PAD has been linked to all-cause mortality as well as major adverse cardiovascular events (MACE) and major adverse limb events (MALE), Dr. Connie N. Hess of the University of Colorado School of Medicine, in Aurora, and colleagues note in the Journal of the American College of Cardiology.
Reducing LDL-C with lipid-lowering therapies (LLTs) decreases the risk of these ischemic events, which is why they are guidelines recommend their use in patients with PAD. An LDL-C threshold for initiation or intensification of treatment in the United States is 70 mg/dL or higher.
To determine LLT use, the researchers studied data on PAD patients with commercial health insurance or Medicare supplemental health insurance.
Of the more than 250,000 patients identified, at baseline 20.5% received high-intensity LLT (high-intensity statin, statin plus ezetimibe, or PCSK9 inhibitor); 39.5% received low-intensity LLT (any other lipid regimen); and 40.0% were on no LLT.
Over a median follow-up of 15 months, high-intensity LLT increased by 1.5%. Hospitalizations for MACE or MALE were common.
In the 18,747 patients with baseline and follow-up LDL-C data, 25.1% were on high-intensity LLT, median LDL-C was 91 mg/dL, and 24.5% had LDL-C less than 70 mg/dL. Within the high-intensity LLT subgroup, median LDL-C was 81 mg/dL and 64% had LDL-C at or greater than 70 mg/dL.
During follow-up, high-intensity LLT use increased by 3.7%, median LDL-C decreased by 4.0 mg/dL, and a further 4.1% of patients had an LDL-C below 70 mg/dL. High-intensity LTT use was greater after follow-up MACE (55.0%) or MALE (41.0%) compared to no ischemic event (26.1%).
LDL-C was less than 70 mg/dL in 41.5% after MACE and 36.1% after MALE. The corresponding proportion was 27.1% in those without an event.
"Despite the increased ischemic risk in PAD and proven benefit for risk reduction with lowering of LDL-C, LLT remains underused in PAD patients," the researchers write. "Although LLT is intensified after ischemic events, PAD is treated less aggressively than coronary or cerebrovascular disease. Strategies to better implement proven therapies to reduce risk in PAD are needed."
Dr. Eric A. Secemsky of Harvard Medical School, Boston, co-author an accompanying editorial, agrees, telling Reuters Health by email that the researchers "have reminded us of our healthcare system's ongoing failure to optimize lipid management for patients with PAD. This is another call to action to invest further in the healthcare of patients with PAD. A key unanswered question in our field, however, is how to best approach closing the gap between published guidelines and patient care."
Dr. Hess did not respond to requests for comments.
SOURCE: https://bit.ly/3zw9jxw and https://bit.ly/3gvYjc9 Journal of the American College of Cardiology, online June 14, 2021.
By David Douglas
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