Shoji Satoshi, Shah Nishant P, Shrader Peter, Thomas Laine E, Arnold Jonathan D, Dhalwani Nafeesa N, Thomas Neena A, Kalich Bethany, Priest Elisa L, Syed Mahanaz, Wójcik Cezary, Peterson Eric D, Navar Ann Marie
Duke Clinical Research Institute, Durham, NC, USA.
Division of Cardiology and Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
Am J Prev Cardiol. 2024 Dec 21;21:100921. doi: 10.1016/j.ajpc.2024.100921. eCollection 2025 Mar.
Lowering lipid to reach guideline-indicated goals significantly reduces cardiovascular outcomes in very-high-risk (VHR) patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (DM2). How well VHR patients currently achieve these goals in community practice is unknown.
VHR patients with ASCVD and DM2 were identified across 14 US healthcare systems using electronic health records between 1/1/2021-12/31/2022. Achievement of guideline-based lipid goals was determined according to the 2018 AHA/ACC/Multisociety guideline, defined as either having a low-density lipoprotein-cholesterol <70 mg/dL or receiving maximal lipid-lowering therapy (i.e., on a PCSK9i monoclonal antibody). Multivariable logistic regression was used to evaluate factors associated with the achievement of these goals.
Among 213,380 eligible patients (median age 71.0 years, 42 % women), 51.8 % achieved guideline-based lipid goals. Female sex (odds ratio [OR], 0.64; 95 % confidence interval [CI], 0.61-0.66), Black race (OR, 0.67; 95 % CI, 0.63-0.72 vs white race), and those on Medicaid (OR, 0.92; 95 % CI, 0.86-0.97 vs Medicare) were associated with a lower likelihood of achieving guideline-based lipid goals. Overall, 76.0 % of patients were on statin, 40.5 % were on a high-intensity statin and only 5.8 % were on a statin in combination with ezetimibe or a PCSK9i monoclonal antibody.
Almost half of all VHR patients with ASCVD and DM2 do not achieve current guideline lipid goals. Women, Black individuals, and those on Medicaid were significantly less likely to achieve these goals relative to their counterparts. Further targeted quality improvement interventions are needed to improve the equitable achievement of guideline-based lipid goals.
对于患有动脉粥样硬化性心血管疾病（ASCVD）和2型糖尿病（DM2）的极高风险（VHR）患者，降低血脂以达到指南规定的目标可显著降低心血管疾病发生风险。目前在社区医疗实践中，VHR患者实现这些目标的情况尚不清楚。
利用电子健康记录，在2021年1月1日至2022年12月31日期间，从美国14个医疗系统中识别出患有ASCVD和DM2的VHR患者。根据2018年美国心脏协会（AHA）/美国心脏病学会（ACC）/多学会指南确定基于指南的血脂目标达成情况，该目标定义为低密度脂蛋白胆固醇<70mg/dL或接受最大强度降脂治疗（即使用前蛋白转化酶枯草溶菌素9抑制剂[PCSK9i]单克隆抗体）。采用多变量逻辑回归分析评估与实现这些目标相关的因素。
在213,380例符合条件的患者中（中位年龄71.0岁，42%为女性），51.8%实现了基于指南的血脂目标。女性（比值比[OR]为0.64；95%置信区间[CI]为0.61 - 0.66）、黑人（OR为0.67；95%CI为0.63 - 0.72，与白人相比）以及参加医疗补助计划的患者（OR为0.92；95%CI为0.86 - 0.97，与参加医疗保险的患者相比）实现基于指南的血脂目标的可能性较低。总体而言，76.0%的患者使用他汀类药物，40.5%的患者使用高强度他汀类药物，只有5.8%的患者使用他汀类药物联合依泽替米贝或PCSK9i单克隆抗体。
几乎一半患有ASCVD和DM2的VHR患者未达到当前指南规定的血脂目标。相对于其他人群，女性、黑人以及参加医疗补助计划的患者实现这些目标的可能性显著更低。需要进一步有针对性的质量改进干预措施，以提高基于指南的血脂目标的公平达成率。
