCYON Survey. Adv Ther 2023; 40:460-473. [PMID: 36355313 PMCID: PMC9898401 DOI: 10.1007/s12325-022-02357-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/12/2022] [Indexed: 11/12/2022]
Abstract
AIMS Low-density lipoprotein cholesterol (LDL-C) reduction in hypercholesterolemia patients at very high cardiovascular (CV) risk is essential in preventing future CV events. The objective was to assess the perception on hypercholesterolemia management in secondary prevention in Germany. METHODS PROCYON was a two-part online survey, including a patient questionnaire as well as a physician questionnaire. RESULTS A total of 109 general practitioners, internists, and cardiologists participated. The current ESC/EAS recommendation for high-risk patients is followed by 19.3% of the physicians. The majority (80.7%) reported an LDL-C target failure rate of at least 30%. More than two thirds (71.6%) have stated treating less than half of their patients with the maximum approved statin dose. The survey included 1696 secondary prevention patients. The majority (86.7%) consult their general practitioner for hypercholesterolemia; 54.0% consult a cardiologist (multiple answers allowed). Most patients (87.0%) were receiving lipid-lowering medication. Among these, 800 (54.2%) reported improved LDL-C levels since diagnosis, 569 (38.6%) reported no improvement, and 106 (7.2%) had no information. Of the treated patients with (N' = 800) and without (N' = 569) improvement, 34.3% vs. 37.3% were on their initial drug and dose, 24.8% vs. 23.7% received multiple drug therapy, 48.9% vs. 48.9% reported a dose change, and 16.1% vs. 14.2% had discontinued at least one drug (multiple answers). Disease knowledge was rated as good or very good by 29.8% of patients. CONCLUSION PROCYON demonstrated insufficient ESC/EAS guideline implementation regarding target levels and therapeutic escalation strategies. Furthermore, a lack of specialist involvement and patient education was identified.
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Affiliation(s)
- Umidakhon Makhmudova
- grid.275559.90000 0000 8517 6224Klinik Für Innere Medizin I, Universitätsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Michaela Wolf
- Cholesterin & Co E. V.: Patientenorganisation Für Patienten Mit Familiärer Hypercholesterinämie Oder Anderen Schweren Genetischen Fettstoffwechselstörungen (CholCo), Frankfurt/M., Germany
| | - Kathy Willfeld
- grid.467675.10000 0004 0629 4302Novartis Pharma GmbH, Nuremberg, Germany
| | - Lea Beier
- grid.467675.10000 0004 0629 4302Novartis Pharma GmbH, Nuremberg, Germany
| | - Oliver Weingärtner
- Klinik Für Innere Medizin I, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
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