Eight in 10 Primary-Prevention Patients Skip Statins, Dutch Study Finds

Marlene Busko

May 26, 2015

AMSTERDAM, THE NETHERLANDS — A "shocking" 80% of individuals in a large Dutch cohort who were eligible for primary prevention with statin therapy reported not taking the drug, a new analysis has shown[1]. Moreover, approximately one in three patients with existing cardiovascular disease also reported forgoing therapy with the LDL-cholesterol-lowering drugs.

Dr Jan-Willem Balder (University of Groningen, the Netherlands) presented the results of more than 70,000 participants in the LifeLines cohort study and acknowledged that the study design has drawbacks. For example, the data are based on patient recall, which can be faulty, and the researchers could not distinguish whether statins had been appropriately prescribed or patients were being truthful, said Balder.

Dr Wiek van Gilst (University of Groningen), who cochaired the session at the International Symposium on Atherosclerosis 2015, where the results were presented, told heartwire from Medscape that the study has other limitations. The researchers were unable to determine in the secondary-prevention analysis whether the patient's MI was recent or occurred long ago. Also, the group had no way of determining whether patients stopped their statin because of a lack of adherence or because their physician failed to prescribe, said van Gilst.

Nevertheless, the study did highlight a large gap between recommended and actual preventive therapy with statins, even in people at the highest risk of a cardiovascular event, Balder told heartwire . "We were quite surprised, especially with [individuals with] severe dyslipidemia—an LDL-cholesterol above 6.5 mmol/L (>250 mg/dL)—where only one in 153 [individuals] reported being on statin therapy," he said.

Recommended vs Actual Statin Use

Despite strong evidence that statin therapy can reduce cardiovascular events, studies have suggested that many eligible patients may not be taking the preventive therapy, Balder said. To estimate what percentage of the Dutch population were adhering to guideline-recommended therapy with statins, they assessed the use of statins among 70,292 participants in LifeLines from 2006 to 2012.

The participants replied to a questionnaire and had lab tests and a medical examination at baseline. The mean age of participants was 42 years, and the average LDL-cholesterol level was 3.2 mmol/L (124 mg/dL). A total of 3172 participants (4.5%) reported using a statin, and 1338 participants (1.9%) reported having a cardiovascular event. The researchers estimated the patients' 10-year risk of cardiovascular disease based on a Dutch model.

Using the Dutch clinical guidelines, patients are eligible for primary-prevention with a statin if their LDL-cholesterol is greater than 2.5 mmol/L (97 mg/dL) and they have additional risk factors with a medium or high 10-year risk of cardiovascular disease (or a total cholesterol-to-HDL-cholesterol ratio greater than 8). Statins are recommended for secondary prevention in people who have had coronary surgery, MI, stroke, or peripheral artery disease and have an LDL-cholesterol greater than 2.5 mmol/L plus additional risk factors.

Of the 3268 participants who were deemed eligible for primary prevention with statin therapy, only 753 patients (23%) reported taking a statin. Patients with a total cholesterol-to-HDL cholesterol ratio greater than 8 most frequently reported not taking a statin, whereas patients with type 2 diabetes most frequently reported taking the medication.

Of the 1302 participants who were eligible for secondary prevention with statin therapy, 899 participants (69%) reported taking a statin. Just over half of the participants (52%) who were eligible but were not taking a statin had had a stroke.

This cohort is roughly 240 times smaller than the Dutch population, Balder explained. Based on their findings, the researchers estimate that in 5 years, 12,189 CV events could have been prevented if guideline-recommended statin therapy had been followed.

"There are a lot of study limitations, but this gives you a rough idea," Balder said.

The study identifies room for improvement, according to the researchers. Despite clear guidelines and multiple countrywide efforts to improve the care of patients with cardiovascular disease, adherence to the guidelines remains a major challenge in the Netherlands, they state. The results suggest a need for greater efforts to heighten public awareness and to improve patient management to prevent unnecessary cardiovascular-disease–related morbidity and mortality, according to the group.

Like Balder, Van Gilst was surprised that the rate of statin use was "shockingly low." "I think this is indicating that the biggest challenge for us is not only to develop new drugs but also to be absolutely sure that patients are taking the drugs," he said.

Balder had no relevant financial relationships.

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