冠状动脉血运重建术后开具前蛋白转化酶枯草溶菌素 9 抑制剂的障碍。

Barriers to prescribing proprotein convertase subtilisin-kexin type 9 inhibitors after coronary revascularisation.

机构信息

Department of Pharmacy, Fiona Stanley Hospital, Perth, Western Australia, Australia.

Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia.

出版信息

Intern Med J. 2023 Jun;53(6):994-1001. doi: 10.1111/imj.15700. Epub 2022 Sep 4.

DOI:10.1111/imj.15700

PMID:35112773

Abstract

BACKGROUND

Guidelines advocate for intensive lipid-lowering in patients with atherosclerotic cardiovascular disease (ASCVD). In May 2020, evolocumab, a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor, became government subsidised in Australia for patients with ASCVD requiring further low-density lipoprotein cholesterol (LDL-C) lowering.

AIM

To identify barriers to prescribing PCSK9 inhibitors in hospitalised patients with ASCVD.

METHODS

A retrospective 3-month, single-site, observational analysis was conducted in consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Lipid-lowering therapy prescriptions, including PSCK9 inhibitors, were assessed using electronic medical records, compared against the Australian Pharmaceutical Benefits eligibility criteria, and barriers to PCSK9 inhibitor use identified.

RESULTS

Of 331 patients, 244 (73.7%) underwent PCI and 87 (26.3%) underwent CABG surgery. A lipid profile during or within 8 weeks of admission was measured for 202 (82.8%) patients undergoing PCI and 59 (67.8%) undergoing CABG surgery. In patients taking high-intensity statins on admission (n = 109), LDL-C ≥1.4, ≥1.8 and >2.6mmol/L was seen in 64 (58.7%), 44 (40.4%) and 19 (17.4%) patients respectively. High-intensity statin prescribing at discharge was high (>80%); however, ezetimibe was initiated in zero patients with LDL-C ≥1.4 mmol/L. There was variable advice given by clinicians for LDL-C targets. No patients met the criteria for subsidised PSCK9 inhibitor therapy, largely due to lack of qualifying lipid levels following combined statin and ezetimibe therapy.

CONCLUSION

Prescribing of non-statin LDL-C-lowering therapies remains low in patients with ASCVD. Underprescribing of ezetimibe and suboptimal lipid testing rates are barriers to accessing subsidised PCSK9i therapy using current Australian eligibility criteria.

摘要

背景

指南提倡对动脉粥样硬化性心血管疾病（ASCVD）患者进行强化降脂治疗。2020 年 5 月，前蛋白转化酶枯草溶菌素 9（PCSK9）抑制剂依洛尤单抗在澳大利亚被政府补贴，用于需要进一步降低低密度脂蛋白胆固醇（LDL-C）的 ASCVD 患者。

目的

确定住院 ASCVD 患者开具 PCSK9 抑制剂的障碍。

方法

对连续接受经皮冠状动脉介入治疗（PCI）或冠状动脉旁路移植术（CABG）的患者进行了为期 3 个月的回顾性单站点观察性分析。使用电子病历评估降脂治疗处方，包括 PCSK9 抑制剂，并与澳大利亚药品福利资格标准进行比较，确定 PCSK9 抑制剂使用的障碍。

结果

331 例患者中，244 例（73.7%）接受 PCI，87 例（26.3%）接受 CABG 手术。202 例（82.8%）行 PCI 和 59 例（67.8%）行 CABG 手术的患者在入院期间或入院后 8 周内测量了血脂谱。入院时服用高强度他汀类药物的患者（n=109）中，LDL-C≥1.4mmol/L、≥1.8mmol/L 和>2.6mmol/L 的患者分别为 64 例（58.7%）、44 例（40.4%）和 19 例（17.4%）。出院时高强度他汀类药物的处方率很高（>80%）；然而，LDL-C≥1.4mmol/L 的患者无一例开始使用依折麦布。临床医生对 LDL-C 目标的建议各不相同。没有患者符合补贴 PCSK9 抑制剂治疗的标准，主要是由于联合使用他汀类药物和依折麦布治疗后缺乏合格的血脂水平。