Missed Opportunity in the Treatment of Hyperlipidemia in Patients with Coronary Heart Disease: The Primary Care Setting. DISCUSSION
The frequency of lipid-lowering therapy (74.8%) in patients with CHD in this outpatient setting was relatively high but not as high as the frequency of patients on aspirin or antiplatelet therapy (88.4%). More than one-quarter of the patients in this cohort were not on any lipid-lowering therapy. In addition, only 55 patients (45.8%) were at a goal LDL <100 mg/dl. There was a significant proportion of patients that had LDL values from 100-129 mg/dl. At the time of this study, NCEP II provided the current practice guidelines. These recommendations called for an LDL <100 mg/dl for patients with known CHD and to consider drug therapy if LDL was greater than 130 mg/dl. NCEP III recommendations currently published have maintained an LDL goal <100 mg/dl with a consideration of drug therapy for those with LDL levels between 100-129 mg/dl.
While lipid-lowering therapy was prescribed in 74.8% of patients, only 45.8%) of CHD patients were at a goal LDL <100 mg/dl. A large portion of patients were on a moderate statin dose of 40 mg (54.6%). However, only seven patients (6.5%) were on the maximum statin dose of 80 mg. Forty-two patients (38.9%) were on a relatively low statin dose of 10-20 mg. This would suggest a failure to appropriately titrate statin doses for LDL values not at goal.
This study was performed at a large, urban hospital affiliated with a major teaching institution. Despite a stress on lipid management and the importance of CHD risk factor control, the frequency of patients with goal LDL values was relatively low. There are several possible reasons for this. First, the failure of physicians to prescribe and/or titrate lipid-lowering therapy in CHD patients may have lead to suboptimal LDL control. In addition, a large proportion of the study patients were African-American. There may be metabolic differences in this population that makes it harder to reach NCEP goals, such as having higher baseline LDL values or a greater percentage with an atherogenic diet. In addition, the presence of higher HDL values (mean HDL of 51 mg/dl) compared to other populations may cause physicians to be less aggressive in their LDL goals. Finally, patient noncompliance with therapy and diet may have played a role in poor LDL control. Medication you can afford cialis super active
Other studies in the outpatient setting have also demonstrated the lack of LDL control in patients with CHD. The Lipid Treatment Assessment Project showed that LDL control is most difficult in high-risk patients. In their cohort, only 18% of patients with CHD were at LDL goal. In a large cardiology outpatient study, similar results were found with only 25% of CHD patients reaching NCEP goals.
The current study suggests that more effort should be focused on improving outpatient adherence to lipid-lowering therapy and LDL control in CHD patients. One approach to achieve this goal is to initiate or titrate therapy as an inpatient. While the outpatient setting allows ample time to assess the need for the initiation of therapy, the inpatient setting may provide more focused motivation for initiating such therapy. Fonarow et al. showed that the use of lipid-lowering therapy at discharge in patients hospitalized with acute myocardial infarction was low, particularly in older patients, in those with a history of hypertension and those undergoing coronary artery bypass grafting. In a study by Muh-lestein et al., a low percentage of patients with an angiographic diagnosis of CHD were discharged on a statin. This study also showed that long-term statin compliance was significantly higher among patients initially discharged on these medications. Perhaps more importantly, this study showed a trend towards a mortality benefit in patients discharged on statin therapy. Thus, statin titration prior to discharge may be a missed opportunity for lipid control.
While the initiation of lipid-lowering therapy as an inpatient has been shown to increase the frequency of appropriate outpatient therapy and may improve mortality, there needs to be more focus on guideline adherence in the outpatient setting. A ran¬domized controlled trial performed at an academic institution showed significant improvements in compliance with NCEP guidelines in those physicians who were educated to the guidelines and offered patient-specific feedback. Specific disease management programs are often helpful. Labresh et al. showed an improvement in LDL control after the initiation of a physician-supervised, nurse-managed lipid control program. Suffer no more! Buy levitra professional online at a price you can afford.
While the frequency of lipid-lowering therapy in this cohort was relatively high, the number of patients at goal LDL was disproportionately lower. Foley et al. showed that in a large cohort of high-risk CHD patients (n=2,829), only about one-half of the patients achieved goal LDL values on a starting dose of statin. Of those not at goal, only 45% had their statin dose titrated. Furthermore, two-thirds of patients who had their dose titrated still did not achieve goal LDL values. Family or general practice physicians were particularly poor at titrating their patients’ statin doses to try to achieve goal LDL values. The current study supports the possibility that failure to titrate statin doses may be a major contributor to poor LDL control. Despite a low number of patients with LDL values <100, only seven patients (6.5%) were on maximum statin doses. These results suggest that it may be beneficial to initiate statin therapy at higher doses with more aggressive titration.
The above methods focus on the physician’s role in improving the frequency of lipid-lowering therapy and achieving goal LDL values. However, many of the patients in the current study may not fully understand the importance of hyperlipidemia as a modifiable CHD risk factor or the relative safety and efficacy of these medications. In our setting, low health literacy levels may affect medication understanding and compliance. In addition, many patients have financial limitations that affect medication compliance. Patient education efforts are likely to be important. Such efforts could include improved patient education and counselling during the office visit, group classes for CHD patients and improved patient education materials that avoid technical terms and large proportion of African Americans (91.8%) and a large percentage of women with CHD (54.4%). In addition, while much of the current data focuses on long-term benefits of statins and tight LDL control, this study takes a cross-sectional view of the number of patients on lipid-lowering therapy and their level of control. Finally, the practice setting of an attending supervised, resident clinic in a large, academic hospital is unique and may be different from the community. Don’t let the pharmacy companies beat you. Buy viagra oral jelly online
Several limitations of this study should be acknowledged. First, the frequency of lipid-lowering therapy was assessed only by physician or pharmacy database documentation of medication regimens. Although most patients receive their medications from the hospital pharmacy, some may actually receive them at private pharmacies. Actual patient compliance could not be assessed. Second, the study was retrospective and initial LDL values could not be assessed. Third, the large proportion of African-American patients and the urban, resident clinic setting limits the ability to extrapolate the data to other settings or populations. Finally, we did not look at the specific reasons patients were not on lipid-lowering therapy, such as contraindications to medications, specific patient wishes or side effects. In addition, the reasons for physicians’ lack of statin titration, such as the absence of LDL values for decision-making, lack of awareness of the NCEP guidelines, clinical “inertia” or unknown patient factors (i.e., cost, noncompliance or comorbidities), could not be determined. Buy female viagra
There has been recent clinical trial evidence that suggests even a lower LDL goal in patients with CHD. The Heart Protection Study has shown that there is a cardiovascular benefit of lipid-lowering therapy in patients with CHD regardless of baseline LDL level. In fact, the NCEP recently released modifications for the Adult Treatment Panel III treatment algorithm that suggest a goal LDL of <70 mg/dl would be reasonable in very-high-risk patients with CHD. Despite this mounting evidence, there remains a large therapeutic gap in the outpatient treatment of hyperlipidemia in CHD patients. This continues despite the increasing arsenal of more potent lipid-lowering medications that can now be used either as monotherapy or in combination therapy. This study suggests that more effort is needed in the area of physician and patient awareness in improving this therapeutic gap in high-risk secondary prevention in the outpatient setting.