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. 2017 May 10;7(5):e013851.
doi: 10.1136/bmjopen-2016-013851.

Management of lipid-lowering therapy in patients with cardiovascular events in the UK: a retrospective cohort study

Mark D Danese  1 , Michelle Gleeson  1 , Lucie Kutikova  2 , Robert I Griffiths  1   3 , Kamlesh Khunti  4 , Sreenivasa Rao Kondapally Seshasai  5 , Kausik K Ray  6
Affiliations

Management of lipid-lowering therapy in patients with cardiovascular events in the UK: a retrospective cohort study

Mark D Danese et al. BMJ Open. .

Abstract

Objectives: To describe low-density lipoprotein (LDL) cholesterol management and lipid-lowering treatment patterns in patients with a cardiovascular (CV) event.

Design: Retrospective cohort study using Clinical Practice Research Datalink records linked with Hospital Episode Statistics data.

Setting: Routine clinical practice in the UK from 2006 to 2012.

Participants: Individuals ≥18 years were selected at their first CV-related hospitalisation (first event cohort) if they had received ≥2 lipid-lowering therapy prescriptions within 180 days beforehand. Patients were stratified into four mutually exclusive subgroups based on the presence or absence of vascular disease and of diabetes. Those with a second CV hospitalisation within 36 months were included in a separate cohort (second event cohort).

Primary and secondary outcome measures: LDL levels in the year prior to the CV event and 12 months later as well as measures of adherence to lipid-lowering therapy during the 12 months after the CV hospitalisation.

Results: There were 24 093 patients in the first event cohort, of whom 5274 were included in the second event cohort. Most received moderate intensity statins at baseline and 12 months. Among the four first event cohort subgroups at baseline, the proportions with an LDL of <1.8 mmol/L was similar between the two diabetic cohorts (36% to 38%) and were higher than those in the two non-diabetic cohorts (17% to 22%) and in the second event cohort (31%). An incremental 5% to 9% had an LDL below 1.8 mmol/L at 12 months, suggesting intensification of therapy. The proportion of adherent patients (medication possession ratio of≥0.8) was highest for statins, ranging from 68% to 72%. For ezetimibe, the range was 65% to 70%, and for fibrates, it was 48% to 62%.

Conclusions: Despite the existence of effective therapies for lowering cholesterol, patients do not reach achievable LDL targets.

Keywords: cardiovascular disease; low density lipoprotein; treatment adherence.

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Conflict of interest statement

Competing interests: MD, MG, and RG work with Outcomes Insights, Inc., which was funded to conduct this study. LK is an employee of Amgen, Inc. KK has acted as a consultant and speaker for Novartis, Novo Nordisk, Sanofi-Aventis, Lilly, Merck Sharp & Dohme, Janssen, Astra Zeneca and Boehringer Ingelheim. He has received grants in support of investigator and investigator-initiated trials from Novartis, Novo Nordisk, Sanofi-Aventis, Lilly, Pfizer, Boehringer Ingelheim, Merck Sharp & Dohme, Janssen and Roche and has served on advisory boards for Lilly, Sanofi-Aventis, Merck Sharp & Dohme, Novo Nordisk, Boehringer Ingelheim, Janssen and Astra Zeneca. SRKS has provided consulting to Amgen and received grants from Kowa and Sanofi. KKR has provided consultancy to Amgen, Sanofi, Pfizer, Regeneron, Astra Zeneca, Kowa, Aegerion, Merck Sharp & Dohme, Lilly and ISIS, and received grants from Sanofi, Regeneron, Amgen, Pfizer and Merck Sharp & Dohme through his institution.

Figures

Figure 1
Figure 1
Study overview. Patients were stratified into four subgroups as indicated, based on their medical history prior to the first CV event. CV, cardiovascular; LDL, low-density lipoprotein.
Figure 2
Figure 2
Management of LDL cholesterol. Note: distributions of LDL cholesterol at baseline represent the value closest to the index date. Distributions at 12 months represent the value closest to month 12. Across the cohorts, between 49% and 62% of the first event cohort and 53% of the second event cohort had an analysable LDL value. The proportion was between 40% and 46% at 12 months in the first event subgroups and 40% in the second event cohort. CV, cardiovascular; LDL, low-density lipoprotein.
Figure 3
Figure 3
Category of lipid-lowering therapy over time. Note: lipid-lowering therapy category prior to index refers to the prescription qualifying the patient for the study. Not all patients had an active prescription on their index CV event date, as indicated by the no treatment group. Proportions at 12 months reflect the closest prescription prior to or at month 12 regardless of discontinuation. Patients who died were included in the no treatment group. CV, cardiovascular.
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