Variation in Lipid-Lowering Therapy Use in Patients With Low-Density Lipoprotein Cholesterol ≥190 mg/dL: Insights From the National Cardiovascular Data Registry–Practice Innovation and Clinical Excellence Registry

Virani, Salim S.; Kennedy, Kevin F.; Akeroyd, Julia M.; Morris, Pamela B.; Bittner, Vera A.; Masoudi, Frederick A.; Stone, Neil J.; Petersen, Laura A.; Ballantyne, Christie M.

doi:10.1161/circoutcomes.118.004652

Cited by 53Lipoproteins and Cardiovascular HealthCoronary Interventions and DiagnosticsAcute Myocardial Infarction Research

Variation in Lipid-Lowering Therapy Use in Patients With Low-Density Lipoprotein Cholesterol ≥190 mg/dL: Insights From the National Cardiovascular Data Registry–Practice Innovation and Clinical Excellence Registry

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Virani, Salim S., Kennedy, Kevin F., Akeroyd, Julia M., Morris, Pamela B., Bittner, Vera A., Masoudi, Frederick A., Stone, Neil J., Petersen, Laura A. +1 more·2018·Circulation: Cardiovascular Quality and Outcomes

DOI 10.1161/circoutcomes.118.004652PMC PMC5951397

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Abstract

Background: Patients with low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL are at high risk of atherosclerotic cardiovascular disease events. Treatment guidelines recommend intensive treatment in these patients. Variation in the use of lipid-lowering therapies (LLTs) in these patients in a national sample of cardiology practices is not known. Methods and Results: Using data from the American College of Cardiology National Cardiovascular Data Registry–Practice Innovation and Clinical Excellence registry, we assessed the proportion of patients with LDL-C ≥190 mg/dL (n=49 447) receiving statin, high-intensity statin, LLT associated with ≥50% LDL-C lowering, ezetimibe, or a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor between January 2013 and December 2016. We assessed practice-level rates and variation in LLT use using median rate ratio (MRR) adjusted for patient and practice characteristics. MRRs represent the likelihood that 2 random practices would differ in treatment of identical patients with LDL-C ≥190 mg/dL. The proportion of patients receiving a statin, high-intensity statin, LLT associated with ≥50% LDL-C reduction, ezetimibe, or PCSK9 inhibitor were 58.5%, 31.9%, 34.6%, 8.5%, and 1.5%, respectively. Median practice-level rates and adjusted MRR for statin (56% [interquartile range, 47.3%–64.8%]; MRR, 1.20 [95% confidence interval [CI], 1.17–1.23]), high-intensity statin (30.2% [interquartile range, 12.1%–41.1%]; MRR, 2.31 [95% CI, 2.12–2.51]), LLT with ≥50% LDL-C lowering (31.8% [interquartile range, 15.3%–45.5%]; MRR, 2.12 [95% CI, 1.95–2.28]), ezetimibe (5.8% [interquartile range, 2.8%–9.8%]; MRR, 2.42 [95% CI, 2.21–2.63]), and PCSK9 inhibitors (0.16% [interquartile range, 0%–1.9%]; MRR, 2.38 [95% CI, 2.04–2.72]) indicated significant gaps and >200% variation in receipt of several of these medications for patients across practices. Among those without concomitant atherosclerotic cardiovascular disease, even larger treatment gaps were noted (proportion of patients on a statin, high-intensity statin, LLT with ≥50% LDL-C reduction, ezetimibe, or PCSK9 inhibitor were 50.8%, 25.25%, 26.8%, 4.9%, and 0.74%, respectively). Conclusions: Evidence-based LLT use remains low among patients with elevated LDL-C with significant variation in care. System-level interventions are needed to address these gaps and reduce variation in care of these high-risk patients.

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In a registry of nearly 50,000 US patients with LDL-C levels greater than 190 mg/dL but without cardiovascular disease, only 58.5% were taking a statin.
“In a registry of nearly 50 000 US patients with LDL-C levels greater than 190 mg/dL but without cardiovascular disease, only 58.5% were taking a statin.15”
From Bempedoic Acid for Primary Prevention of Cardiovascular Events in Statin-Intolerant Patients (2023) · cites this paper as [15]
The Results (page unavailable) report 49,447 patients with LDL-C ≥190 mg/dL and a 58.5% statin-therapy rate for the full cohort. The Abstract’s Methods and Results give a different rate, 50.8%, for patients without concomitant ASCVD. The Discussion also clarifies that the registry recorded prescriptions, not whether patients took the medication. (LLM, conf=0.91)
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[5]Vallejo-Vaz AJ Robertson M Catapano AL Watts GF Kastelein JJ Packard CJ Ford I Ray KK LDL-Cholesterol Lowering for the Primary Prevention of Cardiovascular Disease Among Men with Primary Elevations of LDL-Cholesterol Levels of 190 mg/dL or Above: Analyses from the WOSCOPS 5-year Randomised Trial and 20-year Observational Follow-Up Circulation 2017 136 1878 1891 28877913

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Getting to an ImprOved Understanding of Low-Density Lipoprotein-Cholesterol and Dyslipidemia Management (GOULD): Methods and baseline data of a registry of high cardiovascular risk patients in the United States
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Abstract 15913: Two-year Results of the Getting to an Improved Understanding of Low-density Lipoprotein Cholesterol and Dyslipidemia Management (GOULD) Registry of Patients With Atherosclerotic Cardiovascular Disease (ASCVD)
Cannon, C. P., de Lemos, J. A., Ballantyne, C. M., Rosenson, R. S., Alam, S., Mues, K., Gao, Q., Bhatt, D. L., & Kosiborod, M. (2020) · Circulation · doi:10.1161/circ.142.suppl_3.15913
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Authors: Virani, S. S., Kennedy, K. F., Akeroyd, J. M., Morris, P. B., Bittner, V. A., Masoudi, F. A., Stone, N. J., Petersen, L. A., & Ballantyne, C. M.
Affiliations: Houston Methodist (US)
Saint Luke's Health System (US)
Michael E. DeBakey VA Medical Center (US)
Medical University of South Carolina (US)
University of Alabama at Birmingham (US)
University of Colorado Anschutz (US)
Northwestern University (US)
ORCID: Virani, Salim S.
Kennedy, Kevin F.
Bittner, Vera A.
Masoudi, Frederick A.
Stone, Neil J.
Petersen, Laura A.
Ballantyne, Christie M.
Venue: Circulation: Cardiovascular Quality and Outcomes
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2018-05
Volume: 11
Issue: 5
Pages: e004652-e004652
ISSN: 1941-7705 (ISSN-L)
1941-7713
DOI: 10.1161/circoutcomes.118.004652
PMC: PMC5951397
OpenAlex: W2802080707
Cited by: 53
References: 40
Citations by year: 2026: 1 · 2025: 3 · 2024: 6 · 2023: 11 · 2022: 12 · 2021: 8 · 2020: 7 · 2019: 4 · 2018: 1
FWCI: 5.20
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: Circulation Cardiovascular Quality and Outcomes (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
eCommons - AKU (Aga Khan University) (submittedVersion)
Funders: American Diabetes Association
U.S. Department of Veterans Affairs
American Heart Association
American College of Cardiology Foundation
Health Services Research and Development
National Heart, Lung, and Blood Institute (HH-SN-268201100006C)
Topics: Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
Keywords: lipid-lowering therapy, hypercholesterolemia, statins, high-intensity statin therapy, ezetimibe, PCSK9 inhibitors, treatment variation, practice-level variation, atherosclerotic cardiovascular disease, guideline adherence, LDL cholesterol lowering
MeSH terms: Ezetimibe, Proprotein Convertase 9, Professional Practice Gaps, PCSK9 Inhibitors, Cardiology, Humans, Cholesterol, LDL, Practice Patterns, Physicians', Drug Prescriptions, Registries, Time Factors, United States, Biomarkers, Down-Regulation, Serine Proteinase Inhibitors, Treatment Outcome, Practice Guidelines as Topic, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Guideline Adherence, Quality Indicators, Health Care, Dyslipidemias, Healthcare Disparities

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Variation in Lipid-Lowering Therapy Use in Patients With Low-Density Lipoprotein Cholesterol ≥190 mg/dL: Insights From the National Cardiovascular Data Registry–Practice Innovation and Clinical Excellence Registry

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