Physicians' Academy for Cardiovascular Education

Treament intertia for lipid-lowering therapy in patients with FH and CVD

Treatment Inertia in Patients with Familial Hypercholesterolemia

Literature - Langer A, Mancini J, Tan M, et al. - J Am Heart Assoc. 2021;190:e020126. DOI: 10.1161/JAHA.120.020126

Introduction and methods

The Canadian Cardiovascular Society (CCS) guidelines recommend LDL-c lowering therapy (LLT) with high efficacy statin therapy and addition of ezetimibe and/or PCSK9i as needed in patients with established CVD, if LDL-c levels are not decreased by at least 50% or below 2.0 mmol/L [1]. The CCS recommends the same therapeutic approach in patients with FH, albeit with an LDL-c attainment goal of <2.5 mmol/L [2]. Despite these treatment guidelines, many patients with elevated LDL-c do not achieve LDL-c target goals [3-6]. A recent study, however, has demonstrated that physician support based on a reminder system for recommended LLT led to an increase in the proportion of patients who achieved guideline-recommended LDL-c levels [7]. This post hoc analysis specifically assessed the care gap in patients with FH with respect to LLT. Furthermore, this analysis explored whether lipid management differed between patients with CVD and patients with FH.

The Guidelines Oriented Approach to Lipid Lowering (GOAL) Canada was an investigator-initiated interventional program. The intervention was physician education based on lipid management reminders when entering LLT data in the electronic case report form. A total of 177 physicians (58% primary care and 42% specialists) enrolled 2009 patients (at least 12 patients per physician) with clinical vascular diseases such as, CAD, PAD, cerebrovascular disease, abdominal aortic aneurysm, or with FH. In addition, eligible patients had to have LDL-c levels of >2 mmol/L at baseline while receiving maximally tolerated statins (having tried a minimum of 2 statins, each at least on 2 reduced doses) for at least 3 months before enrollment. A total of 1054 (52.4%) patients with CVD, 636 (31.7%) patients with FH, and 319 (15.9%) patients with FH and established CVD were included. LLT was assessed on enrollment (visit 1) and twice during follow-up (visit 2 and 3, each between ~4 to 6 months apart). The prespecified primary endpoint was the proportion of patients who achieved the CCS recommended LDL-c targets of ≥50% reduction or <2 mmol/L in patients with CVD and ≥50% reduction or <2.5 mmol/L in patients with FH.

Main results


This post hoc analysis suggests that physician reminders for recommended LLT led to an increase in the proportion of patients with FH and/or CVD achieving LDL-c treatment goals. However, treatment inertia remains to exists in patients with FH, including those with established CVD.


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Find this article online at J Am Heart Assoc.

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