Treatment of Hyperlipidemia in Primary Practise in Germany: Sub-group Analyses from the 4E-registry with Particular Emphasis on Men and Women with Diabetes Mellitus

Adherence of hospital-based cardiologists to lipid guidelines in patients at high risk for cardiovascular events (2L registry)

OBJECTIVES

According to various national and international guidelines, the target LDL-C level is <100 mg/dl for patients with established coronary heart disease (CHD) or CHD risk equivalent (CE). We aimed to investigate aspects of the lipid-lowering management of patients at high cardiovascular risk in-hospital care and the achievement of target values.

METHODS

In the internet-based 2L registry in Germany (2005-2006), cardiologists in 42 hospitals documented at a single visit 3,131 consecutive patients with known CHD, and/or diabetes mellitus, peripheral arterial disease, or a 10-year CHD risk >20% (summarized as CE), who were on chronic statin treatment. They received instructions on the guidelines and instant feedback on the effect of their treatment decisions (educational study component).

RESULTS

The three groups comprised 1,458 patients with CHD + CE (46.6%; median LDL-C 107 mg/dl), 1,104 patients with CHD only (35.3%; median LDL-C 104 mg/dl), and 569 with CE only (18.2%; median LDL-C 111 mg/dl). At admission, LDL-C levels <100 mg/dl were observed in 43.1, 44.8 and 37.9% of patients in the three groups, respectively. Statin doses at admission were usually in the low to intermediate range (e.g., simvastatin 10-20 mg/day). Cardiologists switched to another statin in 14.6%, increased the dose of statins (if same drug) in 22.9% (mean increase from 26.8 mg/day at baseline to 31.6 mg/day) and/or added a cholesterol absorption inhibitor (CAI) in 11.6%. The cardiologists' intervention improved estimated LDL-C levels (using a lipid calculator); however, the 100 mg/dl LDL-C target was only reached in 49.0, 48.5, and 42.9%.

CONCLUSIONS

When compared with earlier studies in the outpatient setting, the treatment to target for LDL-C of high-risk CHD patients has improved, but is not satisfactory.

Projected cost-effectiveness of ezetimibe/simvastatin compared with doubling the statin dose in the United Kingdom: findings from the INFORCE study

OBJECTIVE

To evaluate the incremental cost-effectiveness ratio (ICER) of switching to ezetimibe/simvastatin (Eze/Simva) compared with doubling the submaximal statin doses, in patients with acute coronary syndrome (ACS) events in the INFORCE study.

METHODS

Lifetime treatment costs and benefits were computed using a Markov model. Model inputs included each patient's cardiovascular risk factor profile and actual lipid values at baseline and 12 weeks (endpoint). Cardiovascular event and drug costs were discounted at 3.5%. Age-specific utilities were based on UK literature values and non-coronary heart disease mortality rates on the Office of National Statistics data. In the INFORCE study, 384 patients taking statins at stable doses for ≥6 weeks before hospital admission were stratified by statin dose/potency (low, medium, and high) and then randomized to doubling the statin dose or switching to Eze/Simva 10/40mg for 12 weeks.

RESULTS

The Eze/Simva group (n=195) had a higher mean baseline total cholesterol than the double-statin group (n=189). Analyses were adjusted for baseline characteristics. In the INFORCE study, Eze/Simva reduced low-density lipoprotein cholesterol (LDL-C) by ∼30% (vs. 4% with doubling statin doses) and significantly enhanced LDL-C goal attainment. In the cost-effectiveness analysis, Eze/Simva conferred 0.218 incremental discounted quality-adjusted life year (QALY) at a discounted incremental cost of £2524, for an ICER of £11,571/QALY (95% confidence interval=£8181-£18,600/QALY). The ICER was £13,552/QALY, £11,930/QALY, and £10,148/QALY in the low-, medium-, and high-potency strata, respectively.

CONCLUSIONS

Switching to Eze/Simva 10/40 mg is projected to be a cost-effective treatment (vs. double-statin) in UK patients with ACS.

Characteristics, management and attainment of lipid target levels in diabetic and cardiac patients enrolled in Disease Management Program versus those in routine care: LUTZ registry

Background

Since 2002 the sick funds in Germany have widely implemented disease management programs (DMPs) for patients with type 2 diabetes mellitus (DM) and coronary heart disease (CHD). Little is known about the characteristics, treatment and target attainment lipid levels of these patients enrolled in DMPs compared to patients in routine care (non-DMP).

Methods

In an open, non-interventional registry (LUTZ) in Germany, 6551 physicians documented 15,211 patients with DM (10,110 in DMP, 5101 in routine care) and 14,222 (6259 in DMP, 7963 in routine care) over a follow-up period of 4 months. They received the NCEP ATP III guidelines as a reminder on lipid level targets.

Results

While demographic characteristics of DMP patients were similar to routine care patients, the former had higher rates of almost all cardiovascular comorbidities. Patients in DMPs received pharmacological treatment (in almost all drug classes) more often than non-DMP patients (e.g. antiplatelets: in DM 27.0% vs 23.8%; in CHD 63.0% vs. 53.6%). The same applied for educational measures (on life style changes and diet etc.). The rate of target level attainment for low density lipoprotein cholesterol (LDL-C) < 100 mg/dl was somewhat higher in DMP patients at inclusion compared to non-DMP patients (DM: 23.9% vs. 21.3%; CHD: 30.6% vs. 23.8%) and increased after 4 months (DM: 38.3% vs. 36.9%; CHD: 49.8% vs. 43.3%). Individual LDL-C target level attainment rates as assessed by the treating physicians were higher (at 4 months in DM: 59.6% vs. 56.5%; CHD: 49.8% vs 43.3%). Mean blood pressure (BP) and HbA_1c values were slightly lowered during follow-up, without substantial differences between DMP and non-DMP patients.

Conclusion

Patients with DM, and (to a greater extent) with CHD in DMPs compared to non-DMP patients in routine care have a higher burden of comorbidities, but also receive more intensive pharmacological treatment and educational measures. The present data support that the substantial additional efforts in DMPs aimed at improving outcomes resulted in quality gains for achieving target LDL-C levels, but not for BP or HbA_1c. Longer-term follow-up is needed to substantiate these results.