Treatment Gap: In Patients with ASCVD, Low Use of Statins, High-intensity Statins Persists

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In a study of more than 600 000 patients with atherosclerotic cardiovascular disease (ASCVD), nearly half were not being treated with a statin and less than one-quarter had a prescription fill for a high-intensity statin, according to a May 2022 study published in the Journal of the American College of Cardiology.

The authors also report that among the patients much less likely to receive guideline-recommended statins were younger individuals (aged <45 years), women, and those with noncoronary atherosclerosis (peripheral arterial and cerebrovascular disease). Study authors, led by Christopher B Granger, MD, professor of medicine, Duke University School of Medicine, note it is one of the largest recent analyses of US statin prescribing habits.

To augment current understanding of patterns and predictors of high-intensity statin use, Granger and colleagues conducted a retrospective cohort study of pharmacy and medical claims data for patients enrolled in a large commercial health plan (HealthCore Integrated Research Environment.) Eligible patients had a diagnosis of ASCVD between January 31, 2018, and an index date of January 31, 2019. The investigators evaluated statin use on the index date, 12-month adherence to statin therapy, and treatment discontinuation. The primary endpoint was a prescription fill for a high-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) that began on or included ±30 days of the index date.

The final cohort numbered 601 934; mean age was 67.5 years and 41.7% were women. The majority had coronary artery disease (69.2%), 19.5% had cerebrovascular disease, 35.2% had peripheral artery disease (PAD) and 19.8% had polyvascular disease.

Findings

The researchers found just 1 in 5 (22.5%) of study patients met the primary endpoint of a prescription fill for a high intensity statin around the study index date. Of significant concern, they note, 49.9% were not on any statin therapy while only slightly more than one-quarter (27.6%) were on low- or moderate-intensity statin.

Among patients not receiving statin therapy, 70.9% had a cardiologist visit in the previous 12 months. Further, more than three-quarters (81.3%) of those identified as having lower levels of treatment adherence had seen their cardiologist or primary care physician in the previous 12 months.

After multivariable analysis, Granger and colleagues found that younger age (<45 years), being a woman, and a higher Charlson comorbidity score were associated with a lower likelihood of being prescribed any statin. Among those who were taking a statin, characteristics of patients less likely to be prescribed a high-intensity statin were being a woman, older age, and having a diagnosis of PAD. The investigators did find, however, that treatment adherence was high (83.7%) among those taking a high-intensity statin.

The investigators did report that when they analyzed pharmacy claims over the 12 months following the index date, 82.8% of patients prescribed a high-intensity statin regimen achieved coverage for at least 75% of days. Approximately 10% had coverage ranging between 50% and 74%.

As one of the largest studies of US statin use overall, the authors emphasize is it also one of the largest to evaluate statin use in “very premature ASCVD,” with >20 000 of the total 601 934 patients in the age group younger than 45 years. “Our concerning finding that only 22.4% of ‘younger’ patients were using a statin likely reflects a knowledge gap around premature ASCVD contributing to underuse at both the patient and clinician level.”

In addition to the gaps in appropriate statin use in younger persons the authors point to the lower likelihood of receiving any statin for women and for sicker patients as reflected by Charlson comorbidity score and to their concern for patients with PAD, a group less likely to be prescribed high-intensity ASCVD treatment.

Salim S. Virani, MD, PhD, Baylor College of Medicine and Michael DeBakey VA Medical Center, Houston, and colleagues write in a related editorial, “In a remarkable show of unanimity, all guidelines, including those from the [ACC] and the American Heart Association, recommend high-intensity statin therapy as a Class I recommendation in patients with ASCVD. It is puzzling, then, that the use of statins and high-intensity statins remains low in these patients.”

Barriers are likely complex, the editorialists suggest, and will be found at the individual physician level, among patients “and their social network,” and within the health care system at large.

The study by Granger et al, they write "serves as yet another call to action for us to intensify our efforts to improve provision of a lifesaving therapy to our high-risk patients."

Reference: Nelson AG, Haynes K, Shambhu S, et al. High-intensity statin use among patients with atherosclerosis in the US. J Am Coll Cardiol. 2022;79:1802-1813.

Editorial comment: Guideline-concordant statin therapy use in secondary prevention: Should the medical community wait for divine intervention?