Journal Article

Real-world exploration of LDL-cholesterol management in patients with atherosclerotic cardiovascular disease

Chiswell, Karen, Cohen, Lauren, Lampron, Zachary, Morin, Daniel P., Shah, Nishant P., Lydon, Elizabeth, Taubes, Susan, Hernandez, Adrian F., Pagidipati, Neha J., Patel, Manesh R., Song, Wenliang, Mulder, Hillary, Bradley, Steven M., Mulukutla, Suresh R., Saeed, Anum, Hu, Xingdi

2025

Overview

Although guidelines recommend low-density lipoprotein cholesterol (LDL-C) to be < 70 mg/dL in patients with atherosclerotic cardiovascular disease (ASCVD), the rate of achieving this goal remains suboptimal. We sought to understand real world contemporary practice patterns of LDL-C management in patients with ASCVD, and whether LDL-C testing influenced management across US health systems. A retrospective cohort study utilizing electronic medical record data from five health systems participating in the CardioHealth Alliance was performed on patients with an LDL-C measurement in 2021 and prior ASCVD. Multivariable regression modeling was used to determine the relationship of clinical factors with achievement of guideline directed LDL-C target. Changes in lipid lowering therapy (LLT) after LDL-C testing were also described. Among 216,074 patients with ASCVD, 129,886 (60.1%) had uncontrolled LDL-C (i.e. ≥ 70 mg/dL). Compared with participants with controlled LDL-C (< 70 mg/dL), those with uncontrolled LDL-C were more frequently female (50.9% vs. 35.1%), or Black (13.7% vs. 10.3%), and less commonly had coronary artery disease as the form of vascular disease (73.0% vs. 83.5% %), heart failure (21.3% vs. 29.1% %), diabetes (34.1% vs. 48.2%), atrial fibrillation (19.3% vs. 26.1%), or chronic kidney disease (25.1% vs. 32.2%). In multivariable analyses, the factors most strongly associated with failure to achieve LDL-C control were female sex (RR 1.13 [95% CI 1.12-1.14] P < .001) and Black race (1.15 [1.14-1.17] P < .001). Among the 53,957 (41.5%) of those with uncontrolled LDL-C ≥70 mg/dL not on lipid lowering therapy (LLT) at baseline, only 21% were initiated on any LLT within 6 months of the uncontrolled LDL-C value. Within 5 diverse large health systems in the CardioHealth Alliance, more than half of the patients with ASCVD had uncontrolled LDL-C with significant disparities based on sex and race at baseline. The vast majority were not initiated on any lipid lowering therapy within 6 months of an elevated test result indicating persistent gaps in care that will likely worsen health inequities in outcomes. This highlights the urgent need for implementation efforts to improve equitable care.

• Publisher: Elsevier Inc,Elsevier Limited
• Subject: Aged / Anticholesteremic Agents - therapeutic use / Arteriosclerosis / Atherosclerosis / Atherosclerosis - blood / Atherosclerosis - drug therapy / Cardiovascular disease / Cardiovascular diseases / Cholesterol / Cholesterol, LDL - blood / Clinical outcomes / Codes / Congestive heart failure / Coronary artery disease / Diabetes / Diabetes mellitus / Disease management / Electronic health records / Electronic medical records / Evidence-based practice / Female / Females / Health disparities / Heart / Heart diseases / High density lipoprotein / Humans / Hydroxymethylglutaryl-CoA Reductase Inhibitors - therapeutic use / Ischemia / Kidney diseases / Lipids / Lipoproteins / Low density lipoprotein / Male / Medical history / Middle Aged / Multivariable control / Patients / Retrospective Studies / Sex / Statins / Therapy / United States - epidemiology / Vascular diseases