Missed Opportunity in the Treatment of Hyperlipidemia in Patients with Coronary Heart Disease: The Primary Care Setting

Patients with Coronary Heart DiseaseBACKGROUND
Coronary heart disease (CHD) affects approximately 13.5 million people in the United States. This accounts for significant morbidity and mortality, including approximately 900,000 myocardial infarctions and 250,000 deaths each year. A major goal for physicians caring for patients with CHD focuses on the management of risk factors known to be associated with recurrent cardiovascular events. Diabetes and hypertension have long been associated with coronary disease, and the benefit of controlling these diseases has been well documented. However, in the past 10 years, hyperlipidemia has emerged as another risk factor strongly associated with coronary disease. There is now sufficient evidence that aggressive control of hyperlipidemia has a beneficial effect. Several large, multicenter trials have shown that lipid-lowering medications are safe and effective in reducing CHD morbidity and mortality. In addition, a meta-analysis of five studies showed that the benefits of lipid-lowering is demonstrated in both men and women and in those age >65. Long-term clinical benefits have also been shown for lipid-lowering in the primary prevention setting, including patients with normal-to-only-moderately-elevated lipid levels.

In May 2001, the National Cholesterol Education Program (NCEP) Adult Treatment Panel III revised guidelines for the initiation and titration of lipid-lowering therapy for adults. One highlight of the new guidelines is the importance of tighter lipid control with lower LDL goals in patients with CHD, diabetes and other CHD risk equivalents.
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Despite this evidence for the beneficial effect of lipid control and national guidelines for lipid management, there continues to be a wide therapeutic gap between those eligible for therapy and those actually on therapy. Several studies have shown that many patients hospitalized for coronary events do not receive appropriate lipid management. In addition, there is evidence that initiation of lipid-lowering therapy as an inpatient enhances medication compliance and may reduce mortality. However, the majority of lipid management occurs in the outpatient setting. Outpatient visits still offer many opportunities to fully evaluate coronary risk factors and ample time to initiate and titrate appropriate therapy, yet one large study of CHD patients (n=48,586) managed in the cardiology outpatient setting demonstrated that only 25% of patients reached NCEP goals. Buy omnicef

The purpose of this study is to evaluate the level of appropriate lipid management in CHD patients attending an outpatient primary care clinic in a large, urban, academic setting. To date, there is little data that evaluates the appropriateness of lipid management of CHD patients in this type of setting. Outpatient lipid management in patients with CHD may represent a substantial opportunity to close the therapeutic gap.


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