Real-world exploration of LDL-cholesterol management in patients with atherosclerotic cardiovascular disease

Nishant P Shah; Hillary Mulder; Elizabeth Lydon; Karen Chiswell; Xingdi Hu; Zachary Lampron; Lauren Cohen; Manesh R Patel; Susan Taubes; Wenliang Song; Suresh R Mulukutla; Anum Saeed; Daniel P Morin; Steven M Bradley; Adrian F Hernandez; Neha J Pagidipati

doi:10.1016/j.ahj.2024.10.009

Real-world exploration of LDL-cholesterol management in patients with atherosclerotic cardiovascular disease

Am Heart J. 2024 Oct 16:279:50-58. doi: 10.1016/j.ahj.2024.10.009. Online ahead of print.

Authors

Affiliations

¹ Duke University Hospital, Division of Cardiology, Durham, NC; Duke Clinical Research Institute, Durham, NC. Electronic address: nishant.shah@duke.edu.
² Duke Clinical Research Institute, Durham, NC.
³ Novartis Pharmaceuticals corporation, NJ.
⁴ Duke University Hospital, Division of Cardiology, Durham, NC; Duke Clinical Research Institute, Durham, NC.
⁵ Vanderbilt University, Division of Cardiology, Nashville, TN.
⁶ University of Pittsburgh, Division of Cardiology, Pittsburgh, PA.
⁷ Ochsner Medical Center, Division of Cardiology, New Orleans, LA.
⁸ Allina Health Minneapolis Heart Institute, Minneapolis, MN.

PMID: 39423990
DOI: 10.1016/j.ahj.2024.10.009

Abstract

Background: Although guidelines recommend low-density lipoprotein cholesterol (LDL-C) to be < 70 mg/dL in patients with atherosclerotic cardiovascular disease (ASCVD), the rate of achieving this goal remains suboptimal. We sought to understand real world contemporary practice patterns of LDL-C management in patients with ASCVD, and whether LDL-C testing influenced management across US health systems.

Methods: A retrospective cohort study utilizing electronic medical record data from five health systems participating in the CardioHealth Alliance was performed on patients with an LDL-C measurement in 2021 and prior ASCVD. Multivariable regression modeling was used to determine the relationship of clinical factors with achievement of guideline directed LDL-C target. Changes in lipid lowering therapy (LLT) after LDL-C testing were also described.

Results: Among 216,074 patients with ASCVD, 129,886 (60.1%) had uncontrolled LDL-C (i.e. ≥ 70 mg/dL). Compared with participants with controlled LDL-C (< 70 mg/dL), those with uncontrolled LDL-C were more frequently female (50.9% vs. 35.1%), or Black (13.7% vs. 10.3%), and less commonly had coronary artery disease as the form of vascular disease (73.0% vs. 83.5% %), heart failure (21.3% vs. 29.1% %), diabetes (34.1% vs. 48.2%), atrial fibrillation (19.3% vs. 26.1%), or chronic kidney disease (25.1% vs. 32.2%). In multivariable analyses, the factors most strongly associated with failure to achieve LDL-C control were female sex (RR 1.13 [95% CI 1.12-1.14] P < .001) and Black race (1.15 [1.14-1.17] P < .001). Among the 53,957 (41.5%) of those with uncontrolled LDL-C ≥70 mg/dL not on lipid lowering therapy (LLT) at baseline, only 21% were initiated on any LLT within 6 months of the uncontrolled LDL-C value.

Conclusions: Within 5 diverse large health systems in the CardioHealth Alliance, more than half of the patients with ASCVD had uncontrolled LDL-C with significant disparities based on sex and race at baseline. The vast majority were not initiated on any lipid lowering therapy within 6 months of an elevated test result indicating persistent gaps in care that will likely worsen health inequities in outcomes. This highlights the urgent need for implementation efforts to improve equitable care.