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:e004332

Background

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.

References

Show references

Find this article online at JAHA