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Many high-risk Asians inadequately treated for high LDL-C

Pearl Toh
21 Sep 2018

Low-density lipoprotein cholesterol (LDL-C) levels remained high in many patients with stable or acute coronary heart disease (CHD) in Asia, despite having a very high risk of recurrent cardiovascular (CV) events, indicating that the use of lipid-lowering therapies and lipid monitoring were inadequate.

The results were from an observational, cross-sectional, multinational DYSIS* II study, which enrolled 4,592 patients comprising 2,794 with stable CHD (mean age 63.7 years, 78.6 percent men) and 1,798 hospitalized with an acute coronary syndrome (ACS; mean age 62.2 years, 74.3 percent men) across nine Asia-Pacific countries (Singapore, Hong Kong, Taiwan, South Kore, Philippines, Thailand, Vietnam, India, and Indonesia).

Both cohorts had a high rate of comorbidities, including type 2 diabetes, hypertension, chronic kidney disease, and prior stroke. [Eur J Prev Cardiol 2018;doi: 10.1177/2047487318798927]

“Despite the majority of patients being at such a high risk of a CV adverse event, LDL cholesterol levels were high in both cohorts,” observed the researchers led by Dr Poh Kian-Keong from the National University Heart Centre, Singapore. The mean LDL-C levels were 86.9 mg/dL and 103.2 mg/dL in the CHD and the ACS cohorts, respectively.   

Despite a majority of the patients having received lipid-lowering medications (91.7 percent and 63.4 percent, respectively), only 31 percent of the CHD cohort and 23 percent of the ACS cohort had achieved the guideline-recommended LDL-C target of <70 mg/dL.  

When analysis was stratified by use of lipid-lowering therapies, unsurprisingly, more patients who received treatment achieved the recommended LDL-C target than untreated patients across the two cohorts (32.6 percent vs 12.9 percent in the CHD cohort and 31.1 percent vs 9.0 percent in the ACS cohort, respectively).   

“Although it is clear that lipid-lowering therapy was associated with a reduction in LDL cholesterol levels, such poor target attainment indicates that the medication was not being used effectively,” the researchers stated.

For the 30 percent of patients (n=1,748) from the ACS cohort with lipid profile available at 4-month follow-up, more patients had attained the LDL-C target after 4 months compared with baseline at hospital admission for ACS (41.7 percent vs 20.5 percent). Nonetheless, the proportion reaching the recommended target of <70 mg/dL was still lower than half of the subgroup.

“This demonstrates improved treatment in response to the ACS, but also indicates that there is significant room for improvement. It also shows that the monitoring of lipid levels after discharge was poor and against the advice of guidelines, which recommend retesting 4–6 weeks after an ACS. [Eur Heart J 2011;32:1769-1818]

From guidelines to practice: Where are the gaps?

Although the majority of CHD and ACS patients were on lipid-lowering therapies, the use of combination treatment (with the addition of non-statin agents) and the daily statin dosage were low, at atorvastatin-equivalent dosage of only 20 mg/day in the CHD cohort and 27 mg/day in the ACS cohort.

This treatment patterns could explain the low rate of LDL-C target attainment observed in both cohorts, according to the researchers. They believed reasons such as fear of dose-dependent side effects and previous report suggesting that Asians may require a lower dose of statin than non-Asians for the same effect in LDL-C reduction to be contributing factors to the prescription patterns. [BMC Cardiovasc Disord 2015;15:6]

Furthermore, guidelines recommended patients be initiated on high-dose lipid-lowering therapies after an ACS for preventing recurrent CV events. [Eur Heart J 2016;37:2999-3058; Circulation 2013;127:e362-e425. “[The low daily stain dosage prescribed in the ACS cohort] provides further support for the idea that evidence-based guidelines are not being adhered to in this region of the world,” said Poh and co-authors.

“Closer adherence to evidence-based guidelines is needed, with the addition of non-statin therapy to statin regimens a potential strategy for reducing the morbidity and mortality associated with CV disease in Asia,” they urged.

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