Navar Ann Marie, Shah Nishant P, Shrader Peter, Thomas Laine E, Ahmad Zahid, Allred Clint, Chamberlain Alanna M, Chrischilles Elizabeth A, Dhalwani Nafeesa, Effron Mark B, Hayek Salim, Jones Laney K, Kalich Bethany, Shapiro Michael D, Wójcik Cezary, Peterson Eric D
Department of Medicine, Division of Cardiology, UT Southwestern Medical Center, Dallas, TX, USA.
Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
Am Heart J. 2025 Jan;279:107-117. doi: 10.1016/j.ahj.2024.06.012. Epub 2024 Jul 6.
Reflecting clinical trial data showing improved outcomes with lower LDL-C levels, guidelines across the globe are increasingly recommending a goal of LDL-C <55 mg/dL in persons with atherosclerotic cardiovascular disease (ASCVD). What proportion of patients with ASCVD are already meeting those goals in the US remains understudied.
Using electronic health record data from 8 large US health systems, we evaluated lipid-lowering therapy (LLT), LDL-C levels, and factors associated with an LDL-C <55 mg/dL in persons with ASCVD treated between 1/1/2021-12/31/2021. Multivariable modeling was used to evaluate factors associated with achievement of an LDL-C <55 mg/dL.
Among 167,899 eligible patients, 22.6% (38,016) had an LDL-C <55 mg/dL. While 76.1% of individuals overall were on a statin, only 38.2% were on a high-intensity statin, 5.9% were on ezetimibe, and 1.7% were on a PCSK9i monoclonal antibody (mAb). Factors associated with lower likelihood of achieving an LDL-C <55 mg/dL included: younger age (odds ratio [OR] 0.91 per 10y), female sex (OR 0.69), Black race (OR 0.76), and noncoronary artery disease forms of ASCVD including peripheral artery disease (OR 0.72) and cerebrovascular disease (OR 0.85), while high-intensity statin use was associated with increased odds of LDL-C <55 mg/dL (OR 1.55). Combination therapy (statin+ezetimibe or statin+PCSK9i mAb) was rare (4.4% and 0.5%, respectively) and was associated with higher odds of an LDL-C <55 mg/dL (OR 1.39 and 3.13, respectively).
Less than a quarter of US patients with ASCVD in community practice are already achieving an LDL-C <55 mg/dL. Marked increases in utilization of both high intensity statins and combination therapy with non-statin therapy will be needed to achieve LDL-C levels <55 mg/dL at the population level in secondary prevention.
临床试验数据显示，较低的低密度脂蛋白胆固醇（LDL-C）水平可改善预后，全球范围内的指南越来越多地建议，动脉粥样硬化性心血管疾病（ASCVD）患者的LDL-C目标值应<55mg/dL。在美国，ASCVD患者中已达到这些目标的比例仍有待深入研究。
利用美国8个大型医疗系统的电子健康记录数据，我们评估了2021年1月1日至2021年12月31日期间接受治疗的ASCVD患者的降脂治疗（LLT）、LDL-C水平以及与LDL-C<55mg/dL相关的因素。采用多变量建模来评估与LDL-C<55mg/dL达成相关的因素。
在167,899名符合条件的患者中，22.6%（38,016名）的LDL-C<55mg/dL。总体而言，76.1%的患者正在服用他汀类药物，但只有38.2%的患者服用高强度他汀类药物，5.9%的患者服用依折麦布，1.7%的患者服用前蛋白转化酶枯草溶菌素9（PCSK9）抑制剂单克隆抗体（mAb）。与LDL-C<55mg/dL达成可能性较低相关的因素包括：年龄较小（每10岁的优势比[OR]为0.91）、女性（OR为0.69）、黑人种族（OR为0.76）以及ASCVD的非冠状动脉疾病形式，包括外周动脉疾病（OR为0.72）和脑血管疾病（OR为0.85），而使用高强度他汀类药物与LDL-C<55mg/dL的优势增加相关（OR为1.55）。联合治疗（他汀类药物+依折麦布或他汀类药物+PCSK9抑制剂mAb）很少见（分别为4.4%和0.5%），且与LDL-C<55mg/dL的较高优势相关（分别为OR为1.39和3.13）。
在社区实践中，美国ASCVD患者中不到四分之一的人已实现LDL-C<55mg/dL。在二级预防中，要在人群层面实现LDL-C水平<55mg/dL，需要大幅提高高强度他汀类药物的使用率以及与非他汀类药物的联合治疗率。
