Highlights from

ACC 2019

American College of Cardiology Annual Scientific Session & Expo

New Orleans 16-18 March 2019

Patients with polyvascular disease significantly undertreated with lipid lowering therapies

Lowering of low-density lipoprotein (LDL) has been shown to reduce cardiovascular (CV) events and all-cause mortality in patients who suffer from atherosclerotic disease [1]. Patients with polyvascular disease in particular have a significantly higher rate of major adverse cardiovascular events than patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease alone. Despite strong guideline recommendations and clinical trial data, many patients are unable to receive adequate LDL lowering therapy, which results in excess CV risk.

Peterson et al. aimed to determine the LDL treatment patterns over time in patients with polyvascular disease in the USA. In the multicentre, observational Getting to an Improved Understanding of Low-Density Lipoprotein Cholesterol and Dyslipidemia Management (GOULD) Registry of atherosclerotic cardiovascular disease patients on lipid therapy, baseline treatment was assessed by medical chart review at participating clinical sites across the USA for 5,006 patients and stratified by evidence of polyvascular disease, i.e. vascular disease in ≥2 vascular bed (CAD, stroke or transient ischaemic attack, carotid artery stenosis, or PAD).

Of these patients, 16.7% had polyvascular disease; median baseline LDL-C was 90 mg/dL (IQR, 77-114). At baseline and among the 96 patients on proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, 32.3% were on statins and 20.8% were on ezetimibe. Of the 315 patients with an LDL of ≥100 mg/dL, 88.6% were on statins, 32.7% were taking a high-intensity statin, and 10.5% were on ezetimibe. Of the 422 patients with an LDL of 70 to <100, 96.2% were taking a statin, 47.4% were taking a high-intensity statin, and 8.1% were taking ezetimibe (see Figure).

Figure: Baseline statin intensity stratified by group [1]


These findings led to the conclusion that patients with polyvascular disease as observed in this cohort study are undertreated with lipid lowering therapies. Two-thirds of the patients in this cohort were treated with only a single LDL-lowering agent, despite harbouring a median LDL cholesterol level of 90 mg/dL. In this respect, it needs to be noted that according to the latest lipid guidelines, a goal of 70 mg/dL is recommended in this high-risk group. This untreated margin of LDL cholesterol may represent excess CV risk for a large segment of the US population with polyvascular atherosclerotic disease.

keywords: low-density lipoprotein, cardiovascular, atherosclerotic disease, polyvascular disease, coronary artery disease, peripheral artery disease, GOULD

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