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<ѻý class="page_title">ASCVD: Contemporary Approaches
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MedpageToday

Statin Use in People with ASCVD Could Be (Much) Better

<ѻý class="dek">—Cholesterol guidelines recommend at least a moderate-intensity statin in older adults with ASCVD. But that’s not happening consistently in clinical practice.

Although prescription rates for statins increased between 2007 and 2018, statins continue to be underused in older adults with atherosclerotic cardiovascular disease (ASCVD), a recent study has found.1

In a list of top 10 take-home messages, clinical practice guidelines issued by the American College of Cardiology/American Heart Association (ACC/AHA) in 2018 recommended that individuals with clinical ASCVD be treated with high-intensity or maximally tolerated statin therapy to decrease their levels of low-density lipoprotein cholesterol (LDL-C).2

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However, after similar guidelines were issued in 2013, a subsequent study, published in 2019, found that statin use in the U.S. didn’t increase and that more than 40% of individuals ages 40 years and over with a history of ASCVD weren’t on statin therapy.3 The same study also identified gender and ethnic-based disparities in statin use. A new study therefore aimed to evaluate current trends and disparities in statin use among older adults with ASCVD.

Tapping a large patient database

“Using data from a large multispecialty outpatient care organization in Northern California, we sought to evaluate temporal statin prescribing patterns and predictors of guideline-concordant statin prescription [use] in a multiethnic population of older adults with ASCVD,” wrote Gabriela Spencer-Bonilla, MD, MSc, of the Stanford University School of Medicine, Stanford, Calif., and her colleagues in the Journal of the American Geriatrics Society.

Patients (N=24,651) in this retrospective longitudinal study were older than 75 years of age, had ASCVD, and recorded ≥2 outpatient visits within 2 consecutive years. These criteria were also used to select a cohort of patients ages 65 to 75 years old.

Patients reported their own smoking status and demographics information. Comorbidities, which included diabetes, hypertension, heart failure, malignancy, dementia, and renal disease, were identified via International Classification of Diseases (ICD) codes. Total cholesterol and LDL-C were measured closest to and within at least 1 year of the index date, and again 30 days following the start of statin therapy. Body mass index was categorized as underweight (<18.5 kg/m2), normal (18.5 to <25 kg/m2), overweight (25 to <30 kg/m2), and obese (≥30 kg/m2).

Prescription information was derived from the patient’s last visit during the study period. Statin intensity was categorized as high, moderate, or low according to ACC/AHA guidelines, and nonstatin, lipid-lowering prescriptions were also recorded.

Who’s more likely to use statins for ASCVD?

Of the study participants, nearly half (48%) were women, and 62%, 13%, 5%, and 1% were non-Hispanic white, Asian, Hispanic, and black, respectively. Coronary artery disease (CAD) was followed by cerebrovascular disease as the most frequent indications for statin therapy. More than half (56%) of the patients were overweight or obese; 4% were underweight. The most common comorbidity was hypertension (68%), followed by renal disease (46%), malignancy (28%), diabetes (26%), heart failure (18%), and dementia (10%).

Less than half (42%) of the patients were prescribed statin therapy, with 36% receiving moderate-to-high-intensity statin therapy, after patient data were pooled across years. The moderate-to-high-intensity statin prescription rate for secondary ASCVD prevention increased from 35% in 2007 to 45% in 2018. However, compared with the cohort of patients ages 65 to 75 years, rates remained 13% lower for those >75 years (odds ratio 0.87, 95% confidence interval 0.85 to 0.89).

Among patients older than 75 years, women and patients with heart failure, dementia, or who were underweight were found to be less likely to receive moderate-to-high-intensity statin therapy. Asian patients and those with >9 prescription medications were more likely than non-Hispanic whites to receive moderate-to-high-intensity statin therapy. Finally, patients with CAD were found to be less likely than patients with other forms of ASCVD to receive moderate-to-high-intensity statin therapy.

The study’s authors observed that the lower rates of statin use in women and in patients with specific comorbidities reflected prior studies’ findings. However, the decreased likelihood of patients with CAD to receive statin therapy compared with patients with other ASCVD forms was a novel finding. The authors hypothesized that this may be due to the later stages in which cerebrovascular disease and peripheral artery disease are diagnosed, a point at which statin therapy is more consistently implemented. Another proposed hypothesis was the stability of symptoms that often accompany CAD when it’s entered as a code during patient evaluation.

Future implications of statin underuse

Dr. Spencer-Bonilla and her colleagues found that, despite the statin prescription increase over time, fewer than half of patients received prescriptions for moderate-to-high-intensity statin therapy. “Future studies will need to unpack reasons for statin under-prescription and generate evidence tailored to improving guideline-recommended statin use in the growing population of older adults with ASCVD,” the authors wrote.1

The investigators also acknowledged the study’s limitations, which involved an insured cohort with regular healthcare, thereby potentially limiting generalizations to other patient populations. Additionally, the study didn’t discern de novo high-intensity statin therapy from low-to-moderate or high-intensity therapy. Measures of patients’ function and mobility, which may affect statin prescriptions, were also not included.

“This represents an opportunity to decrease gaps in guideline adherence for this high-risk patient group,” study author Fatima Rodriguez, MD, MPH, of the Division of Cardiovascular Medicine at Stanford University, told ѻý. “For secondary prevention, we know that elderly patients benefit from statins—perhaps to an even greater extent than younger patients—but there remain significant patient-, provider-, and system-level barriers to use of these lifesaving medications.”

Published:

References

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Metabolically Healthy Obesity? Another Piece of the Puzzle
To allow for easier identification of MHO, a subset of obese individuals at lower risk of CVD death and all-cause mortality, investigators used data from 2 large patient cohorts to craft a definition of MHO based on common risk factors.
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Can Inspiratory Muscle Strength Training Improve Heart Health?
This study that examined whether this type of strength training would improve blood pressure, endothelial function, and arterial stiffness in older patients with elevated systolic BP.
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Recurrent CV Event Risk Hiked by Long Work Hours
Findings from a prospective cohort study indicate that reducing work hours—from 55 or more a week to between 35 and 40—may be a preventive strategy for patients with a history of heart attack.
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BP and Sodium Intake: New Investigation, New Concerns
A meta-analysis demonstrated a positive and substantially linear relationship between sodium exposure and blood pressure, even at sodium intake levels lower than current public health recommendations.
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STEMI Patients Without Risk Factors: New Strategies Needed
Data from the Swedish MI registry showed an increased risk of all-cause mortality in this group of patients, suggesting a need to re-examine use of evidence-based pharmacotherapy.
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ASCVD Risk Stratification Using Family History
Validated family history is a key risk factor for ASCVD and may be the largest contributor to risk. An accurate family history of ASCVD can help determine the need for measuring CAC--and ultimately the need for lipid-lowering therapy.