Symposium Article| Volume 348, ISSUE 2, P108-114, August 2014

Statin Underuse and Low Prevalence of LDL-C Control Among U.S. Adults at High Risk of Coronary Heart Disease



      Statins reduce the risk of coronary heart disease (CHD) in individuals with a history of CHD or risk equivalents. A 10-year CHD risk >20% is considered a risk equivalent but is frequently not detected. Statin use and low-density lipoprotein cholesterol (LDL-C) control were examined among participants with CHD or risk equivalents in the nationwide Reasons for Geographic and Racial Differences in Stroke study (n=8812).


      Participants were categorized into 4 mutually exclusive groups: (1) history of CHD (n=4025); (2) no history of CHD but with a history of stroke and/or abdominal aortic aneurysm (AAA) (n=946); (3) no history of CHD or stroke/AAA but with diabetes mellitus (n=3134); or (4) no history of the conditions in (1) through (3) but with 10-year Framingham CHD risk score (FRS) >20% calculated using the third Adult Treatment Panel point scoring system (n=707).


      Statins were used by 58.4% of those in the CHD group and 41.7%, 40.4% and 20.1% of those in the stroke/AAA, diabetes mellitus and FRS >20% groups, respectively. Among those taking statins, 65.1% had LDL-C <100 mg/dL, with no difference between the CHD, stroke/AAA, or diabetes mellitus groups. However, compared with those in the CHD group, LDL-C <100 mg/dL was less common among participants in the FRS >20% group (multivariable adjusted prevalence ratio: 0.72; 95% confidence interval: 0.62-0.85). Results were similar using the 2013 American College of Cardiology/American Heart Association cholesterol treatment guideline.


      These data suggest that many people with high CHD risk, especially those with an FRS >20%, do not receive guideline-concordant lipid-lowering therapy and do not achieve an LDL-C <100 mg/dL.

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      1. Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult treatment panel III) final report.
        Circulation. 2002; 106: 3143-3421
        • Stone N.J.
        • Robinson J.
        • Lichtenstein A.H.
        • et al.
        ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task force on practice guidelines.
        J Am Coll Cardiol. 2013; 2013
        • Dhamoon M.S.
        • Elkind M.S.
        Inclusion of stroke as an outcome and risk equivalent in risk scores for primary and secondary prevention of vascular disease.
        Circulation. 2010; 121: 2071-2078
        • Lackland D.T.
        • Elkind M.S.
        • D'Agostino Sr., R.
        • et al.
        Inclusion of stroke in cardiovascular risk prediction instruments: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2012; 43: 1998-2027
        • Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
        Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).
        JAMA. 2001; 285: 2486-2497
        • Grundy S.M.
        • Cleeman J.I.
        • Merz C.N.
        • et al.
        Implications of recent clinical trials for the national cholesterol education program adult treatment panel III guidelines.
        Circulation. 2004; 110: 227-239
        • Goff Jr., D.C.
        • Lloyd-Jones D.M.
        • Bennett G.
        • et al.
        ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College ofCardiology/American Heart Association task force on practice guidelines.
        Circulation. 2013; 2013
        • Truong Q.A.
        • Murphy S.A.
        • McCabe C.H.
        • et al.
        Benefit of intensive statin therapy in women: results from PROVE IT-TIMI 22.
        Circ Cardiovasc Qual Outcomes. 2011; 4: 328-336
        • Howard B.V.
        • Roman M.J.
        • Devereux R.B.
        • et al.
        Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes: the SANDS randomized trial.
        JAMA. 2008; 299: 1678-1689
        • Setoguchi S.
        • Glynn R.J.
        • Avorn J.
        • et al.
        Ten-year trends of cardiovascular drug use after myocardial infarction among community-dwelling persons>or=65 years of age.
        Am J Cardiol. 2007; 100: 1061-1067
        • Shillinglaw B.
        • Viera A.J.
        • Edwards T.
        • et al.
        Use of global coronary heart disease risk assessment in practice: a cross-sectional survey of a sample of U.S. physicians.
        BMC Health Serv Res. 2012; 12: 20
        • Mann D.
        • Reynolds K.
        • Smith D.
        • et al.
        Trends in statin use and low-density lipoprotein cholesterol levels among U.S. adults: impact of the 2001 National Cholesterol Education Program guidelines.
        Ann Pharmacother. 2008; 42: 1208-1215
        • Muntner P.
        • Levitan E.B.
        • Brown T.M.
        • et al.
        Trends in the prevalence, awareness, treatment and control of high low density lipoprotein- cholesterol among United States adults from 1999–2000 through 2009–2010.
        Am J Cardiol. 2013; 112: 664-670
        • Howard V.J.
        • Cushman M.
        • Pulley L.
        • et al.
        The reasons for geographic and racial differences in stroke study: objectives and design.
        Neuroepidemiology. 2005; 25: 135-143
        • Levey A.S.
        • Stevens L.A.
        • Schmid C.H.
        • et al.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Foundation N.K.
        K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
        Am J Kidney Dis. 2002; 39: S1-S266
        • Levey A.S.
        • Coresh J.
        • Balk E.
        • et al.
        National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
        Ann Intern Med. 2003; 139: 137-147
        • Friedewald W.T.
        • Levy R.I.
        • Fredrickson D.S.
        Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge.
        Clin Chem. 1972; 18: 499-502
        • White I.R.
        • Royston P.
        • Wood A.M.
        Multiple imputation using chained equations: issues and guidance for practice.
        Stat Med. 2011; 30: 377-399
        • Peterson E.D.
        • Roe M.T.
        • Chen A.Y.
        • et al.
        The NCDR ACTION Registry-GWTG: transforming contemporary acute myocardial infarction clinical care.
        Heart. 2010; 96: 1798-1802
        • Derose S.F.
        Automated outreach to increase primary adherence to cholesterol-lowering medications.
        JAMA Intern Med. 2013; 173: 38-43
        • Jackevicius C.A.
        • Mamdani M.
        • Tu J.V.
        Adherence with statin therapy in elderly patients with and without acute coronary syndromes.
        JAMA. 2002; 288: 462-467
        • Go A.S.
        • Mozaffariun D.
        • Roger V.L.
        • et al.
        Heart disease and stroke statistics-2013 update: a report from the American Heart Association.
        Circulation. 2013; 127: e6-e245
        • D'Agostino S.R.B.
        Validation of the Framingham coronary heart disease prediction scores: results of a multiple Ethnic Groups Investigation.
        JAMA: The J Am Med Assoc. 2001; 286: 180-187
        • Mosca L.
        • Linfante A.H.
        • Benjamin E.J.
        • et al.
        National study of physician awareness and adherence to cardiovascular disease prevention guidelines.
        Circulation. 2005; 111: 499-510