Compliance With Dyslipidemia Guidelines in Daily Practice: How Effective Is Cardiovascular Risk Prevention?

PURPOSE

Cardiovascular disease (CVD) due to atherosclerosis is the leading cause of early mortality and morbidity. The current European guidelines on CVD prevention in clinical practice recommend the use of the Systematic Coronary Risk Estimation (SCORE) system. The current American Heart Association guidelines recommend the use of the new pooled cohort risk assessment equations to estimate the 10-year atherosclerotic CVD risk. The purpose of this article was to investigate the compliance of dyslipidemia guidelines in daily practice in patients with dyslipidemia or who have risk factors for CVD.

METHODS

The study group consisted of 500 outpatients who had dyslipidemia or risk factors for CVD. The risk level was computed according to the European and American Heart Association guidelines. Therapeutic LDL-C targets were identified based on the calculated risk level. Therapeutic target levels were compared based on the dosage of statins used and achievement of the LDL-C goal in daily practice according to the risk levels.

FINDINGS

According to the European dyslipidemia guidelines, 231 patients were in the very-high/high-risk group, and 106 patients (45.9%) achieved the LDL-C target (<100 mg/dL); 210 patients were in the moderate-risk group, and 156 (74.3%) patients achieved the LDL-C target (<115 mg/dL); and 59 patients were in the low-risk group, and 55 (93.2%) patients achieved the LDL-C target (<155 mg/dL). Univariate and multivariate logistic regression analyses revealed that the LDL-C level and presence of coronary artery disease were significantly reverse associated with achievement of the LDL-C goal (both, P < 0.001).

IMPLICATIONS

Our results showed that the majority of patients were in the very-high/high-risk group in daily practice. Although the European dyslipidemia guidelines are more likely to be used in daily practice, achievement of the guidelines-recommended treatment goals was low.

Assessment of low-density lipoprotein targets

The clinical importance of lowering of total cholesterol and low-density lipoprotein cholesterol (LDL-C) to decrease cardiovascular (CV) risk has been verified over many years starting with significant support in 1984 of the then previous lipid hypothesis. Significant support of this hypothesis began that year with publication of the Lipid Research Clinic study. Since then, multiple other studies including outcomes studies have established the value of LDL-C reduction in decreasing CV risk. In addition, multiple other factors such as inflammation, endothelial dysfunction, nitric oxide, antioxidant properties, and plaque stabilization appear important for modifying CV risk and possible favorable alterations by medications such as statins must be considered. Nevertheless, reduction of LDL-C has well-established value and is being accepted by clinicians as a major guideline for CV disease prevention. However, there are still problems with adherence by many clinicians to CV risk modification. Therefore, abandoning LDL-C reduction as a target, as has been advocated by some, appears premature and contraindicated. A strategy of LDL-C reduction in no way interferes with increased understanding of the complexities of atherosclerosis and new approaches to CV disease prevention as they become supported by outcomes studies.

How many patients need statin treatment in a low-cardiovascular-risk country? Low-density lipoprotein-cholesterol target and distance from target distribution in an Italian cohort

BACKGROUND AND AIM

To assess cardiovascular risk distribution, distribution of individual low-density lipoprotein (LDL)-cholesterol target and distance of LDL cholesterol from the target in a representative sample of the Italian population.

METHODS AND RESULTS

Cross-sectional, population-based study of a representative sample of the Italian adult population, comprising 5458 individuals (from 40 to 79 years of age, both sexes) from general practices in Italy. Of the subjects, 65.2% were in the low-cardiovascular-risk class, whereas 10.5%, 18.3% and 6.0% had moderate, high, and very high cardiovascular risk profiles, respectively; 8.2% of the subjects were treated with statins at enrolment. Of the cohort, 68.3% displayed LDL-cholesterol values below their LDL target, as calculated according to their individual risk profile. Among the 31.7% 'not at target', 42.3% were ≤ 15%, 44.3% were between 15% and 40% and 13.4% were >40% over their LDL target.

CONCLUSIONS

About two-thirds of adults in a low-cardiovascular-risk country, such as Italy, have LDL-cholesterol levels 'at target', as defined in current guidelines. Accordingly, the remaining subjects require a lifestyle or pharmacological intervention to reach their target; 24% of the total cohort, in detail, need to be treated with a statin (or to continue the prescribed statin treatment) to reach the proper LDL target. This type of data analysis might help to optimise resource allocation in preventive medicine.

Lipid-lowering drugs as primary prevention in general practice: do patients reach guideline goals and continue treatment? ADDITION Denmark

OBJECTIVE

To describe lipid-lowering treatment in a primary care setting and how well target levels are reached. Furthermore, the aim is to describe long-term adherence to treatment.

DESIGN

Population-based cross-sectional study with follow-up.

SETTING

A total of 139 general practices from three of five Danish regions, taking part in the ADDITION study from 2001 to 2006.

SUBJECTS

The study population comprises 1468 patients who started lipid-lowering drugs and were followed for a minimum of one year after starting treatment. Median time of follow-up after starting drug therapy was 936 days (range: 366-2068).

RESULTS

Of 1468 patients starting treatment, a total of 781 (53%) reached the treatment goal of total cholesterol <5.0 and low-density lipoprotein <3 mmol/l within one year after drug therapy start. The percentage increased throughout the study period from 27% of patients initiating treatment in 2001 to 66% of patients initiating treatment in 2005. Age over 50, repeated cholesterol measurements within three months after treatment start, larger initial dose, and calendar year of treatment start were associated with reaching the goal within the first year, and most recent total cholesterol measurement before start of treatment >7 mmol/L was associated with not reaching the goal in the first year. Among patients followed for a minimum of three years after drug therapy started (n = 536), adherence was 77%, 72%, 75% in the first, second, and third year respectively.

CONCLUSION

Initial doses and the percentage reaching their goal increased substantially throughout the study period. Adherence to lipid-lowering treatment is relatively high in a primary care setting. However, current practice shows room for improvement if treatment recommendations are to be met.

Individualized initiation of statin therapy determined by baseline LDL-C: Are you more likely to achieve goal LDL-C?

Cardiovascular disease remains the leading cause of death in the world. A significant amount of clinical data are available to demonstrate the positive influence that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy has on slowing the progression of cardiovascular disease and improving clinical outcomes. Achieving the treatment goals for cholesterol in cardiovascular disease continues to present challenges. Recent clinical trial information is available assessing the use of more aggressive initial doses of statin therapy based on initial low-density lipoprotein cholesterol (LDL-C) measurements in an attempt to reach treatment goals sooner. Six clinical trials assessed low-, moderate- and high-risk individuals as well as those with type 2 diabetes mellitus to determine if this treatment approach is both safe and effective. The studies concluded that initial dosing of statin therapy determined by a baseline LDL-C measurement demonstrates good achievement in reaching treatment goals and does not result in a higher rate of adverse effects.