More than half of patients with heart disease are not hitting cholesterol targets, leaving them at greater risk for heart attack and strokes, according to a new study by Duke University School of Medicine.
About 25% of the U.S. population has high cholesterol, which contributes to 3.2 million deaths a year. Guidelines recommend lowering low-density lipoprotein cholesterol (LDL-C), known as “bad cholesterol,” below 100 mg/dl for healthy adults, and under 70 mg/dL for those with atherosclerotic cardiovascular disease (ASCVD).
But data from 216,000 heart disease patients with ASCVD at five different health systems showed 60% had LDL at or above this level. Even when high cholesterol was detected, most patients didn’t receive additional treatment, said first study author Nishant P. Shah, MD, a preventative cardiologist at Duke Heath.
Of those with uncontrolled LDL, 41.5% weren’t on medication, and just 21% started treatment within six months.
The study, published in the January issue of American Heart Journal, found treatment rates were especially low for Black and Hispanic people, and women whose cholesterol levels were high were also often undertreated.
“These real-world findings reveal gaps in care that put patients at risk,” said Shah, an assistant professor of medicine and member of the Duke Clinical Research Institute. “Addressing these disparities could save lives and prevent future heart disease.”
Statins, a common cholesterol-lowering drug, were prescribed most often, but only 7.9% of patients received high-intensity statins, which are more effective at lowering LDL-C, especially in patiens with heart disease. Non-statin options like PCSK9 inhibitors and ezetimibe were rarely used, though they are often an excellent adjunct to help lower LDL-C.
At the provider level, Shah urged clinicians to reassess how they manage cholesterol. “This should be striking for health care providers. Providers should ask, ‘Who can I intensify cholesterol care for? What barriers do I face in getting my patients to their goals?’”
He also called for greater patient education. “Patients should feel empowered to ask their doctors, 'What’s my LDL? Should we check it again?'” he said. “Patient activation can also help drive better care.”
Previous research suggests that if all patients with heart disease reduced their LDL-C to below 70 mg/dl, hundreds of cardiovascular events could be prevented each year.
Changing behaviors can help bring cholesterol numbers in line, including regular exercise along with eating more vegetables, fruits, whole grains, legumes, and low-fat protein sources, and less sugar and saturated fat (especially red meat).
But some patients may already be exercising as much as they possibly can and eating healthily but have some underlying genetic reason for elevated cholesterol.
“So that person needs more than lifestyle changes alone, and other folks may not be in a position to exercise as much as it takes to lower their cholesterol to those low guideline-based targets,” Shah said.
The recent study by Shah and colleagues highlights the need for better cholesterol management programs. Health systems could improve care by expanding cholesterol monitoring, closing care gaps, and pushing for affordable mediations.
Efforts to close gaps for women and Black patients are especially important to ensure equitable health outcomes, authors said.
Additional Authors: Senior author Neha Pagidipati, MD, MPH, Adrian F. Hernandez, MD; Manesh R. Patel, MD; Lauren Cohen; Zachary Lampron, MPH; Karen Chiswell, PhD; Elizabeth Lydon; and Hillary Mulder, all of Duke; Xingdi Hu, PhD; Susan Taubes, MPH; and Suresh R. Mulukutla, MD, of Novartis Pharmaceuticals Corp.; Wenliang Song, MD, of Vanderbilt University; Anum Saeed MD, of University of Pittsburgh; Daniel P. Morin, MD, MPH, of Ochsner Medical Center; and Steven M. Bradley, MD, of Allina Health Minneapolis Heart Institute.