Statins in Primary Care: Bridging The Treatment Gap
Many patients with coronary heart disease do not have any, or adequate, lipid-lowering treatment. This article describes strategies to bridge the gap between potentially achievable targets and actual lipid levels.
Audits of cholesterol management in patients with coronary heart disease (CHD) demonstrate that many patients do not achieve targets set out in national guidelines. Under-treatment is a component of the treatment gap and many patients are prescribed low-dose statins. The delivery of systematic care and adoption of more efficacious initial doses will increase the number of patients who achieve recommended low-density lipoprotein cholesterol (LDL-C) levels and maintain their LDL-C goals. Current studies indicate that rosuvastatin, atorvastatin and simvastatin are the most efficacious agents for lowering LDL-C and triglycerides. Compliance and persistence with statin treatment are poor and represent significant barriers to delivering mortality reductions in clinical practice. Efforts to improve concordance are necessary to ensure that treatment benefits are realised in clinical practice.
Despite the benefits of statin therapy, which have been demonstrated in large-scale clinical trials, recent secondary prevention audits show that cholesterol management remains suboptimal and that many patients treated with statins still do not achieve their recommended low-density lipoprotein cholesterol (LDL-C) goals. In the EUROASPIRE II study, a total of 5,556 patients had their lipid levels reviewed following hospitalisation for coronary heart disease (CHD). Only 61% of patients were receiving lipid-lowering therapy and, of these, 51% had total cholesterol levels below their treatment goals. The Healthwise I study demonstrated that 44% of patients with CHD who had their cholesterol checked still had a total cholesterol greater than 5 mmol/L (mean cholesterol 5.9 mmol/L), while the proportion receiving statins was only 16%. The Healthwise II study found that 48% of patients had their cholesterol measured, of whom 55% were taking a statin; only 53% of these had a total cholesterol below 5 mmol/L, and the mean cholesterol of patients on completion of the study was 4.8 mmol/L (± 1.1 mmol/L).
Valuable information can be gained from examining the largest published audit of cholesterol management in English general practice, which assessed the clinical records of 2.4 million people - approximately 4% of the UK population. Among patients with CHD, the mean total cholesterol level in patients taking statins was 5.13 mmol/L, while in patients who were not taking statins the mean cholesterol level was only slightly higher, at 5.27 mmol/L. The study found that the 'rule of halves' applies to cholesterol management in patients with CHD - half had a record of cholesterol measurement, only half of these were receiving a statin, and only half of these had reached their cholesterol goal (figure 1). These and other studies point to a treatment gap in the current UK lipid management of patients with CHD; many patients are under-treated and others remain untreated. Ensuring the delivery of systematic care should address lack of treatment but the reasons and remedies for under-treatment warrant further examination.
(Enlarge Image)
Cholesterol management in patients with CHD - the rule of halves[5]
Many patients with coronary heart disease do not have any, or adequate, lipid-lowering treatment. This article describes strategies to bridge the gap between potentially achievable targets and actual lipid levels.
Audits of cholesterol management in patients with coronary heart disease (CHD) demonstrate that many patients do not achieve targets set out in national guidelines. Under-treatment is a component of the treatment gap and many patients are prescribed low-dose statins. The delivery of systematic care and adoption of more efficacious initial doses will increase the number of patients who achieve recommended low-density lipoprotein cholesterol (LDL-C) levels and maintain their LDL-C goals. Current studies indicate that rosuvastatin, atorvastatin and simvastatin are the most efficacious agents for lowering LDL-C and triglycerides. Compliance and persistence with statin treatment are poor and represent significant barriers to delivering mortality reductions in clinical practice. Efforts to improve concordance are necessary to ensure that treatment benefits are realised in clinical practice.
Despite the benefits of statin therapy, which have been demonstrated in large-scale clinical trials, recent secondary prevention audits show that cholesterol management remains suboptimal and that many patients treated with statins still do not achieve their recommended low-density lipoprotein cholesterol (LDL-C) goals. In the EUROASPIRE II study, a total of 5,556 patients had their lipid levels reviewed following hospitalisation for coronary heart disease (CHD). Only 61% of patients were receiving lipid-lowering therapy and, of these, 51% had total cholesterol levels below their treatment goals. The Healthwise I study demonstrated that 44% of patients with CHD who had their cholesterol checked still had a total cholesterol greater than 5 mmol/L (mean cholesterol 5.9 mmol/L), while the proportion receiving statins was only 16%. The Healthwise II study found that 48% of patients had their cholesterol measured, of whom 55% were taking a statin; only 53% of these had a total cholesterol below 5 mmol/L, and the mean cholesterol of patients on completion of the study was 4.8 mmol/L (± 1.1 mmol/L).
Valuable information can be gained from examining the largest published audit of cholesterol management in English general practice, which assessed the clinical records of 2.4 million people - approximately 4% of the UK population. Among patients with CHD, the mean total cholesterol level in patients taking statins was 5.13 mmol/L, while in patients who were not taking statins the mean cholesterol level was only slightly higher, at 5.27 mmol/L. The study found that the 'rule of halves' applies to cholesterol management in patients with CHD - half had a record of cholesterol measurement, only half of these were receiving a statin, and only half of these had reached their cholesterol goal (figure 1). These and other studies point to a treatment gap in the current UK lipid management of patients with CHD; many patients are under-treated and others remain untreated. Ensuring the delivery of systematic care should address lack of treatment but the reasons and remedies for under-treatment warrant further examination.
(Enlarge Image)
Cholesterol management in patients with CHD - the rule of halves[5]