Post-ACS patients are not adequately treated with high-potency statin regimens
Predictors of Non use of a High-Potency Statin After an Acute Coronary Syndrome: Insights From the Stabilization of Plaques Using Darapladib-Thrombolysis in Myocardial Infarction 52 (SOLID-TIMI 52) Trial
Literature - Eisen A, Cannon CP, Braunwald E, et al. - J Am Heart Assoc. 2017;6:e004332Background
High-potency statin regimens (HPSR) reduce the risk of recurrent CV events in post-ACS patients, and ACS management guidelines recommend the use of HPSR in all patients after an ACS, regardless of their baseline lipid profile [1-4]. However, in clinical practice, HPSR are not prescribed for 50% to 70% of patients following hospitalisation due to an ACS, for reasons that are not clear [5,6].
In this study, the patient characteristics associated with non-use of an HPSR were examined in a large, multinational, contemporary, randomised trial population after ACS. An HPSR was defined as ≥40 mg atorvastatin, ≥20 mg rosuvastatin, or 80 mg simvastatin daily. Of the 13 026 patients in the SOLID-TIMI 52 study, 96% had information about their statin therapy at baseline.
Main results
- 95.2% of patients were on a statin at baseline after ACS and 41.9% were on an HPSR. Patients who were not on any type of statin at baseline had a known intolerance of or contraindication to statin therapy.
- Patients not treated with an HPSR at baseline were older (median age 65 vs. 63 yrs), more likely to be female (27.5 vs. 23.1%), more likely to be hospitalised with non-STE (NSTE)–ACS as the qualifying event (57.0 vs. 51.0%), less likely to undergo PCI for the qualifying event (71.0 vs. 84.4%), less likely to be treated with other evidence-based therapies including aspirin (95.8 vs. 97.3%), P2Y12 receptor inhibitors (84.3 vs. 93.7%), and beta blockers (86.0 vs. 89.1%, P<0.001 for each).
- The independent predictors of non-use of an HPSR at the baseline visit after ACS were age ≥75 yrs (OR: 1.39; 95% CI: 1.24–1.56), female sex (OR: 1.11; 95% CI: 1.02–1.22), non-white race (OR: 1.89; 95% CI: 1.69–2.10), estimated glomerular filtration rate <60 mL/min per 1.73 m2 (OR: 1.17; 95% CI: 1.03–1.32), no statin therapy within 8 wks prior to hospitalisation (OR: 1.43; 95% CI: 1.32–1.54), hospitalisation with an NSTE–ACS as the qualifying event (OR: 1.15; 95% CI: 1.06–1.24), no PCI for the qualifying event (OR: 1.92; 95% CI: 1.74–2.12), HF during hospital admission (OR: 1.43; 95% CI: 1.27–1.62).
- After 3 months from the baseline visit, only 4.4% of the patients who were not on an HPSR at baseline had been started on an HPSR, and of the patients who were treated with an HPSR at baseline, 10.2% discontinued this treatment after 3 months.
- After a median follow-up of 2.3 yrs, 10.3% of the patients who were not on an HPSR at baseline, were subsequently initiated on an HPSR, and of the patients who were on an HPSR at baseline, 17.9% subsequently had discontinued it.
- Of the patients who were not on an HPSR at 3 months (59%), a lower achieved LDL-C concentration at that time was an independent predictor of non-use of an HPSR at the end-of-treatment visit (adjusted OR for 10 mg/dL decrease: 1.15; 95% CI: 1.11–1.19; P<0.001).
Conclusion
In a large, multinational, post-ACS population, most patients were not treated with high-potency statin regimens early and late after the event, including many patients at the highest risk of recurrent CV events. These findings emphasize the need of a better adherence to ACS guideline recommendations.