Secondary-Prevention Statins Underprescribed at ACS Discharge: CRUSADE Registry

Marlene Busko

April 03, 2015

Durham, NC — Among more than 20 000 patients who were hospitalized with non–ST-segment-elevation-acute coronary syndrome (ACS) a decade ago, one in five was discharged without a prescription for a statin[1]. Receipt of statins fell stepwise from 88.1% in patients with the highest LDL-cholesterol levels (>130 mg/dL) to 63.8% in patients with the lowest LDL-cholesterol levels (<70 mg/dL), according to a CRUSADE registry analysis published March 23, 2015 in the American Journal of Cardiology.

"I was surprised to see that only four out of every five eligible patients received statins at discharge, and the gap between the proportions who received statins in the very low LDL-cholesterol category vs the highest LDL-cholesterol category was quite high," lead author Dr Emily C O'Brien (Duke Clinical Research Institute, Durham, NC) told heartwire from Medscape.

Asked to comment, Dr Robert P Giugliano (Brigham and Women's Hospital, Boston, MA) said the study shows how statins are often underused. "This snapshot from a decade ago is yet another piece of evidence that we are underutilizing statins in treating hypercholesterolemia in many patients, [where] clearly [these drugs] would provide benefit."

For example, in the 32% of patients with an LDL-cholesterol level above 130 mg/dL, which is "high by any standard," Giugliano noted, one in seven had diabetes and 41.7% had a family history of CAD. "Why aren't we treating these patients [with statins]?"

Is Statin Use Appropriate, Based on LDL-C and Other Risk?

Recent guidelines encourage the use of high-intensity statins in all patients with CAD, but few studies examined the association between statin treatment at hospital discharge and initial LDL cholesterol in patients hospitalized for non–ST-segment-elevation MI or angina pectoris who were not receiving statins, O'Brien and colleagues write.

The authors looked at 22 938 patients enrolled in CRUSADE who were hospitalized in the US with non–ST-segment-elevation ACS from 2003 to 2006; who were not already receiving on statins; who were without prior MI, peripheral artery disease, PCI, or CABG; or who had missing data. Their median age was 60 years; 79.3% were white and 38.9% were women.

Patients were classified into one of four LDL-cholesterol categories (according to the earliest measurement during admission):

  • Very low (<70mg/dL): 10.4% of patients.

  • Low (70–99 mg/dL): 24.9% of patients,.

  • High (100–129 mg/dL): 32.1% of patients.

  • Very high (>130 mg/dL): 32.6% of patients.

Those in the lowest LDL-cholesterol group were older (median 67 years) and had significantly higher rates of hypertension, diabetes, congestive heart failure, and renal insufficiency. They were less likely to be white or current or former smokers or have a history of CAD compared with other patients. They also had lower rates of diagnostic catheterization and revascularization and were slightly less likely to receive aspirin, clopidogrel, or beta-blockers on discharge.

The rates of statin treatment in-hospital ranged from 45.8% for patients in the lowest LDL-cholesterol group to 58.5% for patients in the highest LDL-cholesterol group.

Compared with patients in the lowest LDL-cholesterol group, those in the two highest LDL-cholesterol categories were significantly more likely to be discharged with a prescription for a statin after adjustment for multiple patient and hospital-stay characteristics.

Statins Often Not Prescribed for Clearly Eligible Patients

In patients with no history of CAD who were not taking statins when they were admitted, a third had LDL-cholesterol levels above 130 mg/dL and would need a high-intensity statin to meet a target of 70 mg/dL, O'Brien and colleagues write. In contrast, nearly a third of the patients had LDL-cholesterol levels below 100 mg/dL, likely classifying them as lower risk, according to the lipid guidelines in place at the time.

In the middle, "under the new [2013] guidelines, patients with LDL-[cholesterol] of at least 70 mg/dL but less than 100 mg/dL at the time of [non–ST-segment-elevation MI/unstable angina] (25% of our study population) represent an uncertain group of patients who may now qualify for statin treatment based on the presence of other risk factors," as they present at an older age with more comorbidities, the authors continue.

"What we are seeing is there are higher rates of undertreatment [with statins] for eligible patients with low LDL-cholesterol levels, and any strategies that can be effectively implemented to improve these disparities in receipt are certainly worth considering," according to O'Brien. "I think if we had data from the past few years, hopefully we would see a narrowing of that gap," she said.

Although the data are about a decade old, this large registry analysis shows that "many patients who present with a non–ST-segment-elevation acute coronary syndrome are not on statins, and we're grossly undertreating patients and ought to be thinking more seriously about which patients should be put on statins for primary [and] secondary prevention for [ACS]," Giugliano observed.

"Statin treatment during hospitalization is fine, but the horse is already out of the barn" by then, he added. A large proportion of patients who had high LDL-cholesterol in this cohort had known risk factors for heart disease and certainly should have been treated.

Although not everyone can tolerate statins, by hospital discharge, statin use should be as close as possible to 100% in the patients with the highest LDL-cholesterol levels, according to Giugliano.

CRUSADE was funded by Millennium Pharmaceuticals, Schering-Plough, and the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership. The current study was supported by the Duke Clinical Research Institute. O'Brien has disclosed no relevant financial relationships. Disclosures for the coauthors are listed in the article. Giugliano receives research support and honoraria for lectures from Amgen, Daiichi-Sankyo, and Merck and is a consultant for Amgen, Daiichi-Sankyo, Lexicon, and Merck.

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