Lipid-lowering therapy for primary prevention of premature atherosclerotic coronary artery disease: Eligibility, utilization, target achievement, and predictors of initiation

Abstract

Objectives Despite advances in screening and prevention, rates of premature coronary artery disease (CAD) have been stagnant. The goals of this study were to investigate the barriers to early risk detection and preventive treatment in patients with premature CAD. In particular, we: 1) assessed the performance of the latest versions of major international guidelines in detection of risk of premature CAD and eligibility for preventive treatment; and, 2) investigated real-life utilization of primary prevention with lipid-lowering therapies in these patients. Methods We included patients in the Study to Avoid cardioVascular Events in British Columbia (SAVE BC), an observational study of patients with premature (males ​≤ ​50 years, females ​≤ ​55 years) angiographically confirmed CAD. Eligibility for primary prevention and treatment received were assessed retrospectively based on information recorded prior to or at the index presentation with CAD. Results Of 417 patients (28.1% females) who met the criteria, 94.3% had at least one major cardiovascular risk factor. In the retrospective risk assessment, 41.7%, 61.4%, and 34.3% (p ​< ​0.001) of patients met criteria for initiation of statin therapy, and an additional 13.9%, 8.4%, and 46.8% may be considered for treatment using the American College of Cardiology/American Heart Association, Canadian Cardiovascular Society, and European Society of Cardiology guidelines, respectively. Only 17.1% of patients received statins and 11.0% achieved guideline-recommended lipid goals before presentation. Diabetes and elevated plasma lipid levels were positively associated with treatment initiation, while smoking was associated with non-treatment. Conclusions The current versions of major guidelines fail to recognize many patients who develop premature CAD as being at risk. The vast majority of these patients, including patients who have guideline-directed indications, do not receive lipid-lowering therapy before presenting with CAD. Our findings highlight the need for more effective screening and prevention strategies for premature CAD .

Lipid profiles in ST-elevation myocardial infarction with and without diabetes: the gap between prescription and targets

“…Nevertheless, over two-thirds of patients across both cohorts were deemed at high or very high CVD risk. Despite this, a significant proportion of patients, regardless of diabetic status, failed to attain LDL-C targets [4,15,16].…”

“…Nevertheless, over twothirds of patients across both cohorts were deemed at high or very high CVD risk. Despite this, a significant proportion of patients, regardless of diabetic status, failed to attain LDL-C targets [4,15,16]. It should be emphasized that to assess the LDL-C target, we referred to the Martin formula because, in a large cross-sectional analysis, this method of LDL-C estimation was found to be more accurate than the Friedewald equation for both fasting and non-fasting.…”

Impact of Active vs Passive Statin Selection for Primary Prevention

“…Despite this firm evidence base and guideline recommendations, there remains a large treatment gap and an opportunity for improved prevention, especially for primary prevention. 10 , 13 , 20 , 21 For example, in a study of individuals presenting with premature, angiographically documented CAD, 41% would have qualified for a statin by current guidelines, with an additional 14% who could be considered for treatment. However, only 17% had received a statin and only 11% had achieved guideline-recommended treatment goals.…”

“…7 , 8 Unfortunately, studies have consistently noted a major lag/gap in risk assessment, statin initiation, and statin persistence. 9 , 10 , 11 , 12 , 13 , 14 Furthermore, a high percentage of individuals, especially younger individuals with a first ASCVD event (eg, myocardial infarction [MI]) would not have been identified as at high enough risk to warrant prior preventive therapy based on current risk assessment algorithms, 9 , 10 , 11 , 15 indicating an ongoing need for improved primary risk prediction tools.…”

Longitudinal Control of Lipid Levels in Patients With Premature Coronary Artery Disease

“…Definitions of cardiovascular risk factors and methods of assessment of diet and physical activity are listed in the Supplemental Methods and described elsewhere. 30 The presence of familial hypercholesterolemia was assessed with Dutch Lipid Clinic Network criteria using pre-treatment lipid values. 31 For patients without pre-treatment data available (11% of the study cohort), LDL-C levels were imputed according to the lipid-lowering medication and dose.…”