A Real-World Study of Patients With ASCVD Demonstrates Prevalence of High LDL-C, Demographic Disparities, and Underutilization of Lipid-Lowering Therapy

The results of a recent retrospective analysis of patients with established atherosclerotic cardiovascular disease (ASCVD) demonstrated that prior testing for lipoprotein(a) (Lp[a]) was associated with an increased likelihood of attaining guideline-based targets for low-density lipoprotein cholesterol (LDL-C).¹ Study findings were presented as a poster, “Real-World Exploration of LDL-Cholesterol Management in Patients With Atherosclerotic Cardiovascular Disease,” at the American Heart Association (AHA) Scientific Sessions 2023, which took place from November 11 to 13, 2023, in Philadelphia, Pennsylvania.²

Seeking to understand patient characteristics and regional patterns of care associated with LDL-C control, investigators analyzed electronic health record data from 5 health systems participating in the CardioHealth Alliance: Duke University Medical Center, University of Pittsburgh Medical Center, Vanderbilt University Medical Center, Allina Health, and Ochsner Health System.^1,2 Adults 18 years and older with established ASCVD were included in the study cohort if they received an LDL-C test in 2021, had experienced an ASCVD event in the 5 years prior to this test, and had at least 2 encounters with the health system between 2019 and 2020 (N = 216,074).¹ The index date was defined as the date of the last LDL-C test in 2021. At index, mean (SD) age was 70.3 (11.3) years and patients were predominantly White (85.3%) and male (55.4%). Overall, 77.2% had coronary artery disease and 88.0% had hypertension. Mean (SD) LDL-C level was 82.6 (34.1) mg/dL and 0.47% of patients had received a prior Lp(a) test. At index, 62.6% of patients had a prescription for a statin medication and 65.1% had a prescription for 1 or more lipid-lowering therapies (LLT; a statin, monoclonal antibody-based proprotein convertase subtilisin/kexin type 9 inhibitor [PCSK9i], ezetimibe, or bempedoic acid). Overall, 3.8% had a prescription for a sodium glucose transporter 2 inhibitor and 4.5% had a prescription for a glucagon-like peptide-1 receptor agonist.¹

Baseline characteristics and LLT patterns were compared among patients with serum LDL-C levels above and below 70 mg/dL, which the AHA and American College of Cardiology cite as a threshold for therapeutic intervention for ASCVD.^1,3 Investigators followed patients for 6 months and assessed LLT initiation, which was defined as receiving a prescription for LLT in the 6 months following an LDL-C test and having no evidence a prescription for LLT in the year prior to the index date.¹ To determine which clinical factors were associated with LDL-C levels below 70 mg/dL, investigators used multivariable regression modeling.

Results of the analysis demonstrated that 60% (n = 129,886) of patients did not have serum LDL-C levels below 70 mg/dL at index. Among factors associated with not attaining this threshold were Black race (relative risk [RR] = 1.15; 95% CI, 1.14-1.16; P < .001), Hispanic ethnicity (RR = 1.04; 95% CI, 1.01-1.06; P = .0001), and female sex (RR = 1.13; 95% CI, 1.12-1.14; P < .001).¹

The National Lipid Association recognizes Lp(a) testing as reasonable to refine risk assessment for ASCVD events in certain patient populations and as potentially reasonable as a tool for treatment decision-making.⁴ Receiving Lp(a) testing prior to the index was associated with attaining the LDL-C target (RR = 0.87; 95% CI, 0.82-0.92; P < .0001).¹

Among those with LDL-C serum levels of at least 70 mg/dL, only 20.8% had initiated LLT in the 6 months following the index LDL-C test.¹

Diagnostic miscoding and missing data may have limited the data set, the study, and its findings. The small number of health systems from which the data were analyzed and laboratory testing challenges arising from the study’s overlap with the COVID-19 pandemic may have served as additional limitations.¹

The study demonstrated that over half of this population of patients with established ASCVD did not meet the guideline­-based target for LDL-C and that patients who were Black, Hispanic, and/or female were particularly unlikely to achieve this goal. Moreover, only 1 in 5 patients had initiated LLT in the 6 months following the index LDL-C test. However, Lp(a) testing was associated with attaining the LDL-C target. Investigators concluded that connecting health systems to the communities they serve through multidisciplinary and inclusive efforts is vital to improving LDL-C care nationally.¹

References

1. Shah NP, Mulder H, Lydon B, et al. Real-world exploration of LDL-cholesterol management in patients with atherosclerotic cardiovascular disease. Poster presented at: American Heart Association Scientific Sessions 2023; November 11-13, 2023; Philadelphia, PA. PR.APS.P3
2. Shah NP, Mulder H, Lydon B, et al. Abstract 16059: Real-world exploration of LDL-cholesterol management in patients with atherosclerotic cardiovascular disease. Circulation. 2023;148(suppl 1):A16059. doi:10.1161/circ.148.suppl_1.16059
3. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25):e1082-e1143. doi:10.1161/CIR.0000000000000625
4. Wilson DP, Jacobson TA, Jones PH, et al. Use of lipoprotein(a) in clinical practice: a biomarker whose time has come. A scientific statement from the National Lipid Association. J Clin Lipidol. 2019;13(3):374-392. doi:10.1016/j.jacl.2019.04.010