LDL-C goal attainment among patients newly diagnosed with coronary heart disease or diabetes in a commercial HMO

Leveraging Healthcare System Data to Identify High-Risk Dyslipidemia Patients

PURPOSE OF REVIEW

While randomized controlled trials have historically served as the gold standard for shaping guideline recommendations, real-world data are increasingly being used to inform clinical decision-making. We describe ways in which healthcare systems are generating real-world data related to dyslipidemia and how these data are being leveraged to improve patient care.

RECENT FINDINGS

The electronic medical record has emerged as a major source of clinical data, which alongside claims and pharmacy dispending data is enabling healthcare systems the ability to identify care gaps (underdiagnosis and undertreatment) in patients with dyslipidemia. Availability of this data also allows healthcare systems the ability to test and deliver interventions at the point-of-care. Real-world data possess great potential as a complement to randomized controlled trials. Healthcare systems are uniquely positioned to not only define care gaps and areas of opportunity, but to also to leverage tools (e.g., clinical decision support, case identification) aimed at closing them.

Prevalence and Predictors of Out-of-Target LDL Cholesterol 1 to 3 Years After Myocardial Infarction. A Subanalysis From the EYESHOT Post-MI Registry

BACKGROUND

There is an incomplete understanding of the prevalence and predictors of attainment of low-density lipoprotein cholesterol (LDL-C) goal after myocardial infarction (MI).

AIM

To evaluate the prevalence of achievement of LDL-C goal of 70 mg/dL, to identify the baseline features associated with suboptimal lipid control, and to assess the use of LDL-C-lowering drug therapies (LLT) beyond the first year after MI.

METHODS

The EYESHOT Post-MI was a prospective, cross-sectional, Italian registry, which enrolled patients presenting to cardiologist 1 to 3 years after MI. In this retrospective post-hoc analysis, patients were categorized in 2 groups according to the achievement or not of the LDL-C goal of 70 mg/dL. Univariable and multivariable logistic regression analyses were performed to identify the baseline features associate with LDL-C≥70 mg/dL.

RESULTS

The study population included 903 patients (mean age 65.5 ± 11.5 years). Among them, LDL-C was ≥70 mg/dL in 474 (52.5%). Male sex (P = 0.031), hypertension (P = 0.024), prior percutaneous coronary intervention (P = 0.016) and high education level (P = 0.008) were higher in the LDL-C <70 group. At multivariable analysis, low education level was an independent predictor of LDL-C≥70 mg/dL (OR:1.582; 95%CI, 1.156-2.165; P = 0.004). Conversely, hypertension increased the probability to achieve the LDL-C goal (OR:0.650; 95%CI, 0.443-0.954; P = 0.028). Among off-target patients, LLT was not modified in the majority of cases (67.3%), intensified in 85 (18.6%), and actually reduced in 63 patients (13.8%).

CONCLUSIONS

In patients presenting to cardiologists 1 to 3 years from the last MI event, LDL-C is not under control in a large proportion of patients, particularly in those with a low education level or without hypertension. LLT is underused in this very-high-risk setting.

Quantifying Unmet Need in Statin-Treated Hyperlipidemia Patients and the Potential Benefit of Further LDL-C Reduction Through an EHR-Based Retrospective Cohort Study

BACKGROUND

Statins are effective in helping prevent cardiovascular disease (CVD). However, studies suggest that only 20%-64% of patients taking statins achieve reasonable low-density lipoprotein cholesterol (LDL-C) thresholds. On-treatment levels of LDL-C remain a key predictor of residual CVD event risk.

OBJECTIVES

To (a) determine how many patients on statins achieved the therapeutic threshold of LDL-C < 100 mg per dL (general cohort) and < 70 mg per dL (secondary prevention cohort, or subcohort, with preexisting CVD); (b) estimate the number of potentially avoidable CVD events if the threshold were reached; and (c) forecast potential cost savings.

METHODS

A retrospective, longitudinal cohort study using electronic health record data from the Indiana Network for Patient Care (INPC) was conducted. The INPC provides comprehensive information about patients in Indiana across health care organizations and care settings. Patients were aged > 45 years and seen between January 1, 2012, and October 31, 2016 (ensuring study of contemporary practice), were statin-naive for 12 months before the index date of initiating statin therapy, and had an LDL-C value recorded 6-18 months after the index date. Subsequent to descriptive cohort analysis, the theoretical CVD risk reduction achievable by reaching the threshold was calculated using Framingham Risk Score and Cholesterol Treatment Trialists' Collaboration formulas. Estimated potential cost savings used published first-year costs of CVD events, adjusted for inflation and discounted to the present day.

RESULTS

Of the 89,267 patients initiating statins, 30,083 (33.7%) did not achieve the LDL-C threshold (subcohort: 58.1%). In both groups, not achieving the threshold was associated with patients who were female, black, and those who had reduced medication adherence. Higher levels of preventive aspirin use and antihypertensive treatment were associated with threshold achievement. In both cohorts, approximately 64% of patients above the threshold were within 30 mg per dL of the respective threshold. Adherence to statin therapy regimen, judged by a medication possession ratio of ≥ 80%, was 57.4% in the general cohort and 56.7% in the subcohort. Of the patients who adhered to therapy, 23.7% of the general cohort and 50.5% of the subcohort had LDL-C levels that did not meet the threshold. 10-year CVD event risk in the at-or-above threshold group was 22.78% (SD = 17.24%) in the general cohort and 29.56% (SD = 18.19%) in the subcohort. By reducing LDL-C to the threshold, a potential relative risk reduction of 14.8% in the general cohort could avoid 1,173 CVD events over 10 years (subcohort: 15.7% and 454 events). Given first-year inpatient and follow-up costs of $37,300 per CVD event, this risk reduction could save about $1,455 per patient treated to reach the threshold (subcohort: $1,902; 2017 U.S. dollars) over a 10-year period.

CONCLUSIONS

Across multiple health care systems in Indiana, between 34% (general cohort) and 58% (secondary prevention cohort) of patients treated with statins did not achieve therapeutic LDL-C thresholds. Based on current CVD event risk and cost projections, such patients seem to be at increased risk and may represent an important and potentially preventable burden on health care costs.

DISCLOSURES

Funding support for this study was provided by Merck (Kenilworth, NJ). Chase and Boggs are employed by Merck. Simpson is a consultant to Merck and Pfizer. The other authors have nothing to disclose.

Guidelines impact cholesterol management

BACKGROUND

Previous research demonstrates increased utilization of high-intensity statins, but unchanged low-density lipoprotein cholesterol (LDL-C) levels, immediately after the 2013 American College of Cardiology (ACC) and the American Heart Association (AHA) guideline release.

OBJECTIVE

The objective of this study was to determine achievement of statin therapy goals in patients with atherosclerotic cardiovascular disease (ASCVD) before and up to 4 years after the 2013 ACC/AHA guideline release compared with LDL-C goals of <70 mg/dL and <100 mg/dL previously recommended by other professional societies.

METHODS

The single-system cohort study used medical records, laboratory results, and claims data (November 2012-October 2017) of adults with ≥1 claim for a statin, ≥1 ASCVD diagnosis in propensity score-matched analyses.

RESULTS

Among 1938 patients (mean age 70 ± 11, 48% female) with ASCVD, the percentage on high-intensity statin therapy significantly increased over time: 24% in 2013, 34% 2014, 42% 2015, and 49% 2016 (P < .0001). The increase in high-intensity statin use was 13 to 22% higher among patients managed by subspecialists (cardiologist and endocrinologists) compared with those managed by primary care providers. Mean LDL-C level was slightly, but not significantly, lower in 2013 (80 mg/dL) than in other years: 85 mg/dL in 2014, 83 mg/dL in 2015, and 82 mg/dL in 2016. The proportion of patients reaching LDL-C goals ranged from 51% to 56% for the <70 mg/dL target and 77% to 85% for the <100 mg/dL target over time.

CONCLUSION

High-intensity statin use among secondary prevention patients increased significantly immediately after the 2013 ACC/AHA guidelines release, primarily in those managed by subspecialists. However, the mean LDL-C and the proportion of patients reaching LDL-C < 70 mg/dL and < 100 mg/dL remain unchanged across comparison cohorts.

The decreased achievement of therapeutic goal in lipid lowering therapy in obese and diabetic patients in Poland

BACKGROUND

Statins are used to reduce a cardiovascular risk. However, the effectiveness of the therapy in many cases remains unsatisfactory. Therefore, the aim of this study was to evaluate the influence of obesity and diabetes on the achievement of therapeutic goal in lipid-lowering therapy in patients with a various cardiovascular risk in the daily clinical practice.

METHODS

This study was conducted on the basis of questionnaires obtained from 7018 patients (41.4% obese, 65.9% viscerally obese and 25.3% diabetics) treated with statins for at least three months. The effectiveness of the treatment was assessed in a subgroup of 3218 patients with a full lipid profile.

RESULTS

The LDL-cholesterol target, adjusted for cardiovascular risk, was obtained by 8.1% of patients, less frequently by those with a very high risk of a cardiovascular disease (3.7%), obesity (5.5%), visceral obesity (5.5%) and the type 2 diabetes (5.3%). The obese patients with type 2 diabetes were the least likely to reach the target (3.0%). Male gender, age, the body mass index (BMI)≥28kg/m², visceral obesity, type 2 diabetes, and a low/moderate statin dose prescription were independent factors decreasing the chance of reaching the low-density lipoprotein (LDL) cholesterol target.

CONCLUSIONS

1. The prescribed statin doses do not fully explain the lower frequency of achieving the recommended target in a lipid-lowering therapy in the obese patients and the diabetics. 2. In the daily clinical practice the doses of statins are frequently insufficient and not adjusted for a cardiovascular risk.

The Effectiveness of Medication Adherence Interventions Among Patients With Coronary Artery Disease: A Meta-analysis

BACKGROUND

Despite the known benefits of medication therapy for secondary prevention of coronary artery disease (CAD), many patients do not adhere to prescribed medication regimens. Medication nonadherence is associated with poor health outcomes and higher healthcare cost.

OBJECTIVE

The purpose of this meta-analysis was to determine the overall effectiveness of interventions designed to improve medication adherence (MA) among adults with CAD. In addition, sample, study design, and intervention characteristics were explored as potential moderators to intervention effectiveness.

METHODS

Comprehensive search strategies helped in facilitating the identification of 2-group, treatment-versus-control-design studies testing MA interventions among patients with CAD. Data were independently extracted by 2 trained research specialists. Standardized mean difference effect sizes were calculated for eligible primary studies, adjusted for bias, and then synthesized under a random-effects model. Homogeneity of variance was explored using a conventional heterogeneity statistic. Exploratory moderator analyses were conducted using meta-analytic analogs for analysis of variance and regression for dichotomous and continuous moderators, respectively.

RESULTS

Twenty-four primary studies were included in this meta-analysis. The overall effect size of MA interventions, calculated from 18,839 participants, was 0.229 (P < .001). The most effective interventions used nurses as interventionists, initiated interventions in the inpatient setting, and informed providers of patients' MA behaviors. Medication adherence interventions tested among older patients were more effective than those among younger patients. The interventions were equally effective regardless of number of intervention sessions, targeting MA behavior alone or with other behaviors, and the use of written instructions only.

CONCLUSIONS

Interventions to increase MA among patients with CAD were modestly effective. Nurses can be instrumental in improving MA among these patients. Future research is needed to investigate nurse-delivered MA interventions across varied clinical settings. In addition, more research testing MA interventions among younger populations and more racially diverse groups is needed.

Assessment of statin therapy, LDL-C levels, and cardiovascular events among high-risk patients in the United States

BACKGROUND

Statins have demonstrated significant benefit in reducing cardiovascular disease (CVD) risk.

OBJECTIVE

To evaluate statin treatment patterns by intensity, elevated low-density lipoprotein cholesterol (LDL-C) levels, and cardiovascular (CV) events in high-risk CVD patients.

METHODS

Patients included were aged ≥ 18 years, with a coronary heart disease (CHD; Jan 1, 2007-Dec 31, 2011, index date) or CHD risk equivalent (CHD RE) diagnosis (Jan 1, 2007-Dec 31, 2010, index date), in the Truven MarketScan claims database, continuously enrolled for 2 years pre- and up to 1 (CHD) or 2 (CHD RE) years post-index. Patients with CHD, CHD RE, rhabdomyolysis, or chronic kidney disease any time pre-index were excluded. Statin therapy was assessed at baseline, 30, 90, and 365 days post-index. LDL-C values were captured in patients with available data at 30-day intervals up to 1 year. CV events were evaluated up to 1 year post-index. Descriptive statistics were used to report results.

RESULTS

There were 175,103 CHD and 68,290 CHD RE patients; 3333 CHD RE patients had post-index CV events. At 1 year, 38.7% of CHD patients and 44.3% of CHD RE patients with post-index CV events were not prescribed statins. Most patients who were prescribed statins, received a moderate-intensity statin. The percentage of patients with LDL-C ≥ 100 mg/dL reduced over time, but at 1 year, 29.3% of CHD and 30.0% of CHD RE patients with post-index CV events had LDL-C ≥ 100 mg/dL. At 1 year post-index, 9.9% CHD and 7.3% CHD RE patients had at least 1 CV event.

CONCLUSION

There is room for better LDL-C management among high-risk CVD patients to reduce their overall CV risk.

Influence of glucose-lowering rate on CKMB and myoglobin serum levels in type-2 diabetes patients with coronary heart disease

OBJECTIVE

To analyze the level of creatine kinase isoenzyme (CKMB), myoglobin, to explore the influence of different glucose-lowering rate on cardiac enzyme in type 2 diabetes mellitus patients with coronary heart disease (T2DMC), to search for the rational glucose-lowering rate.

METHODS

A total number of 293 type 2 diabetic patients who were hospitalized in the First Affiliated Hospital of Harbin Medical University from May 2008 to December 2009 were recruited. Two groups were divided according to the coronary angiography. 142 subjects of type 2 diabetes mellitus (T2DM) and 151 subjects of T2DMC received intensive glucose therapy. After CKMB and myoglobin being measured, variation and correlation factors were evaluated.

RESULTS

In T2DM group, the level of CKMB was significantly lower at follow-up than that before intensive therapy. Then, we got four subgroups according to the glucose-lowering rate. In T2DM group, when the fasting or postprandial glucose-lowering rate was no more than 6 mmolL(-1)d(-1), the level of CKMB and myoglobin were significantly lower than that before intensive therapy (P<0.05). When the fasting glucose-lowering rate is faster than 6 mmolL(-1)d(-1), the level of CKMB is significantly higher after intensive therapy than that before glucose-lowering (P<0.05). In T2DMC group, when the fasting or postprandial glucose-lowering rate was not more than 4 mmolL(-1)d(-1), the level of CKMB and myoglobin was significantly lower than that before intensive therapy (P<0.05, P<0.01). When the fasting glucose-lowering rate was faster than 4 mmolL(-1)d(-1), the level of CKMB and myoglobin was significantly higher at follow-up than that before intensive therapy (P<0.05). Before intensive therapy, high density lipoprotein cholesterol (HDL-C) has a negative linear regression relationship with CKMB (P<0.01). Low density lipoprotein cholesterol (LDL-C) and triglyceride (TG) and glycosylated hemoglobin A1c (HbA1c) have a positive linear regression relationship with CKMB (P<0.05). HDL-C has a negative linear regression relationship with myoglobin (P<0.01). LDL-C and TG have a positive linear regression relationship with myoglobin (P<0.01).

CONCLUSIONS

T2DM patients, no matter with CHD or not, all have a rational fasting glucose-lowering rate; the fasting glucose-lowering rate is more susceptible to myocardial damage anticipation than the postprandial glucose-lowering rate.

Lipid target achievement among patients with very high and high cardiovascular risk in a lipid clinic

This was a retrospective study that assessed achievement of lipid-lowering treatment targets in the setting of a University Hospital Lipid Clinic. Low-density lipoprotein cholesterol (LDL-C) goal attainment according to National Cholesterol Education Program-Adult Treatment Panel III (NCEP ATP III) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines was recorded in 1000 consecutive adult patients followed for ≥3 years (mean 8 years). The LDL-C targets according to the NCEP ATP III were attained by 66% and 86% of patients with "very high" (n = 477) and "high" (n = 408) cardiovascular risk, respectively. Fewer patients were within LDL-C goals according to the ESC/EAS guidelines: 25% and 42%. Overall, 92% of the patients were on statins: 67% were on statin monotherapy, while 33% were on combinations with ezetimibe (25%), ω-3 fatty acids (5%), fibrates (4%), or colesevelam (2%). Even in a specialist lipid clinic, a large proportion of patients are not at goal according to the recent ESC/EAS guidelines.

Limitations of real-world treatment with atorvastatin monotherapy for lowering LDL-C in high-risk cardiovascular patients in the US

BACKGROUND

Guidelines endorse statin therapy for lowering low-density lipoprotein cholesterol (LDL-C) to recommended levels, in patients with cardiovascular disease (CVD) risk, if needed, after lifestyle changes. Atorvastatin is a common statin with greater LDL-C lowering efficacy than most other statins; its availability in generic form will likely increase its use. This study assessed attainment of guideline-recommended LDL-C levels in high-risk CVD patients treated with atorvastatin monotherapy.

METHODS

Analyses of two retrospective US cohorts of patients who received a prescription for atorvastatin monotherapy between January 1, 2008 and December 31, 2010 (index date defined as first prescription date) in the GE Centricity Electronic Medical Record (EMR) (N=10,693) and Humana Medicare (N=16,798) databases. Eligible patients were ≥18 years, diagnosed with coronary heart disease or atherosclerotic vascular disease, with ≥1 LDL-C measurement between 3 months and 1 year postindex date, and continuously enrolled for 1 year prior to and following the index date.

RESULTS

Of the eligible patients, 21.8%, 29.6%, 29.9%, and 18.7% (GE Centricity EMR) and 25.4%, 32.9%, 27.8%, and 14.0% (Humana Medicare) received 10, 20, 40, and 80 mg doses of atorvastatin, respectively. The mean ± standard deviation (SD) follow-up LDL-C levels were 2.1±0.8 mmol/L (83±30 mg/dL) and 2.3±0.8 mmol/L (88±31 mg/dL) for the GE Centricity EMR and Humana Medicare cohorts, respectively. Regardless of dose, only 28.3%-34.8% of patients had LDL-C levels <1.8 mmol/L (<70 mg/dL), and 72.0%-78.0% achieved LDL-C <2.6 mmol/L (<100 mg/dL) in both cohorts. As many as 41% and 13% of patients had LDL-C levels ≥0.5 mmol/L (≥20 mg/dL) above LDL-C 1.8 mmol/L (70 mg/dL) and 2.6 mmol/L (100 mg/dL), respectively, in both cohorts; these percentages were generally similar across atorvastatin doses.

CONCLUSION

In this real-world US setting, a large number of high-risk CVD patients did not attain guideline-recommended LDL-C levels with atorvastatin monotherapy. More than 65% of the patients had LDL-C levels >1.8 mmol/L (>70 mg/dL), and of these, 30%-40% had LDL-C levels ≥0.5 mmol/L (≥20 mg/dL) above this, regardless of dose. This suggests that more effective lipid-lowering strategies, such as statin uptitration, switching to a higher efficacy statin, and/or combination therapy, may be required to achieve optimal LDL-C lowering in high-risk patients.

Electronic clinical laboratory test results data tables: lessons from Mini-Sentinel

PURPOSE

Developing electronic clinical data into a common data model posed substantial challenges unique from those encountered with administrative data. We present here the design, implementation, and use of the Mini-Sentinel Distributed Database laboratory results table (LRT).

METHODS

We developed the LRT and guided Mini-Sentinel data partners (DPs) in populating it from their source data. Data sources included electronic health records and internal and contracted clinical laboratory systems databases. We employed the Logical Observation Identifiers, Names, and Codes (LOINC®) results reporting standards. We evaluated transformed results data using data checks and an iterative, ongoing characterization and harmonization process.

RESULTS

Key LRT variables included test name, subcategory, specimen source, LOINC, patient location, specimen date and time, result unit, and unique person identifier. Selected blood and urine chemistry, hematology, coagulation, and influenza tests were included. Twelve DPs with outpatient test results participated; four also contributed inpatient test results. As of September 2013, the LRT included 385,516,239 laboratory test results; data are refreshed at least quarterly. LOINC availability and use varied across DP. Multiple data quality and content issues were identified and addressed.

CONCLUSION

Developing the LRT brought together disparate data sources with no common coding structure. Clinical laboratory test results obtained during routine healthcare delivery are neither uniformly coded nor documented in a standardized manner. Applying a systematic approach with data harmonization efforts and ongoing oversight and management is necessary for a clinical laboratory results data table to remain valid and useful.

Efficacy and safety of ETC-1002, a novel investigational low-density lipoprotein-cholesterol-lowering therapy for the treatment of patients with hypercholesterolemia and type 2 diabetes mellitus

OBJECTIVE

8-Hydroxy-2,2,14,14-tetramethylpentadecanedioic acid (ETC-1002) is a small molecule with a unique mechanism of action shown in nonclinical studies to modulate pathways of cholesterol, fatty acid, and carbohydrate metabolism. In previous phase 2 clinical trials, once daily oral treatment with ETC-1002 significantly reduced low-density lipoprotein-cholesterol in patients with hypercholesterolemia. In this trial, the lipid-lowering efficacy of ETC-1002 was evaluated in patients with type 2 diabetes mellitus and hypercholesterolemia. Additional cardiometabolic biomarkers, including glycemic measures, were also assessed.

APPROACH AND RESULTS

A single-center, double-blind, placebo-controlled trial evaluated 60 patients with type 2 diabetes mellitus and elevated low-density lipoprotein-cholesterol. Patients discontinued all diabetes mellitus and lipid-regulating drugs and were randomized to receive ETC-1002 80 mg QD for 2 weeks followed by 120 mg QD for 2 weeks or placebo for 4 weeks. ETC-1002 lowered low-density lipoprotein-cholesterol levels by 43±2.6% (least squares mean±SE), compared with a reduction of 4±2.5% by placebo at day 29 (P<0.0001; primary end point). Non-high-density lipoprotein-cholesterol and total cholesterol were also significantly lowered by ETC-1002 compared with placebo (P<0.0001). High-sensitivity C-reactive protein was reduced by 41% (median) compared with a placebo reduction of 11% (P=0.0011). No clinically meaningful safety findings were observed.

CONCLUSIONS

ETC-1002 lowered low-density lipoprotein-cholesterol and other lipids and demonstrated improvement in high-sensitivity C-reactive protein in patients with type 2 diabetes mellitus and hypercholesterolemia without worsening glycemic control. ETC-1002 was well tolerated in this population.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT# 01607294.

Changes in LDL-C levels and goal attainment associated with addition of ezetimibe to simvastatin, atorvastatin, or rosuvastatin compared with titrating statin monotherapy

Background

Many high-risk coronary heart disease (CHD) patients on statin monotherapy do not achieve guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals, and combination lipid-lowering therapy may be considered for these individuals. The effect of adding ezetimibe to simvastatin, atorvastatin, or rosuvastatin therapy versus titrating these statins on LDL-C changes and goal attainment in CHD or CHD risk-equivalent patients was assessed in a large, managed-care database in the US.

Methods

Eligible patients (n = 17,830), initially on statin monotherapy who were ≥18 years with baseline and follow-up LDL-C values, no concomitant use of other lipid-lowering therapy, and on lipid-lowering therapy for ≥42 days, were identified between November 1, 2002 and September 30, 2009. The percent change from baseline in LDL-C levels and the odds ratios for attainment of LDL-C <1.8 and <2.6 mmol/L (70 and 100 mg/dL) were estimated using an analysis of covariance and logistic regression, respectively, adjusted for various baseline factors.

Results

LDL-C reductions from baseline and goal attainment improved substantially in patients treated with ezetimibe added onto simvastatin, atorvastatin, or rosuvastatin therapy (n = 2,312) versus those (n = 13,053) who titrated these statins. In multivariable models, percent change from baseline in LDL-C was −13.1% to −14.8% greater for those who added ezetimibe onto simvastatin, atorvastatin, or rosuvastatin versus those who titrated. The odds of attaining LDL-C <1.8 and <2.6 mmol/L (70 and 100 mg/dL) increased by 2.6–3.2-fold and 2.5–3.1-fold, respectively, in patients who added ezetimibe onto simvastatin, atorvastatin, or rosuvastatin versus titrating statins.

Conclusion

CHD/CHD risk-equivalent patients in a large US managed-care database, who added ezetimibe onto simvastatin, atorvastatin, or rosuvastatin, had greater LDL-C reductions and goal attainment than those who uptitrated these statin therapies. Our study suggests that high-risk CHD patients in need of more intensive LDL-C lowering therapy may benefit by adding ezetimibe onto statin therapy.

Therapeutic practice patterns related to statin potency and ezetimibe/simvastatin combination therapies in lowering LDL-C in patients with high-risk cardiovascular disease

BACKGROUND

Statin combination therapy and statin uptitration have been shown to be efficacious in low-density lipoprotein cholesterol (LDL-C) lowering and are recommended for patients with high-risk coronary heart disease (CHD) who do not reach guideline-endorsed LDL-C goals on statin monotherapy.

OBJECTIVE

This analysis evaluated treatment practice patterns and LDL-C lowering for patients with CHD/CHD risk equivalent on statin monotherapy in a real-world practice setting in the United States.

METHODS

In this retrospective, observational study, patients with CHD/CHD risk equivalent on statin therapy were identified during 2004 to 2008 in a US managed care database. Prescribing patterns and effect of switching from statin monotherapy to combination ezetimibe/simvastatin therapy vs uptitration to higher statin dose/potency level and no change from initial statin potency on LDL-C lowering were assessed. Percentage of change from baseline in LDL-C levels and odds ratios for LDL-C goal attainment were estimated with analyses of covariance and logistic regression.

RESULTS

Of 27,919 eligible patients on statin therapy, 2671 (9.6%) switched to ezetimibe/simvastatin therapy, 11,035 (39.5%) uptitrated statins, and 14,213 (50.9%) remained on the same statin monotherapy. LDL-C reduction from baseline and attainment of LDL-C <100 and <70 mg/dL were substantially greater for patients who switched to ezetimibe/simvastatin therapy (-24.0%, 81.2%, and 35.2%, respectively) than for patients who titrated (-9.6%, 68.0%, and 18.4%, respectively) or remained on initial statin therapy (4.9%, 72.2%, and 23.7%, respectively). The odds ratios for attainment of LDL-C <100 and <70 mg/dL were also higher for patients who switched than for patients who uptitrated and had no therapy change than for patients who titrated vs no therapy change. Similarly, among a subgroup of patients not at LDL-C <100 mg/dL on baseline therapy, attainment of LDL-C <100 and <70 mg/dL was greater for patients who switched than for statin uptitration vs no change, as well as for patients who uptritrated statins vs no therapy change.

CONCLUSION

In this study, LDL-C lowering and goal attainment rates improved substantially for patients with high-risk CHD on statin monotherapy who switched to combination ezetimibe/statin or uptitrated their statin therapies; however, approximately one-third of these patients still did not attain the optional recommended LDL-C goal of <70 mg/dL. Moreover, these higher efficacy lipid-lowering therapies were infrequently prescribed, indicating the need for further assessment of barriers to LDL-C goal attainment in actual practice settings.

Residual dyslipidemia among United States adults treated with lipid modifying therapy (data from National Health and Nutrition Examination Survey 2009-2010)

Despite available medications for dyslipidemia, many treated patients still have suboptimal lipid levels. The aim of this study was to examine the extent of residual dyslipidemia in United States adults. Of 2509 United States adults aged ≥18 years from the National Health and Nutrition Examination Survey (NHANES) 2009-2010, 1,129 (41.8% weighted) had hyperlipidemia on the basis of modified treatment guidelines for low-density lipoprotein (LDL) cholesterol according to risk category or pharmacologic treatment. Of these, 484 (42.4%) were treated with lipid-modifying therapy, and the proportions of subjects who still had LDL cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, or non-HDL cholesterol not at recommended levels were examined. In this cohort treated for hyperlipidemia, the mean age was 60.1 ± 14.9 years, and 52% were men. Only 36.5% of subjects receiving treatment for hyperlipidemia were at goal or normal levels for all 3 lipids (LDL cholesterol, HDL cholesterol, and triglycerides). LDL cholesterol remained higher than goal for 37.5% of subjects, 28.9% had low HDL cholesterol, and 36.3% had elevated triglycerides. One, 2, and 3 lipid parameters were at abnormal levels in 32.4%, 23.0%, and 8.2% of subjects, respectively; 36.5% had no lipid disorder. In addition, 38.6% of treated subjects were above non-HDL cholesterol goal, and even in those at LDL cholesterol goal, 12.9% were not at non-HDL cholesterol goal. Those with cardiovascular disease conditions had poorer goal attainment of LDL cholesterol, HDL cholesterol, and composite all lipids than those without cardiovascular disease. In conclusion, despite widely available treatments for dyslipidemia, many patients remain at suboptimal lipid levels, indicating need for greater adherence to lifestyle and medical therapies to address these gaps in the management of dyslipidemia.

Fatigue heralding multiple sclerosis

BACKGROUND

Fatigue is a common symptom in multiple sclerosis (MS) and is an important determinant of overall well-being and disability.

OBJECTIVE

To assess the frequency with which fatigue precedes the diagnosis of MS using a retrospective database analysis.

METHODS

Between January 1, 2003 and September 30, 2008, patients diagnosed with fatigue with and without fatigue-related medications within a 3-year period prior to newly diagnosed MS were identified from the MarketScan Databases. All statistical analysis was performed using SAS.

RESULTS

Of the 16,976 patients with MS in the overall population, 5305 (31.3%) were newly diagnosed with MS and had three years of continuous healthcare coverage prior to MS diagnosis. Of these patients, 1534 (28.9%) were labeled with chronic fatigue syndrome (ICD9-780.71) or malaise or fatigue (ICD9-780.79) prior to the diagnosis of MS. One-third of these patients were labeled with fatigue one to two years before the diagnosis; 30.8% were diagnosed only with fatigue and had no other MS symptoms prior to their MS diagnosis. Among the patients diagnosed with fatigue, 10.4% were also prescribed medication for fatigue.

CONCLUSION

This study demonstrates that fatigue may herald MS, often by years. A careful history for transient neurological symptoms and a physical examination is warranted in any patient presenting with fatigue.

Effectiveness of lipid-lowering therapy with statins for secondary prevention of atherosclerosis--guidelines vs. reality

BACKGROUND

The aim of the study was to analyze the effectiveness of lipid-lowering therapy and therapeutic decisions made by physicians for patients not achieving LDL targets.

METHODS

11,768 patients undergoing therapy with statins for secondary prevention of atherosclerosis participated in a two-visit survey. In subjects not achieving the LDL-target (< 100 mg/dl), further therapeutic decisions made by physicians were recorded.

RESULTS

Initially the LDL-target was achieved by 7.8% of patients on simvastatin and by 18.0% on atorvastatin, of which 20.8% were treated with at least a 40 mg dose. The most common changes in therapy to improve effectiveness was substituting simvastatin for another statin (75.2%, usually atorvastatin), or increasing atorvastatin dosage (59.8%). Intensification of a low fat diet and weight reduction were more frequently recommended in treatment with atorvastatin than with simvastatin (59.8% vs. 55.9%, p < 0.001). After enhanced therapy, the LDL-target was achieved by 27.8% on simvastatin and by 35.0% on atorvastatin (p < 0.001). In those with LDL levels remaining above the target, substitution of simvastatin with atorvastatin (49.9%), or the increase of atorvastatin dose (41.4%) was recommended. As previously, life-style counseling was more frequent in patients on atorvastatin (66.1% vs. 45.7% p < 0.001).

CONCLUSIONS

1. The use of low dose statins and noncompliance with behavioral modification guidelines are responsible for the low levels of effectiveness found with lipid-lowering therapies. 2. Physicians prefer substitution of less effective statins over the increase of dose in patients not achieving LDL targets. 3. Life-style changes are under-prescribed by physicians and under-implemented by their patients.

Effectiveness of treat-to-target strategy for LDL-cholesterol control in type 2 diabetes: post-hoc analysis of data from the MIND.IT study

BACKGROUND

The paper presents a post-hoc analysis of the intensity of dyslipidaemia care operated in the first 2 years of Multiple-Intervention-in-type-2-Diabetes.ITaly (MIND.IT) study.

DESIGN AND METHODS

MIND.IT is a multicentric, randomized, two-parallel arm trial involving 1461 type 2 diabetic patients at high cardiovascular (CV) risk. The study compares the usual care (UC) of CV prevention with a multifactorial intensive care (IC) approach aiming at achieving target values for the main CV risk factors according to a step-wise treat-to-target approach.

RESULTS

Proportion of patients on target for low-density lipoprotein cholesterol (LDL-C) was about 10% at baseline and increased significantly more with IC than UC (43 vs. 27%; p < 0.001). However, the majority (57%) of patients, in this intended intensively treated cohort, failed to achieve the proposed target. Average LDL-C decreased from 144 ± 35 to 108 ± 31 mg/dl with IC and from 142 ± 28 to 118 ± 32 with UC (p-for-interaction <0.0001). IC was associated with a significantly greater increase in statin prescription and lower withdrawal from treatment than UC (43 vs. 11% and 28 vs. 61%, respectively; both p < 0.001). However, the new treatments were characterized in both groups by the use of low starting doses (≤ 10 mg of atorvastatin, equivalent dose in more than 90% of patients) without increase in case of missed target.

CONCLUSIONS

The application of a multifactorial treat-to-target intervention is associated with a significant improvement in LDL-C beyond usual practice. However, the change in LDL-C appears to be more related to an increased number of treated patients and a decreased treatment withdrawal than to a true treat-to-target approach.

LDL-cholesterol target values and actual values in patients with type 2 diabetes (T2D) uncontrolled on oral antidiabetic monotherapy: the lipid results of the French ESCALADE survey

AIM

While new European guidelines have recommended much lower LDL-c target values than current 2005 French HAS guidelines, it appears that even those ones are not widely implemented. This lipid-side of the ESCALADE study was designed to determine the LDL-c target values of GPs, diabetologists (DIABs) and cardiologists (CARDIOs) and the consistency of actual values in patients with type 2 diabetes (T2D) uncontrolled on antidiabetic monotherapy.

METHODS

ESCALADE was a national multicentre, observational, descriptive, transversal survey. One thousand and three hundred GPs and 350 specialists (DIABs and CARDIOs) agreed to include respectively three and four patients each. For each patient, the physician had to set the LDL-c target value that was compared to the calculated HAS target value. The actual LDL-c value was recorded and compared to those target values.

RESULTS

A total of 412 GPs, 137 DIABs and 27 CARDIOs included respectively 699, 364 and 66 patients. Among them 19.6% had cardiovascular disease (CVD) and 56.9% were on lipid-lowering therapy (LLT). The physician's target value was in concordance with HAS value in 37.3% (GPs), 35.4% (DIABs) and 57.4% (CARDIOs) of the cases. Physicians overestimated the risk in respectively 42.7%, 54.1% and 21.3%. However, very high risk was underestimated in respectively 38.1%, 22.0% and 25.6% of the patients and the actual LDL-c value was in the target range (<100mg/dL) for only 28% of the very high-risk patients.

CONCLUSION

Physicians tend to overestimate the CVD risk in patients with T2D and set lower LDL-c target values than HAS calculated values. Nevertheless, patients with a very high risk are largely under-treated.

Cholesterol goal attainment in hypertensive patients: the impact of metabolic syndrome components

BACKGROUND

Hypertension and dyslipidemia are potentially modifiable cardiovascular risk factors.

METHODS

We studied hypertensive outpatients regarding goal attainment in controlling dyslipidemia, according to individual cardiovascular risk profile, following the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines. Factors of goal attainment for low-density lipoprotein cholesterol (LDL-C) were determined.

RESULTS

Of the 1,202 patients, this study included 886 (73.8% female, 59.9±11.1 years) with available data to determine cardiovascular risk. Overall, 544 (61.4%) had LDL-C within the goal. Individuals with inappropriate LDL-C were older, had higher systolic blood pressure (SBP), and were more likely to have metabolic syndrome, diabetes, and cardiovascular disease (CVD) and were less likely to show a controlled blood pressure. There was a progressive worsening of LDL-C control as the number of components of metabolic syndrome increased. There was also a progressive increase in the percentage of patients with inappropriate LDL-C with the increase in cardiovascular risk. In a logistic regression model including LDL-C inadequacy as a dependent variable, only age, diabetes, and CVD were predictors of inappropriate LDL-C. Moreover, even with correction for demographic and clinical variables, the inappropriate LDL-C was an independent predictor of CVD.

CONCLUSIONS

The control of dyslipidemia in hypertensive patients is far from ideal and results are even worse in individuals with CVD.

Adherence with the National Cholesterol Education Program guidelines in men with chronic spinal cord injury

OBJECTIVE

Describe the management of dyslipidemia and adherence to the National Cholesterol Educational Program (NCEP) guidelines in men with Spinal Cord Injury (SCI).

RESEARCH

Cross-sectional study of a consecutive sample of men with SCI presenting to a single site for coronary heart disease (CHD) risk assessment.

PARTICIPANTS/METHODS

Men age 45 to 70 with traumatic SCI (ASIA A, B, and C) at least 10 years prior to participation in the study with no prior history of clinical CHD. Medical history, blood-pressure, and fasting lipid panel were used to calculate risk for CHD using NCEP guidelines and the Framingham Risk Score (FRS). Adherence to treatment recommendations and adequacy of control were assessed based on the NCEP guidelines.

RESULTS

38 men were assessed; 15/38 (39.5%, 95% CI: 24.0-56.6%) had dyslipidemia, defined as an LDL-C above their LDL-C treatment threshold (n=6) or being on treatment for dyslipidemia (n=9, for a 60% treatment rate (9/15, 95% CI: 32.3-83.7%)). Of the 9 individuals on treatment, 6 (66.7%) met their treatment goals (for a 40% overall control rate (6/15, 95% CI: 16.3-67.7%)). Dyslipidemia was well controlled in low risk individuals, but control was less common in higher risk individuals.

CONCLUSIONS

Dyslipidemia is common in men age 45-70 with chronic SCI and no evidence of clinical cardiovascular disease. Rates of treatment and control of dyslipidemia in this population are far from optimal, especially among the intermediate- and high-risk groups.

Low- and high-density lipoprotein cholesterol goal attainment in dyslipidemic women: The Lipid Treatment Assessment Project (L-TAP) 2

BACKGROUND

Differences between women and men have been documented for both diagnostic testing and treatment in cardiology. This analysis evaluates whether low-density lipoprotein cholesterol (LDL-C) success rates according to current guidelines and high-density lipoprotein cholesterol (HDL-C) levels differ by gender in the L-TAP 2 population.

METHODS

Patients aged > or =20 years with dyslipidemia on stable lipid-lowering therapy were assessed in 9 countries between September 2006 and April 2007. Low-density lipoprotein cholesterol goal attainment by cardiovascular risk level and region and determinants of low HDL-C were compared between genders.

RESULTS

Of 9,955 patients (45.3% women) evaluated, women had a significantly lower overall LDL-C success rate than men (71.5% vs 73.7%, P = .014), due entirely to the difference in the high-risk/coronary heart disease (CHD) group (LDL-C goal <100 mg/dL, 62.6% vs 70.6%, P < .0001) Among CHD patients with > or =2 additional risk factors, only 26.7% of women and 31.5% of men (P = .021) attained the optional LDL-C goal of <70 mg/dL. High-density lipoprotein cholesterol was <50 mg/dL in 32.2% of women and <40 mg/dL in 26.8% of men (P < .0001), including 38.2% of women and 29.8% of men in the high risk/CHD group (P < .0001). Predictors of low HDL-C in women included diabetes, smoking, waist circumference, and hypertension.

CONCLUSIONS

Cholesterol treatment has improved substantially since the original L-TAP a decade ago, when only 39% of women attained their LDL-C goal. However, high-risk women are undertreated compared to men, and a substantial opportunity remains to reduce their cardiovascular risk.

Effect of hypercholesterolemia on myocardial necrosis and apoptosis in the setting of ischemia-reperfusion

BACKGROUND

Hypercholesterolemia is prevalent in patients who experience myocardial ischemia-reperfusion injury (IR). We investigate the impact of dietary-induced hypercholesterolemia on the myocardium in the setting of acute IR.

METHODS AND RESULTS

In normocholesterolemic (NC, n=7) and hypercholesterolemic (HC, n=7) Yucatan male pigs, the left anterior descending coronary artery was occluded for 60 minutes, followed by reperfusion for 120 minutes. Hemodynamic values were recorded, and TTC staining was used to assess necrosis. Oxidative stress was measured. Specific cell death and survival signaling pathways were assessed by Western blot and TUNEL staining. Infarct size was 45% greater in HC versus NC (42% versus 61%, P<0.05), whereas the area at risk (AAR) was similar in both groups (P=0.61). Whereas global LV function (+dP/dt, P<0.05) was higher during entire period of IR in HC versus NC, regional function deteriorated more following reperfusion in HC (P<0.05). Ischemia increased indices of myocardial oxidative stress such as protein oxidation (P<0.05), lipid peroxidation (P<0.05), and nitrotyrosylation in HC versus NC, as well as the expression of phospho-eNOS (P<0.05). The expression of myeloperoxidase, p38 MAPK, and phospho-p38 MAPK was higher in HC versus NC (all P<05). Ischemia caused higher expression of the proapoptotic protein PARP (P<0.05), and lower expression of the prosurvival proteins Bcl2 (P<0.05), phospho-Akt, (P<0.05), and phospho-PKCepsilon (P<0.05) in the HC versus NC. TUNEL-positive cell count was 3.8-fold (P<0.05) higher in the AAR of HC versus NC.

CONCLUSIONS

This study demonstrates that experimental hypercholesterolemia is associated with increased myocardial oxidative stress and inflammation, attenuation of cell survival pathways, and induction of apoptosis in the ischemic territory, which together may account for the expansion of myocardial necrosis in the setting of acute IR.

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.

Trends in cardiovascular disease risk factors in individuals with and without diabetes mellitus in the Framingham Heart Study

BACKGROUND

Individuals with diabetes mellitus are at 2- to 3-fold increased risk for cardiovascular disease (CVD) relative to those without diabetes. Our objective was to examine CVD risk factor level changes among individuals with and without type 2 diabetes mellitus from 1970 to 2005 in the Framingham Heart Study.

METHODS AND RESULTS

We included 4195 participants (3990 with no diabetes and 205 with diabetes) 50 years of age and 3495 participants (3178 with no diabetes and 317 with diabetes) 60 years of age. Contemporaneous CVD risk factor levels were measured; linear regression models were used to assess the interaction between diabetes status and calendar year on CVD risk factor levels. Among 50-year-olds without diabetes mellitus, there was an increase in body mass index of 0.39 kg/m(2) per 10 years, whereas for those with diabetes, there was an increase of 2.52 kg/m(2) (P value for the diabetes-by-calendar year interaction [P for interaction] <0.001). For low-density lipoprotein cholesterol, the mean decrease was -7.43 mg/dL per decade (nondiabetes) and -15.5 mg/dL for diabetes (P for interaction=0.002). For systolic blood pressure, the mean decrease was -3.35 mm Hg per decade (nondiabetes) and -3.50 mm Hg for diabetes (P for interaction=0.97). The direction of the trends for those with diabetes relative to those without diabetes was similar for 60-year-olds.

CONCLUSIONS

Compared with individuals without diabetes mellitus, individuals with diabetes experienced a greater increase in body mass index, a greater decrease in low-density lipoprotein cholesterol, and a similar magnitude of decline in systolic blood pressure. Individuals with diabetes mellitus have not experienced the necessary declines in CVD risk factors to overcome their increased risk of CVD. Further efforts are needed to aggressively control CVD risk factors among individuals with diabetes mellitus.

Prevalence and extent of dyslipidemia and recommended lipid levels in US adults with and without cardiovascular comorbidities: the National Health and Nutrition Examination Survey 2003-2004

BACKGROUND

Despite improvements in low-density lipoprotein cholesterol (LDL-C) levels, recent national data are limited regarding the proportion of adults at recommended lipid levels according to the presence of cardiovascular disease (CVD) and related comorbidities. We evaluated the proportion of US adults with and without these conditions at (and distance to) recommended levels of LDL-C, non-high-density lipoprotein cholesterol (non-HDL-C), HDL-C, and triglycerides.

METHODS

We analyzed data from adults aged > or =20 who had fasted for 8 or more hours (n = 2,883, weighted to a US population of 128.5 million) in the National Health and Nutrition Examination Survey 2003-2004, a nationally representative cross-sectional survey. The number of adults at National Cholesterol Education Program recommended levels for LDL-C, non-HDL-C, HDL-C, triglycerides, and combined lipids, stratified by sex, age group, ethnicity, and the presence of CVD comorbidities was determined.

RESULTS

Although 85% to 89% of persons without CVD or related comorbidities were at recommended levels for LDL-C, non-HDL-C, HDL-C, and triglycerides, only 36% to 37% of those with CVD or related comorbidities were at recommended levels for LDL-C and non-HDL-C, and only 17% were at recommended levels for all lipids. Treated persons compared with those untreated had significantly lower LDL-C (112.3 vs 156.7 mg/dL, P < .001) and non-HDL-C levels (145.9 vs 188.7 mg/dL, P < .001), but similar HDL-C (52.0 vs 50.1 mg/dL, P = .09) and triglyceride (160.1 vs 148.7 mg/dL, P = .20) levels.

CONCLUSIONS

Despite improved LDL-C levels, many adults, especially with CVD or related comorbidities, are not at recommended levels for all lipids. Improved treatment efforts to target the spectrum of dyslipidemia are needed.