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Undertreatment of hyperlipidemia in the secondary prevention of coronary artery disease

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Abstract

OBJECTIVES: To determine adherence to national guidelines for the secondary prevention of coronary artery disease (CAD) using lipid-lowering drugs (LLDs), by studying the rate of use of LLDs, predictors of use, and the rate of achieving lipid goals, among eligible patients recently hospitalized with acute myocardial infarction.

DESIGN: Cross-sectional analysis of 2,938 medical records, collected from July 1995 to May 1996.

SETTING: Thirty-seven community-based hospitals in Minnesota.

PATIENTS: The 622 patients had previously established CAD and hyperlipidemia (total cholesterol >200 mg/dL or currently using LLDs), and were eligible for LLDs according to the National Cholesterol Education Program II (NCEP II) Guidelines.

MEASUREMENTS: The use of LLDs in eligible patients (primary outcome) and successful achievement of NCEP II goals (total cholesterol <160 mg/dL) among treated patients (secondary outcome).

MAIN RESULTS: Only 230 (37%) of 622 eligible patients received LLDs. In multivariate logistic regression, factors independently related to LLD use included age greater than 74 years (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.35, 0.88) and severe comorbidity (AOR 0.60; 95% CI 0.38, 0.95), managed care enrollee (AOR 1.56; 95% CI 1.02, 2.39), past smoker (AOR 1.72; 95% CI 0.98, 3.01), prior revascularization (AOR 2.31; 95% CI 1.51, 3.53), and the use of aspirin (AOR 1.59; 95% CI 1.07, 2.38) or ≥4 medications (AOR 2.89; 95% CI 2.19, 3.84). Of the treated patients who had lipid levels measured (n=149), 15% achieved the recommended goal of a total cholesterol below 160 mg/dL. Of the untreated patients (n=392), 89% were discharged from hospital without a LLD prescription.

CONCLUSIONS: Lipid-lowering drugs, although proven effective for the secondary prevention of CAD, were used by only one third of eligible patients. Among patients receiving LLDs, few achieved recommended lipid goals. Directed quality improvement interventions, such as starting LLDs during hospitalization, may have the potential to substantially reduce CAD morbidity and mortality in this vulnerable population.

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Authors and Affiliations

  1. Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 126 Brookline Ave., Suite 200, 02215, Boston, MA

    Sumit R. Majumdar MD, MPH &  Stephen B. Soumerai ScD

  2. The Meyers Primary Care Institute, University of Massachusetts Medical School, and the Fallon Healthcare System, Worcester, Mass

    Jerry H. Gurwitz MD

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  1. Sumit R. Majumdar MD, MPH
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  2. Jerry H. Gurwitz MD
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  3. Stephen B. Soumerai ScD
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Additional information

This work was supported by grants from the National Institute on Aging (AG14474), the Agency for Health Care Policy and Research (HSO7357), the Healthcare Education and Research Foundation, and the Harvard Pilgrim Health Care Foundation. Dr. Majumdar was the recipient of a National Research Service Award (PE 11001-10).

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Majumdar, S.R., Gurwitz, J.H. & Soumerai, S.B. Undertreatment of hyperlipidemia in the secondary prevention of coronary artery disease. J GEN INTERN MED 14, 711–717 (1999). https://doi.org/10.1046/j.1525-1497.1999.02229.x

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