Real-World Attainment of Low-Density Lipoprotein Cholesterol Goals in Patients at High Risk of Cardiovascular Disease Treated with High-Intensity Statins: The TERESA Study

Abstract

Despite steady improvements in cardiovascular disease (CVD) prevention, a scarce proportion of patients achieve the recommended LDL-C goals, even under high-intensity lipid-lowering therapy (LLT). Our study aimed to evaluate the attainment rate of LDL-C targets recommended by the 2019 European guidelines, and to characterize potential factors associated with LDL-C goal achievement and change patterns in LLT. We conducted a retrospective, observational study on patients treated with high-intensity atorvastatin or rosuvastatin ± ezetimibe at cardiology and internal medicine clinics across Spain. It included 1570 evaluable patients (median age: 62 years; established CVD: 77.5% [myocardial infarction: 34.3%]; and 85.8% at very high cardiovascular risk). Rosuvastatin ± ezetimibe was the LLT in 52.2% of patients, and atorvastatin ± ezetimibe in 47.8%. LLT had been modified in 36.8% of patients (side effects: 10%), being the most common switch from atorvastatin- to rosuvastatin-based treatment (77.2%). The risk-based LDL-C goal attainment rate was 31.1%, with 78.2% high-risk and 71.7% very high-risk patients not achieving the recommended LDL-C targets. Established CVD and familial hypercholesterolemia were significantly associated with the non-achievement of LDL-C goals. Although having limitations, this study shows that the guideline-recommended LDL-C goal attainment rate is still suboptimal despite using high-intensity statin therapy in a real-world setting in Spain.

Rosuvastatin-Based Lipid-Lowering Therapy for the Control of LDL Cholesterol in Patients at High Vascular Risk

“…Despite this, the percentage of patients whose LDL-C levels are within therapeutic targets is very low, including patients with a higher vascular risk [16][17][18]. Although several reasons have been proposed, it seems that underestimation of the risk, as well as an inadequate perception of actual LDL-C control, play essential roles, since they lead to insufficient intensification of lipid-lowering treatment, which is key to the improvement of these figures [17,21,85].…”

Comparative Efficacy and Safety of Statin Monotherapy and Statin plus Ezetimibe Combination in a Real-World Setting

“…Several real-world studies in different countries demonstrated the comparative advantage of ezetimibe added to statins to reach LDL-C target levels [12][13][14][15]. In a Chinese retrospective cohort study of 1727 ASCVD patients, the addition of ezetimibe to a statin produced the achievement rates of LDL-C below 1.8 and 1.4 mmol/L over the first year, as high as 50.6 and 25.6%, respectively.…”

“…They were treated with ezetimibe combined with atorvastatin (47.8%) or rosuvastatin (52.2%) in a high-intensity regimen. Despite these combinations, LDL-C below 1.4 mmol/L was not reached in about 70% of the participants [13]. The Korean retrospective study analyzed electronic medical records from 4252 patients treated between 2015 and 2017 in two tertiary care medical centers.…”

“…However, there is not enough data from the real world. Most studies evaluating the benefits of ezetimibe in addition to statins have also been retrospective [12][13][14][15]. Insufficient use of ezetimibe in many countries depends more on the inertia of physicians and the resistance of patients to current methods of treatment of dyslipidemia.…”

STRUGGLE FOR. Italian-Polish-Spanish-Uzbek-Vietnamese Expert Forum Position Paper 2023 for better control of classical modifiable risk factors in clinical practice

“…Millions of these patients suffer from ASCVD and should be chronically treated with three basic drugs: acetylsalicylic acid (ASA), statins, angiotensin-converting enzyme (ACE) inhibitors in many cases; often also beta-blockers, cardioprotective and metabolic drugs [ 17 ]. Cardiovascular risk factors closely coexist, but arterial hypertension and hypercholesterolemia are undoubtedly among the most feasible to control with the use of adequately selected, modern drugs, well-tolerated by patients [ 18 , 19 ]. The most important reasons for poor control of these two factors on a population scale remain unchanged and can be mainly considered as:…”