Attainment of optional low-density lipoprotein cholesterol goal of less than 70 mg/dl and impact on prognosis of very high risk stable coronary patients: a 3-year follow-up

Hypercholesterolemia and cardiovascular disease: Focus on high cardiovascular risk patients

The widespread use of statins has largely improved the treatment of hypercholesterolemia, but many patients still fail to achieve the LDL-C targets recommended by guidelines. Furthermore, some patients continue to present a very high cardiovascular (CV) risk or even an extreme risk despite being well treated, mainly due to the presence of co-morbidities such as diabetes or peripheral artery disease, which significantly increase their global CV risk. For these very high CV risk patients, the most recent European guidelines have reviewed the LDL-C goals and recommend an LDL-C reduction of at least 50% and a goal of <55 mg/dL or even <40 mg/dL. Recent clinical trials have shown that patient stratification based on the presence or absence of atherothrombotic risk factors may represent a valuable tool to identify patients at extremely high CV risk who may benefit more from an aggressive LDL-C-lowering approach. In these patients it may be appropriate to aim for the lowest LDL-C level, independently of recommended goals, with all the available pharmacological approaches.

Statin prescription strategies and atherogenic cholesterol goals attainment in Lebanese coronary artery disease patients

Background Current guidelines recommend a low-density lipoprotein cholesterol goal of <1.8 mmol/L (<70 mg/dL) and a non high-density lipoprotein cholesterol (non-HDL-C) goal of <2.6 mmol/L (<00 mg/dL) for coronary artery disease (CAD) patients. Objective This study aimed to describe real-life statin prescription strategies and to assess their effectiveness in terms of LDL-C and non-HDL-C goals attainment in a cohort of CAD patients. Setting Outpatient cardiology specialty clinics located in main Lebanese cities. Methods This is a retrospective crosssectional study. Eligible patients were those who had established CAD, treated with statins and having complete follow-up lipid panel at least 3 months from statin prescription. The following statin prescription strategies were considered in data analysis: prescription of different intensity statin as monotherapy, prescription of a statin in combination with: a low fat diet, another lipid-altering agent and another lipidaltering agent plus a low fat diet. Main outcome measure LDL-C goal attainment for each of the statin prescription strategy. Results Of the 423 CAD statin-treated patients, only 38.5 and 36.6% attained their recommended LDL-C and non-HDL-C goals, respectively. Using a statin in combination with ezetimibe or with another lipid-altering agent plus a low fat diet were significantly associated with LDL-C and non-HDL-C goals attainment. Conclusion Improvement of statin prescription strategies, such as using regular and scheduled dosage of high-intensity statins and combining statin therapy with ezetimibe, is therefore required when managing patients with CAD.

A contemporary cross-sectional study on dyslipidemia management, cardiovascular risk status, and patients' quality of life in Greece: The CHALLENGE study

BACKGROUND

Prior studies conducted in Greece consistently indicate that dyslipidemia is suboptimally managed, while the burden of cardiovascular disease (CVD) and related risk factors is rising.

METHODS

CHALLENGE was a multicenter, cross-sectional study carried out following the publication of guidelines advocating stricter low-density lipoprotein cholesterol (LDL-C) targets. It primarily aimed to depict LDL-C target attainment, and to assess the cardiovascular risk status and quality of life (QoL) of patients treated in a primary or secondary CVD prevention setting who had received any medical intervention for cardiovascular risk modification within 6months of enrollment.

RESULTS

Between December 2012 and April 2013, 500 patients (55% males) aged (mean±SD) 62.0±11.7years, participated in the study. Cardiovascular risk according to the 2011 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines was 'very high', 'high', and 'moderate' in 61.2%, 23.4%, and 15.4%, respectively. Overall, 92.0% of patients were on lipid-lowering treatment, yet only 23.3% had attained their ESC/EAS-defined LDL-C target. LDL-C target attainment was more likely among 'moderate' versus 'very high' cardiovascular risk patients (odds ratio: 4.04; 95% confidence interval: 2.32-7.06; p<0.001). QoL improved as cardiovascular risk decreased (EQ-VAS 71.8±16.2 in the 'very high' versus 78.3±15.1 and 80.3±15.7 in the 'high' and 'moderate' risk groups; p<0.001). Time constraints and difficulties in implementation in daily practice were the investigator's main barriers for guideline utilization.

CONCLUSIONS

During contemporary management of dyslipidemia in Greece, LDL-C target attainment is suboptimal. There is an undoubted need for improvement and implementation of cardiovascular risk assessment in routine clinical practice.

Low-density lipoprotein cholesterol of less than 70 mg/dL is associated with fewer cardiovascular events in acute coronary syndrome patients: a real-life cohort in Thailand

BACKGROUND

Elevated low-density lipoprotein cholesterol (LDL-C) is associated with an increased risk of cardiovascular disease or mortality; however, the LDL-C goal for therapy in acute coronary syndrome (ACS) patients is controversial and varies among guidelines. This study aimed to assess the effect of reaching an LDL-C goal of <70 mg/dL (<1.8 mmol/L) on first composite cardiovascular outcomes in routine clinical practice in Thailand.

METHODS

A retrospective cohort study was conducted using medical charts and the electronic hospital database of patients diagnosed with ACS and treated with statins at a tertiary care hospital in Thailand between 2009 and 2012. After admission, patients were followed from the date of LDL-C goal assessment until the first event of composite cardiovascular outcomes (nonfatal ACS, nonfatal stroke, or all-cause death). Cox proportional hazard models adjusted for potential confounders were used.

RESULTS

Of 405 patients, mean age was 65 years (60% males). Twenty-seven percent of the patients attained an LDL-C goal of <70 mg/dL, 38% had LDL-C between 70 and 99 mg/dL, and 35% had LDL-C ≥100 mg/dL. Forty-six patients experienced a composite cardiovascular outcome. Compared with patients with an LDL-C ≥100 mg/dL, patients achieving an LDL-C of <70 mg/dL were associated with a reduced composite cardiovascular outcome (adjusted hazard ratio [HR]=0.42; 95% confidence interval [CI]=0.18-0.95; P-value=0.037), but patients with an LDL-C between 70 and 99 mg/dL had a lower composite cardiovascular outcome, which was not statistically significant (adjusted HR=0.73; 95% CI=0.37-1.42; P-value=0.354).

CONCLUSION

ACS patients who received statins and achieved an LDL-C of <70 mg/dL had significantly fewer composite cardiovascular outcomes, confirming "the lower the better" and the benefit of treating to LDL-C target in ACS patient management.

Trends in outpatient resource utilizations and outcomes for Medicare beneficiaries with nonalcoholic fatty liver disease

BACKGROUND AND AIM

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease. The objective of this study was to describe the recent trend of health care resource utilization and short-term mortality of Medicare beneficiaries with NAFLD.

METHODS

This study utilized data from a random sample of national outpatient claims of Medicare beneficiaries (2005 to 2010) who sought outpatient care for NAFLD.

RESULTS

This study included 29,528 patients who sought outpatient care for NAFLD from 2005 to 2010. The annual number of patients increased consistently from 3585 in 2005 to 6646 in 2010. The prevalence of studied comorbidities including cardiovascular disease, diabetes, hyperlipidemia, and hypertension also increased significantly. At the same time, the mean yearly charge and the mean yearly payment increased significantly from $2624±$3308 and $561±$835 in 2005 to $3608±$5132 and $629±$1157 (P<0.05), respectively. The observed mortality rate remained stable around 2.84% (P=0.64). After adjusting for the other covariates, the total number of outpatient visits and all the comorbidities considered were the most determinant factors for yearly charge and yearly payment (P<0.0001). Overall mortality was associated with age, gender, number of outpatient visits, diabetes, and hyperlipidemia.

CONCLUSIONS

The number of outpatient visits because of NAFLD rose between 2005 and 2010. Short-term mortality rates remained stable throughout the study period, whereas total annual charges and payments increased.

Statin therapy in patients with acute coronary syndrome: low-density lipoprotein cholesterol goal attainment and effect of statin potency

Background

Elevated low-density lipoprotein cholesterol (LDL-C) is associated with an increased risk of coronary artery disease. Current guidelines recommend an LDL-C target of <70 mg/dL (<1.8 mmol/L) for acute coronary syndrome (ACS) patients, and the first-line treatment to lower lipids is statin therapy. Despite current guidelines and the efficacious lipid-lowering agents available, about half of patients at very high risk, including ACS patients, fail to achieve their LDL-C goal. This study assessed LDL-C goal attainment according to use of high and low potency statins in routine practice in Thailand.

Methods

A retrospective cohort study was performed by retrieving data from medical records and the electronic hospital database for a tertiary care hospital in Thailand between 2009 and 2011. Included were ACS patients treated with statins at baseline and with follow-up of LDL-C levels. Patients were divided into high or low potency statin users, and the proportion reaching the LDL-C goal of <70 mg/dL was determined. A Cox proportional hazard model was applied to determine the relationship between statin potency and LDL-C goal attainment. Propensity score adjustment was used to control for confounding by indication.

Results

Of 396 ACS patients (60% males, mean age 64.3±11.6 years), 229 (58%) were treated with high potency statins and 167 (42%) with low potency statins. A quarter reached their target LDL-C goal (25% for patients on high potency statins and 23% on low potency statins). High potency statins were not associated with increased LDL-C goal attainment (adjusted hazards ratio 1.22, 95% confidence interval 0.79–1.88; P=0.363).

Conclusion

There was no significant effect of high potency statins on LDL-C goal attainment. Moreover, this study showed low LDL-C goal attainment for patients on either low or high potency statins. The reasons for the low LDL-C goal attainment rate warrants further investigation.

A case-control validation of Type D personality in Greek patients with stable coronary heart disease

BACKGROUND

Type D personality has been associated with a variety of emotional and social difficulties as well as with poor prognosis in patients with established coronary heart disease (CHD). We examined the psychometric properties and validity of the Type D Scale-14 (DS14) and the prevalence of Type D personality among Greek patients with CHD while taking into account demographic; clinical, such as diabetes mellitus, hypertension, and hypercholesterolemia; as well as psychological variables such as depression, anxiety, and psychological stress.

METHODS

Ninety-six patients with stable coronary heart disease and 80 healthy participants from the general population completed the Greek version of the DS14 and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Cronbach's α coefficient for the negative affectivity (NA) and social inhibition (SI) subscales was 0.83 and 0.72 for the CHD and 0.88 and 0.76 for the control group, respectively. Internal-structural validity was assessed by a factor analysis (two-factor solution), and the factor structure of the original DS14 was replicated. Using the standardized cutoff point of NA ≥10 and SI ≥10, instead of the median scores, in order to have compatible results with the majority of studies, the prevalence of Type D personality was 51% for the CHD patients and 13% for the control group. Higher NA and SI were connected with higher anxiety, depression, and total psychological stress. Finally, more patients with CHD and Type D personality than those without were diagnosed with type 2 diabetes; however, no differences were observed in hypertension or hypercholesterolemia.

CONCLUSIONS

These results indicate that the Type D construct is reliable and valid in a Greek population. The prevalence of Type D personality was higher in patients with stable coronary heart disease than in people from the general population. The DS14 subscales were positively correlated with higher anxiety, depression, and total psychological stress. Regarding other CHD risk factors, only diabetes mellitus was found more frequently in CHD patients with Type D personality.

First-line treatment patterns and lipid target levels attainment in very high cardiovascular risk outpatients

OBJECTIVES

Previous studies have demonstrated gaps in achievement of low-density lipoprotein-cholesterol (LDL-C) goals among patients at very high cardiovascular risk. We aimed to investigate lipid treatment patterns, rates and predictors of lipid targets attainment, in such outpatients in an urban area of Greece.

METHODS

This was a prospective observational study, conducted in 19 outpatient clinics of Western Greece. We recruited patients with established cardiovascular disease (CVD) and/or diabetes mellitus (DM), previously (at least 3 months before baseline assessment) untreated with any lipid lowering medication. Lipid profile assessment was performed at baseline (prior to lipid-lowering treatment initiation) and at follow-up. Lipid lowering treatment choice was at physicians' discretion and was kept constant until follow-up.

RESULTS

We recruited 712 patients with a mean age 61.4 ± 10.4 years, 68.0% males, 43.0% with DM, 64.7% with prior coronary artery disease-CAD. In total, 237/712 (33.3%) of prescribed regimens were of high or very high LDL-C lowering efficacy and out of them 113/237 (47.7%) comprised a combination of statin and ezetimibe. At follow-up the primary target of LDL-C < 70 mg/dL (1.8 mmol/L) was achieved in 71(10.0%) patients. The secondary target of non-HDL-C < 100 mg/dL (2.6 mmol/L) in the subgroup of patients with DM or increased triglycerides levels (>150 mg/dl or 1.7 mmol/L) was achieved in 45(11.6%) of patients. In multivariate logistic regression analysis (AUC = 0.71, 95% CIs 0.65-0.77, p < 0.001) male gender, smoking, baseline LDL-C and very high potency LDL-C lowering regimen emerged as independent predictors of LDL-C goal attainment (OR = 1.88, 95% CIs 1.03-3.44, p = 0.04, OR = 0.57, 95% CIs 0.33-0.96, p = 0.04, OR = 0.98, 95% CIs 0.98-0.99, p < 0.001 and OR = 2.21, 95% CIs 1.15-4.24, p = 0.02 respectively).

CONCLUSIONS

First-line management of dyslipidemia among very-high cardiovascular risk outpatients in Western Greece is unsatisfactory, with the majority of treated individuals failing to attain the LDL-C and non-HDL-C targets. This finding points out the need for intensification of statin treatment in such patients.

Prevalence of dyslipidemia and lipid goal attainment in statin-treated subjects from 3 data sources: a retrospective analysis

Background

Evidence-based randomized clinical trials have shown significant benefit of statin treatment with regard to cardiovascular disease. In anticipation of the National Cholesterol Education Program Adult Treatment Panel IV guidelines, we wanted to assess the current state of lipid goal attainment in the high-risk secondary prevention population in the United States. The objectives of the study were to estimate the proportion of high-risk patients treated with statin monotherapy who achieved Adult Treatment Panel III–recommended low-density lipoprotein cholesterol (LDL-C) goals (<100 mg/dL; optional <70 mg/dL) as well as non–high-density lipoprotein cholesterol goals (<130 mg/dL; optional <100 mg/dL).

Methods and Results

This is a cross-sectional, retrospective study of 3 data sources: electronic medical records (2003–September 2010), administrative claims data (2003–2010), and National Health and Nutrition Examination Survey data (2007–2008). High-risk patients (≥18 years of age) were defined as those with a history of coronary heart disease or coronary heart disease risk equivalent who had the latest complete lipid panel measurement and had been treated with statin monotherapy for >90 days at the time of the lipid panel. Cardiovascular disease, coronary heart disease, and coronary heart disease risk equivalents were defined on the basis of availability, specific to each data source. Across the 3 data sources, 20% to 26% of high-risk patients treated with statin monotherapy for >90 days had LDL-C <70 mg/dL, and 67% to 77% had LDL-C <100 mg/dL. The percentages of those attaining both LDL-C goals and non–high-density lipoprotein cholesterol goals were quantitatively smaller (13.5% to 19.0% and 46% to 70%).

Conclusions

Across the 3 data sources, there was consistency in the proportion of high-risk patients treated with statin monotherapy who were at LDL-C goal. A significant number of these statin-treated patients had additional dyslipidemias.