Statin-Related Factors Predict High LDL-C Post–Coronary Hospitalization

Marlene Busko

February 28, 2017

DRAMMEN, NORWAY — A new study suggests  statin-related side effects, low dose, and poor adherence—rather than psychosocial or socioeconomic factors—are barriers to LDL-cholesterol (LDL-C) control in patients prescribed a statin after a coronary hospitalization[1].

"To our knowledge, this is the first study to explore the effect of psychosocial factors on LDL-C control," Dr John Munkhaugen (Drammen Hospital, Norway) and colleagues write. "We found no association between anxiety, depression, type D personality, insomnia, and illness perception, respectively, and LDL-C control," nor in men vs women or older vs younger patients.

Moreover, although low socioeconomic status is a well-recognized barrier for optimal secondary prevention and predicts a poor cardiac prognosis, "no effects of education, employment, or marital status on LDL-C control" were found.

"The key targets for interventions to improve LDL-C are thus adherence to and prescription of sufficiently potent statins [as well as] side effects," the researchers conclude, and these are the modifiable factors that clinicians should focus on, Munkhaugen told heartwire from Medscape in an email.

For example, during follow-up visits, "treating physicians need to ask their patients questions that specifically address drug adherence," he advised. They should also try to determine whether side effects are truly related to the statin therapy, and if so, consider prescribing a different statin.

There is also a need for more research to better understand the mechanisms behind statin-related side effects, according to Munkhaugen.

These findings, from more than 1000 patients in the NORWEGIAN CORONARY PREVENTION (NOR-COR) study, were published online February 14, 2017 in the European Journal of Preventive Cardiology.

Investigating Why Few Patients Reach Target LDL-C Levels

US guidelines recommend coronary patients receive high-intensity statins to achieve at least a 50% reduction in LDL-C, Munkhaugen and colleagues explain, whereas European guidelines recommend that such patients should attain an LDL-C <1.8 mmol/L (or reduce LDL-C by at least 50% if their baseline LDL-C is 1.8 to 3.5 mmol/L [70 to 135 mg/dL]).

However, only one in five CHD patients on lipid-lowering medication in the recent EUROASPIRE IV study[2] achieved the LDL-C target of <1.8 mmol/L, the researchers note. Thus, they aimed to identify medical and psychosocial factors associated with unfavorable LDL-C control.

To achieve this, they identified 1095 patients (mean age 62 years; 21% female) who had been hospitalized for MI (79%) and/or coronary revascularization at two hospitals in Norway and had LDL-C determined at a follow-up visit 2 to 36 months later (median 16 months).

Statin therapy was deemed to be high intensity if it consisted of >40 mg/day atorvastatin or >20 mg/day rosuvastatin; other statins and doses were defined as moderate- or low-intensity.

At follow-up, patients most frequently were receiving atorvastatin (69.5%), followed by simvastatin (17.6%), pravastatin (3.6%), rosuvastatin (2.2%), and fluvastatin (0.6%), and the selective cholesterol absorption inhibitor ezetimibe (Zetia, Merck) was prescribed to 5.1% of patients.

About one out of four patients reported that they had side effects with cardiovascular drugs and 6.4% reported statin-specific (muscle, liver, or other) side effects.

Only 43% of patients attained the primary outcome of LDL-C <1.8 mmol/L at follow-up.

Finding that almost six out of 10 patients with a coronary event did not reach the recommended target for LDL-C "emphasizes the potential of and need for improved intervention programs," Munkhaugen and colleagues write.

Moreover, "failure to reach target was associated with low statin doses, nonadherence, and side effects of statins, all potentially modifiable factors related to drug management."

Patients with statin-related side effects were more than three times more likely to have LDL-C above the target level than patients without side effects.

Similarly, nonadherent patients were three times more likely to have elevated cholesterol levels than patients who did not miss a statin dose.

Patients who were prescribed a low- or moderate-intensity statin were 62% more likely to have elevated cholesterol levels than patients who received a high-intensity statin.

Risk of Having Above-Target LDL-C, Related to Statin Therapy Factors

Risk factor Odds ratio (95% CI)* P
Moderate- or low-intensity statin therapy 1.62 (1.19–2.21) 0.002
Statin-specific side effects 3.23 (1.61–6.50) 0.001
Taking statins <7/7 days the past week 3.07 (1.35–7.00) 0.008
*Adjusted for multiple covariates

Further studies are needed come up with better ways for GPs and specialists to "ensure adherence and prescription of sufficiently potent statins, while addressing side effects appropriately," according to the researchers.

The study was funded by grants from the department of medicine, Drammen Hospital, and the department for cardiology, Vestfold Hospital. The authors report no relevant financial relationships.

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