美国二级预防中基于指南的降脂治疗的差距：对 322153 例患者的回顾性队列研究。
Gaps in Guideline-Based Lipid-Lowering Therapy for Secondary Prevention in the United States: A Retrospective Cohort Study of 322 153 Patients.
机构信息
Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (A.M.N., A.A.K., E.D.P., A.G., Y.W.).
Esperion Therapeutics, Inc, Ann Arbor, MI (K.K.G., M.K.I.).
出版信息
Circ Cardiovasc Qual Outcomes. 2023 Aug;16(8):533-543. doi: 10.1161/CIRCOUTCOMES.122.009787. Epub 2023 Aug 2.
BACKGROUND
Many patients with atherosclerotic cardiovascular disease (ASCVD) are not on guideline-recommended statin therapy. We evaluated utilization of statins and other lipid-lowering therapy (LLT), and changes in low-density lipoprotein cholesterol (LDL-C), among patients with ASCVD over a 1-year period.
METHODS
LLT and LDL-C levels at the first outpatient visit (January 1, 2017-December 31, 2018) and 1-year follow-up were evaluated using data from Cerner Real-World Data, an electronic health record-derived data set from 92 US health systems. Logistic regression was used to evaluate factors associated with high-intensity statin use.
RESULTS
We identified 322 153 patients with ASCVD (median age 69 years, 58.8% men, 81.8% White). Overall, 76.1% of patients were on statins, with only 39.4% on high-intensity statins. Men were more likely to receive high-intensity statins than women (multivariable-adjusted odds ratio, 1.34 [95% CI, 1.30-1.38]). Increasing age was associated with lower odds of statin use (odds ratio, 0.79 per 5-year increase at 60 years [95% CI, 0.78-0.81]). Patients with peripheral artery disease (odds ratio, 0.40 [95% CI, 0.37-0.42]) and cerebrovascular disease (odds ratio, 0.75 [95% CI, 0.70-0.80]) had lower odds of using high-intensity statins than those with coronary artery disease. At baseline, most patients (61.3%) had elevated LDL-C (≥70 mg/dL), including 59.8% of those on low/moderate-intensity statins and 76.1% on no statin; only 45.3% achieved an LDL-C <70 mg/dL at 1 year. Nonstatin LLT use was low (ezetimibe, 4.4%; proprotein convertase subtilisin/kexin type 9 inhibitors, 0.7%). Among patients on no statin or low/moderate-intensity statin at baseline, 14.8% and 13.4%, respectively, were on high-intensity statins at 1 year.
CONCLUSIONS
Among patients with ASCVD in routine care, high-intensity statins are underutilized, and uptitration and use of nonstatin therapy are uncommon. Women, older adults, and individuals with noncardiac ASCVD are particularly undertreated. Concerted efforts are needed to address therapeutic inertia for lipid management in patients with ASCVD.
背景
许多患有动脉粥样硬化性心血管疾病（ASCVD）的患者并未接受指南推荐的他汀类药物治疗。我们评估了在一年期间 ASCVD 患者他汀类药物和其他降脂治疗（LLT）的使用情况，以及低密度脂蛋白胆固醇（LDL-C）的变化。
方法
使用来自 92 个美国医疗系统的电子健康记录衍生数据集 Cerner Real-World Data 中的数据，评估了首次就诊（2017 年 1 月 1 日至 2018 年 12 月 31 日）和 1 年随访时的 LLT 和 LDL-C 水平。使用逻辑回归评估与高强度他汀类药物使用相关的因素。
结果
我们确定了 322153 名 ASCVD 患者（中位年龄 69 岁，58.8%为男性，81.8%为白人）。总体而言，76.1%的患者服用了他汀类药物，只有 39.4%的患者服用了高强度他汀类药物。男性比女性更有可能接受高强度他汀类药物治疗（多变量调整后的优势比，1.34 [95%CI，1.30-1.38]）。随着年龄的增长，使用他汀类药物的可能性降低（优势比，每 5 岁增加 0.79[95%CI，0.78-0.81]）。患有外周动脉疾病（优势比，0.40 [95%CI，0.37-0.42]）和脑血管疾病（优势比，0.75 [95%CI，0.70-0.80]）的患者使用高强度他汀类药物的可能性低于患有冠状动脉疾病的患者。基线时，大多数患者（61.3%）的 LDL-C 升高（≥70mg/dL），包括 59.8%服用低/中强度他汀类药物的患者和 76.1%未服用他汀类药物的患者；只有 45.3%的患者在 1 年内 LDL-C<70mg/dL。非他汀类 LLT 的使用量较低（依折麦布，4.4%；前蛋白转化酶枯草溶菌素 9 抑制剂，0.7%）。在基线时未服用他汀类药物或服用低/中强度他汀类药物的患者中，分别有 14.8%和 13.4%的患者在 1 年内服用高强度他汀类药物。
结论
在常规护理中的 ASCVD 患者中，高强度他汀类药物的使用率较低，调脂药物的剂量增加和使用非他汀类药物治疗的情况并不常见。女性、老年人和非心脏 ASCVD 患者的治疗不足。需要共同努力，解决 ASCVD 患者血脂管理中的治疗惰性问题。
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