Intensive Lipid-Lowering Therapy in ACS
Intensive Lipid-Lowering Therapy in ACS
Objectives The study aimed to analyze the use of intensive lipid-lowering therapy (LLT) at discharge in a broad population of patients hospitalized with acute coronary syndrome (ACS).
Background Early and intensive statin therapy in ACS was shown to reduce cardiovascular morbidity and mortality. Utilization and predictors of LLT among hospitalized ACS patients are not known.
Methods The GWTG database was analyzed for ACS-related hospitalizations from 2005 to 2009. The use of LLT (defined as dose of statin or combination therapy likely to produce >50% reductions in low-density lipoprotein [LDL]) and less intensive LLT at discharge was assessed. Baseline characteristics and temporal trends in LLT were compared in these 2 treatment groups.
Results Of 65,396 patients receiving LLT, only 25,036 (38.3%) were treated with an LLT regimen. Mean total cholesterol, LDL, and triglycerides were significantly higher in the LLT group. Even among those with LDL >130 mg/dL, 50% or less received LLT. Predictors of LLT at discharge included LLT before admission, hyperlipidemia, prior coronary artery disease, increasing body mass index, and in-hospital percutaneous coronary intervention. Although there was some temporal improvement in the rate of LLT from 2005 to 2007, a decline in use of LLT was noted in 2008 and 2009. This was attributed to a sharp reduction in use of ezetimibe in combination with statin, without corresponding increases in intensive statin monotherapy.
Conclusions In a large cohort of patients admitted with ACS, most of the eligible patients were not discharged on LLT. These data suggest the need for better implementation of guideline-recommended intensive statin therapy in patients with ACS.
Several large studies have consistently demonstrated that lipid-lowering therapy (LLT) with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) reduce cardiovascular risk irrespective of underlying coronary artery disease (CAD). In patients with stable CAD and acute coronary syndrome (ACS), statin therapy has shown a reduction in mortality and recurrent cardiac events. These data have established a very early clinical benefit that persisted on long-term follow-up. The PROVE IT-TIMI 22 and MIRACL trials have shown even better clinical outcomes with early and intensive statin therapy in ACS. It is also well established that the adherence to the use of statin therapy in the post-ACS patient is directly related to statin initiation during the index admission.
In light of above the evidence, the recent National Cholesterol Education Program Adult Treatment Panel guideline update recommended an optional low-density lipoprotein (LDL) treatment goal of <70 mg/dL for patients with ACS. Moreover, the current guidelines of the American College of Cardiology/American Heart Association (ACC/AHA) recommend measurement of lipid levels on admission and instituting LLT before hospital discharge in patients with ACS.
The objective of our study was to assess the use of LLT at time of discharge in patients admitted with ACS along with patient and hospital characteristics associated with use of LLT. This study analyzed data from the hospitals participating in AHA's GWTG-CAD program from 2005 to 2009. Temporal trends in use of LLT were also assessed. In patients admitted with ACS, prescription of various LLTs (various agents and their prescribed doses) at time of the hospital discharge was also assessed in relation to the patients' admission lipid profile with the probability of achieving LDL goal of <100 mg/dL and LDL <70 mg/dL.
Abstract and Introduction
Abstract
Objectives The study aimed to analyze the use of intensive lipid-lowering therapy (LLT) at discharge in a broad population of patients hospitalized with acute coronary syndrome (ACS).
Background Early and intensive statin therapy in ACS was shown to reduce cardiovascular morbidity and mortality. Utilization and predictors of LLT among hospitalized ACS patients are not known.
Methods The GWTG database was analyzed for ACS-related hospitalizations from 2005 to 2009. The use of LLT (defined as dose of statin or combination therapy likely to produce >50% reductions in low-density lipoprotein [LDL]) and less intensive LLT at discharge was assessed. Baseline characteristics and temporal trends in LLT were compared in these 2 treatment groups.
Results Of 65,396 patients receiving LLT, only 25,036 (38.3%) were treated with an LLT regimen. Mean total cholesterol, LDL, and triglycerides were significantly higher in the LLT group. Even among those with LDL >130 mg/dL, 50% or less received LLT. Predictors of LLT at discharge included LLT before admission, hyperlipidemia, prior coronary artery disease, increasing body mass index, and in-hospital percutaneous coronary intervention. Although there was some temporal improvement in the rate of LLT from 2005 to 2007, a decline in use of LLT was noted in 2008 and 2009. This was attributed to a sharp reduction in use of ezetimibe in combination with statin, without corresponding increases in intensive statin monotherapy.
Conclusions In a large cohort of patients admitted with ACS, most of the eligible patients were not discharged on LLT. These data suggest the need for better implementation of guideline-recommended intensive statin therapy in patients with ACS.
Introduction
Several large studies have consistently demonstrated that lipid-lowering therapy (LLT) with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) reduce cardiovascular risk irrespective of underlying coronary artery disease (CAD). In patients with stable CAD and acute coronary syndrome (ACS), statin therapy has shown a reduction in mortality and recurrent cardiac events. These data have established a very early clinical benefit that persisted on long-term follow-up. The PROVE IT-TIMI 22 and MIRACL trials have shown even better clinical outcomes with early and intensive statin therapy in ACS. It is also well established that the adherence to the use of statin therapy in the post-ACS patient is directly related to statin initiation during the index admission.
In light of above the evidence, the recent National Cholesterol Education Program Adult Treatment Panel guideline update recommended an optional low-density lipoprotein (LDL) treatment goal of <70 mg/dL for patients with ACS. Moreover, the current guidelines of the American College of Cardiology/American Heart Association (ACC/AHA) recommend measurement of lipid levels on admission and instituting LLT before hospital discharge in patients with ACS.
The objective of our study was to assess the use of LLT at time of discharge in patients admitted with ACS along with patient and hospital characteristics associated with use of LLT. This study analyzed data from the hospitals participating in AHA's GWTG-CAD program from 2005 to 2009. Temporal trends in use of LLT were also assessed. In patients admitted with ACS, prescription of various LLTs (various agents and their prescribed doses) at time of the hospital discharge was also assessed in relation to the patients' admission lipid profile with the probability of achieving LDL goal of <100 mg/dL and LDL <70 mg/dL.
