Cardiology Pharmaceuticals

Cholesterol Control Falls Short in CAD Patients

For years we’ve known that controlling LDL cholesterol lowers the risk of future cardiovascular events in people with coronary artery disease. And yet, a new JAMA paper reveals that most CAD patients fail to meet recommended cholesterol targets, and many of them still aren’t taking LDL-lowering medications.

Researchers analyzed data from 472 US adults with CAD (2015-2020, 64yr avg age, 40.5% women), finding that…

  • Only 67.9% were on statins, and just 6.4% are taking ezetimibe
  • A whopping 73.5% had LDL-C levels at or above the 70 mg/dL target (94.4 mg/dL avg.)
  • Non-statin-takers were burdened with 120.4 mg/d average LDL-C levels 
  • Even statin-takers were above target, with 82.2 mg/dL average LDL-C levels

In other words, we have a lot of room to improve LDL control, perhaps starting with guideline adherence, since the ACC/AHA guidelines recommend that…

  • All ASCVD patients are treated with statins
  • Higher risk ASCVD patients with LDL-C levels at or above 70 mg/dL also take ezetimibe or a PCSK9 inhibitor 

Noting that low generic costs for statins and ezetimibe eliminate typical economic barriers, an TCTMD interview with lead author Deepak Bhatt, MD, MPH theorized that our LDL-C control challenges are due to other factors…

  • The need for more patient and physician education
  • Concerns about statin side effects, “whether real or perceived”
  • Low use of ezetimibe or PCSK9 inhibitors among the “truly statin intolerant”
  • Reduced ezetimibe marketing since generics became available

The study authors also outlined some straightforward solutions including, increasing statin prescription rates and titrating doses, increasing the use of add-on and novel therapies (ezetimibe, PCSK9i / bempedoic acid), and developing mechanisms to better monitor LDL-C control and therapy adherence.

The Takeaway

There’s never been more clinically-proven, guideline-supported, and (mostly) inexpensive options for LDL-C reduction — and statins are already the most prescribed group of drugs in the United States. The fact that we’re still falling way short in controlling CAD patients’ LDL cholesterol, despite all that, might suggest that the US’ LDL-C control problem is the result of a far greater and more complex guidelines adherence problem.

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