Statin Prescription for Primary Prevention of Cardiovascular Diseases in Patients without Hyperlipidemia: Experience from a Low-middle Income South Asian Country

Abstract

Background: Prescription of statins in primary prevention of atherosclerotic cardiovascular disease (ASCVD) is not as firmly established as it is for secondary prevention, even in high-income countries. The World Health Organization (WHO) has set nine global targets for preventing and controlling noncommunicable diseases (NCDs), including a goal that, by 2025, 50% of eligible individuals receive drug therapy and counseling focused on managing cardiovascular disease. Data from countries classified as low- to middle-income countries (LMIC) show that only one in 10 eligible people is being treated with statins for primary prevention of cardiovascular disease. Statin utilization for primary prevention in patients with normal cholesterol levels could be even lower, but data from LMIC is lacking.

Objectives: We aimed to study statin prescriptions for primary prevention of ASCVD among Sri Lankans without hyperlipidemia.

Methods: This was a cross-sectional study conducted in a hospital setting in eight selected medical clinics of secondary/tertiary care hospitals representing eight out of nine highly populated provinces of Sri Lanka from 15th December 2022 to 30th April 2023. Prescriptions of consecutive, consenting adults aged 40-75 years, without prior ACVD or hyperlipidemia but eligible for statin primary prevention according to the recommendations of the American Heart Association (AHA) guideline, were studied. Prescriptions were evaluated for rates and the intensity of statin prescription, stratified by their CVD risk. Data were gathered by interviewing patients using a questionnaire and reviewing medical records.

Results: We studied 800 patients eligible for statin primary prevention, with a mean age of 62 ± 8.3 years, of which 247 (30.9%) were men, and 566 (70.8%) had diabetes. According to the ASCVD score classification, 176 (22.0%) were at high risk (score >20%) and 624 (78%) were at moderate risk of cardiovascular (CV) events. Statins were prescribed to 659 (82.4%) patients, but only 12 (6.8%) high-risk patients received high-intensity statins, and 470 (75.3%) moderate-risk patients were on moderate-intensity statins. Moreover, 32 (18.2%) high-risk patients were not prescribed any statins. Overall, 482 (60.3%) patients were on guideline-recommended statin doses.

Conclusion: In this research, the rate of statin prescription for primary prevention of ASCVD in Sri Lanka's healthcare system was found to be satisfactory, exceeding the WHO's target of 50% of eligible individuals receiving this drug therapy. However, >90% of patients at high risk of CVD were not on appropriate doses of statins. This highlights the need for improvement in individualizing treatment to administer the right dose of statin to the right patient.