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. 2020 May 1:1:100002.
doi: 10.1016/j.ajpc.2020.100002. eCollection 2020 Mar.

The evaluation and management of patients with LDL-C ≥ 190 ​mg/dL in a large health care system

Candace L Jackson  1 , Zahid Ahmad  2 , Sandeep R Das  3 , Amit Khera  3
Affiliations

The evaluation and management of patients with LDL-C ≥ 190 ​mg/dL in a large health care system

Candace L Jackson et al. Am J Prev Cardiol. .

Abstract

Objectives: Patients with severe hyperlipidemia (low-density lipoprotein-cholesterol (LDL-C) ≥190 ​mg/dL) have a significantly increased risk of cardiovascular disease (CVD) and are more likely to have familial hypercholesterolemia (FH). We sought to determine how often health care providers recognize the implications of and adjust therapy for an LDL-C ≥190 ​mg/dL.

Methods: We conducted a retrospective review of patients with an LDL-C measurement in the medical record of a large health care system between November 2015 and June 2016. Patients were restricted to those with LDL-C ≥190 ​mg/dL and without secondary causes of dyslipidemia, with sensitivity analyses for those with LDL-C ≥220 ​mg/dL.

Results: Of 27,963 patients, 227 had LDL-C ≥190 ​mg/dL. Only 21% were on a statin at the time of LDL-C measurement. More than 90% had a follow-up clinic visit, but 41% had no change in treatment. FH was only included in the differential for 14%. The presence/absence of a family history of dyslipidemia, myocardial infarction, and premature CVD were documented in 26%, 29%, and 31%. Only 20.7% and 22.1% had documentation of the presence or absence of tendinous xanthomas or corneal arcus, respectively. Among those without prior specialist care (cardiologist or endocrinologist), only 13% were referred. These measures were only slightly better for those with LDL-C ≥220 ​mg/dL.

Conclusion: In a large health care system, the possibility of FH was rarely acknowledged in those with residual LDL-C ≥190 ​mg/dL, few were referred to specialists, and therapeutic adjustments were suboptimal. Additional efforts are required to understand barriers to improving the evaluation and management of patients with LDL-C ≥190 ​mg/dL.

Keywords: Familial hypercholesterolemia; Hyperlipidemia; Prevention.

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Conflict of interest statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr Ahmad reports grants from Regeneron Pharmaceuticals Inc, personal fees from Regeneron Pharmaceuticals Inc, personal fees from Amgen, personal fees from Akcea, grants from the National Institutes of Health–National Heart, Lung, and Blood Institute, and grants from the Familial Hypercholesterolemia Foundation.

Figures

Fig. 1
Fig. 1
Provider documentation of presence/absence of family history (CVD: cardiovascular disease; LDL-C: low-density lipoprotein-cholesterol; MI: premature myocardial infarction).
Fig. 2
Fig. 2
Provider documentation of presence/absence of physical examination findings (LDL-C: low-density lipoprotein-cholesterol).
Fig. 3
Fig. 3
(a) Changes in treatment among those with LDL-C ≥190 ​mg/dL. (b) Changes in treatment among those with LDL-C ≥220 ​mg/dL (LDL-C: low-density lipoprotein-cholesterol) ∗Prescribed, recommended, or adjusted (including change in medication type or dose) within 3 months of abnormal LDL-C.
Fig. 4
Fig. 4
(a) Referral pattern among those with LDL-C ≥190 ​mg/dL. (b) Referral pattern among those with LDL-C ≥220 ​mg/dL (LDL-C: low-density lipoprotein-cholesterol) ∗Patient had seen a cardiologist or endocrinologist who acknowledged or managed their LDL-C prior to the abnormal value. ∗∗Referral was mentioned or recommended within 3 months of abnormal LDL-C.
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