Physicians' Academy for Cardiovascular Education

EUROASPIRE IV survey reveals much room for improvement in guideline-recommended statin prescription

Reiner Ž et al., Atherosclerosis 2016

Lipid lowering drug therapy in patients with coronary heart disease from 24 European countries - Findings from the EUROASPIRE IV survey

 
Reiner Ž, De Backer G, Fras Z et al.,
Atherosclerosis. 2016 Mar;246:243-50. doi: 10.1016/j.atherosclerosis.2016.01.018.
 

Background

The benefit of lipid-lowering drugs, in the form of statins, as secondary prevention in patients with established coronary heart disease (CHD) is well established [1], and greater LDL-c lowering effect yields more CHD prevention [2]. US guidelines therefore recommend to use high-intensity statin therapy in coronary patients to achieve at least 50% LDL-c lowering [3]. European guidelines recommend lowering LDL-c <1.8 mmol/L (<70mg/dL) or at least 50% reduction in patients with established CHD [4,5].
The results of the IMPROVE-IT trial have shown that more CHD patients can achieve treatment goals if they are treated with a combination of a statin and ezetimibe, as compared with a statin alone, and this was associated with improved outcomes [6].
This study analyses how lipid lowering drugs were prescribed in CHD patients at discharge from hospital throughout Europe, in the hospital arm of the EUROASPIRE IV survey [7], and how patients reported statin intake at an interview at least 6 months later. Data of 6648 CHD patients were included.
 

Main results

  • Overall, 9.6% of CHD patients were not on statins at discharge, and 14% not at the interview.
  • 37.6% of patients were prescribed a high-intensity LDL-lowering therapy (possibly including ezetimibe) at discharge, which decreased to 32.7% at the time of the interview.
  • Large differences were seen between countries in statin class at discharge. For instance, in centres from Spain, Latvia and Cyprus, 3.7, 4.2 and 1.6% respectively of patients were not discarded with a statin, while in Bosnia-Herzegovina and The Netherlands, 22 and 23.2% respectively left the hospital without a statin.
  • High-intensity LDL-lowering therapy at discharge was prescribed in less than 10% of patients in Germany, Bosnia-Herzegovina and The Netherlands, while this was the case in >50% in Croatia, France, Ireland, Latvia, Romania, Slovenia, Spain and United Kingdom.
  • In 5 countries, the number of patients not on a statin doubled between discharge and the interview. In 6 out of 24 countries the number of patients on a high-intensity statin had increased substantially at the time of the interview.
  • Although statin therapy was initiated in 63.0% of patients who did not receive it at discharge (403/640), the therapy was discontinued in 11.6% (695/6008) of those who did receive statin therapy at discharge. 11.6% (407/3506) of patients on a low/moderate intensity statin at discharge were uptitrated to a high-intensity agent, but 13% (458) interrupted therapy.
  • 24.4% of the patient population were women, but women represented 33.8% of all patients not receiving a statin at discharge and at the interview.
  • Overall 57.8% and 19.3% achieved target values of respectively <2.5 and <1.8 mmol/L at the time of the interview. 28.3% and 9.0% of those not on statins were on either target, and the respective goals were achieved by 59.4% and 17.5% on low/moderate intensity statins, and by 67.9% and 26.6% of those receiving high-intensity statins.
  • Actions regarding statin use taken between discharge and the interview affected the proportion of patients at goal for LDL-c.
  • Statin prescription was analysed in various subpopulations. See article for more details.

Conclusion

Many European patients with dyslipidaemia are inadequately treated and not achieving guideline-recommended LDL-c treatment goals, despite the clear evidence of the benefits of lipid-lowering treatment with statins as secondary prevention. Overall, 1 in 10 patients was discharged from the hospital after a coronary event without any statin treatment, and only one third was prescribed a high-intensity therapy. Large differences were seen between countries.
Subgroup analyses indicate that women were less often prescribed statins, and less often receive high-intensity statin therapy. Similarly, CHD patients older than 60 years receive less statin therapy than younger patients.
These findings underscore the considerable potential to reduce CHD morbidity and mortality throughout Europe by optimising LDL-c lowering therapy.
 
Find this article online at Atherosclerosis
 

References

1. Cholesterol Treatment Trialists’ (CTT) Collaboration, C. Baigent, L. Blackwell, et al., Efficacy and safety of more intensive lowering of LDL cholesterol: a metaanalysis of data from 170,000 participants in 26 randomised trials, Lancet 376 (2010) 1670e1681.
2. Reiner Z, Statins in the primary prevention of cardiovascular disease, Nat. Rev. Cardiol. 10 (8) (2013) 453e464.
3. N.J. Stone, J.G. Robinson, A.H. Lichtenstein, et al., 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American heart association task force on practice guidelines, Circulation 129 (2014) S1eS45.
4. J. Perk, G. De Backer, H. Gohlke, et al., European guidelines on cardiovascular disease prevention in clinical practice (version 2012), Atherosclerosis 223 (2012) 1e68.
5. Catapano AL. Reiner Z, G. De Backer, et al., ESC/EAS guidelines for the management of dyslipidaemias: the task force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European atherosclerosis society (EAS), Eur. Heart J. 32 (2011) 1769e1818.
6. E.A. Bohula, R.P. Giugliano, C.P. Cannon, et al., Achievement of dual low density lipoprotein cholesterol and high-sensitivity c-reactive protein targets more frequent with the addition of ezetimibe to simvastatin and associated with better outcomes in IMPROVE-IT, Circulation 132 (13) (2015) 1224e1233.
7. K. Kotseva, D. Wood, D. De Bacquer et al on behalf of the EUROASPIRE Investigators, EUROASPIRE IV: a European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries, Eur. J. Prev. Cardiol. (2015 Feb 16), http://dx.doi.org/10.1177/2047487315569401 pii: 2047487315569401. [Epub ahead of print].