Study in China Indicates Current Practice of Lipid-Lowering Treatment Needs Improvement

In an article published in the American Heart Journal, Dr. Yueyan Xing emphasized the need to improve on current lipid-lowering treatment practices in patients with a history of myocardial infarction or revascularization.  Patients with a previous history of acute coronary syndrome are at a high risk of a recurrent coronary event and death. Lowering low-density lipoprotein cholesterol (LDL-C) in these patients is essential in order to reduce the risk of a recurrent event. The authors used the Improving Care for Cardiovascular Disease in China (CCC) Project to assess current lipid-lowering treatment practices in China.

Multiple guidelines recommend lowering LDL-C in patients with a history of ACS. One meta-analysis showed that every 1-mmol/L reduction in LDL-C was associated with a 20% reduction in the occurrence of any cardiovascular event. Currently, the Chinese guidelines recommend aiming for an LDL-C of 70mg/dl or lower in patients with a history of ACS. The authors aimed to assess the performance of lipid-lowering treatment strategies in patients admitted with an ACS who have a history of myocardial infarction or revascularization. The CCC-ACS project is a nationwide registry that contains data on 80,282 patients with acute coronary syndrome. Of these patients, 6,523 (8.1%) were identified as having a history of myocardial infarction or revascularization. Although the guidelines recommend that all patients with a history of ACS or revascularization be on lipid-lowering therapy, the authors found that only 2,951 (50.8%) were on some form of therapy before hospitalization. The majority of patients (98.4%) were on a statin, with the remainder being on combination therapy (statin and another lipid-lowering medication).

Certain baseline characteristics associated with high rates of pre-hospital statin use were also identified. The authors found that the longer the interval between the previous event and the present event, the less likely the patient was on a prehospital statin (<0.5 years (64.9%) vs 0.5-2 years (55.9%) vs >2 years (44.3%), p <0.001). Also, patients who were non-smokers were more likely to be on a statin (p =0.015).  Patients with medical insurance with high reimbursement had a higher rate of prehospital statin use when compared to median reimbursement and low reimbursement (53.7% vs 48.4% vs 47.1%, p <0.001). Finally, patients who have previously undergone revascularization in the past were more likely to be on a statin prior to the current hospitalization (54.4% vs 39.5%, p <0.001). Interestingly, there were no significant differences in prehospital statin use in the different age groups.

The authors also found that in patients receiving a prehospital statin, the LDL-C was significantly lower than those who did not (86.4 vs 97.8 mg/dl), p <0.001). Also, a higher proportion of patients who were receiving pre-hospital statins actually reached the LDL-C goal (36.1% vs 24.0%, p <0.001). Patients on combination therapy were more likely to reach the goal as compared to those who were on only a statin (51.3% vs 35.9%, p <0.05).

At discharge, 91.8% of patients who did not have a contraindication to statin were prescribed statin monotherapy. When discussing the results of the study, Dr. Xing wrote, “Underutilization of combination therapy in patients with CHD who have not achieved their LDL-C target indicates that there is a gap between clinical practice and guideline recommendations.” Possible explanations for this gap between clinical practice and guidelines could include the cost of the lipid-lowering medication (especially the newer options such as the proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors) or the lack of awareness from healthcare providers regarding guideline recommendations. Ultimately, the authors believe that the quality of care surrounding lipid management in secondary prevention of ACS needs to be improved.