Medscape/ACC Survey Looks at Current Cholesterol Management

Megan Brooks

November 10, 2018

More than two thirds (69%) of cardiologists follow the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults, yet more than half (56%) think the advice is outdated, according to a survey conducted by Medscape in collaboration with the ACC.

The ACC and AHA will release a revised clinical practice guideline for managing dyslipidemia November 10 during the AHA's 2018 Scientific Sessions in Chicago, Illinois.

"I am thrilled that the 2018 ACC/AHA cholesterol guidelines will bring us up to date and provide clinicians from all disciplines with direction when treating dyslipidemia," commented Seth J. Baum, MD, clinical affiliate professor, Florida Atlantic University, and president, Preventive Cardiology Inc, Boca Raton, Florida.

Ahead of release of the new guideline, Medscape and ACC asked 620 physicians and other healthcare professionals for their views on managing dyslipidemia. Responses came from 204 cardiologists; 101 endocrinologists; 166 primary care physicians (PCPs); and 150 nurse practitioners (NPs), physician assistants (PAs), or registered nurses (RNs).

The survey found that the frequency of guideline use varies by specialty.

While most cardiologists (69%) use the 2013 ACC/AHA guideline for managing dyslipidemia, only 34% of endocrinologists, 48% of PCPs, and 45% of NPs/PAs/RNs favor it.

Not surprisingly, endocrinologists are most likely to use the 2017 American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) guideline for the management of dyslipidemia and prevention of cardiovascular disease, compared with just 31% of cardiologists, 42% of PCPs, and 54% of NPs/PAs/RNs.

PCPs and NPs/PAs/RNs are about as likely to cite the 2017 US Preventive Services Task Force recommendations on statin use for primary prevention as the 2013 ACC/AHA guideline and 2017 AACE/ACE guideline.

Survey results confirm my suspicion that unharmonized guidelines result in discordant clinical practices. Dr Seth J. Baum


"Survey results confirm my suspicion," said Baum, "that unharmonized guidelines result in discordant clinical practices. The 2013 ACC/AHA cholesterol guidelines, though favored by cardiologists, are often not followed because many clinicians prefer to treat to specific LDL-C [low-density lipoprotein cholesterol] goals. I am hopeful that the 2018 ACC/AHA guidelines will be unifying through integration of both LDL-C goals and risk-based treatment," said Baum.

Other key findings of the Medscape/ACC lipid survey include the following:

  • More than one third of cardiologists (35%) think the atherosclerotic cardiovascular disease (ASCVD) risk calculator underestimates risk, the highest of all specialties.

  • Cardiologists and endocrinologists who do not follow the 2013 ACC/AHA cholesterol guideline cite a preference for focusing on target LDL-C as the chief reason. PCPs and NPs/PAs/RNs do not express as strong a focus on LDL-C targets, with the exception of internal medicine physicians. A minority of healthcare providers lack familiarity with the 2013 ACC/AHA guidelines, although it is 20% of PCPs.

  • Overall, more respondents agree (69%) that a target LDL-C less than 100 mg/dL is reasonable for primary prevention than a target of less than 70 mg/dL (39%). Close to three quarters (73%) of cardiologists feel strongly that LDL-C less than 100 mg/dL is a reasonable target for primary prevention.

  • For secondary prevention, a target LDL-C less than 70 mg/dL is considered reasonable by 75% of respondents and by 92% of cardiologists.  Most cardiologists (91%) and endocrinologists (81%) strongly agree that "the lower the LDL-C, the better," compared with 58% of PCPs and 61% of NPs/PAs/RNs.

  • Overall, 69% of respondents agree that statin therapy is sufficient for most patients with elevated LDL-C; 77% of cardiologists are on board with this view, as are 69% of endocrinologists, 74% of PCPs, and 53% of NPs/PAs/RNs.

Statin vs Nonstatin Therapy

The survey also asked about factors and tests providers turn to when considering statin therapy for a patient at risk for cardiovascular disease who does not immediately qualify for statin therapy per ACC/AHA guideline (ie, LDL-C < 190 mg/dL with or without diabetes or patients without ASCVD and an LDL ≥ 190 mg/dL).

The results show that family history of premature ASCVD is the most common factor weighed in considering statin therapy, cited by more than 80% of all respondents and the individual provider groups. Non-high-density lipoprotein cholesterol is considered by 45% of respondents, with endocrinologists the most likely to used this factor (59%).

Compared with other providers, cardiologists, on average, consider more factors when deciding on statin vs nonstatin therapy, including the coronary artery calcium score (76%), high-sensitivity C-reactive protein (hsCRP; 47%), lipoprotein(a) (30%), and ankle-brachial index (25%). 

"The use of coronary artery calcium scores was a major factor in determining statin use in 76% of cardiologists, far more than other forms of risk stratification, such as hsCRP or ankle-brachial index," said Matthew J. Budoff, MD, professor of medicine, University of California, Los Angeles, and program director, Division of Cardiology, Harbor UCLA Medical Center, Torrance, California.

Overall, about one quarter of providers (23%) consider genetic risk scores, compared with just 16% of cardiologists and endocrinologists. Nearly 40% of NPs/PAs/RNs consider genetic risk scores, but only 23% of PCPs do.

Overall, most survey respondents (81%) with patients with CVD or CV risk factors who are receiving lipid therapy use statins; cardiologists skewed highest on this metric (87%).

Ezetimibe (Zetia) is the most common nonstatin therapy used by providers (41%). The percentage is higher for cardiologists (50%) and endocrinologists (49%) and lower for PCPs (40%) and NPs/PAs/RNs (27%).

Bile acid sequestrants (cholestyramine [Questran, Bristol-Myers Squibb], colesevelam [Welchol, Daiichi Sankyo], colestipol [Colestid, Pfizer]) are the second most commonly used nonstatin therapy (17%), with about 20% of endocrinologists, PCPs, and NPs/PAs/RNs using them compared with just 12% of cardiologists.

PCPs and NPs/PAs/RNs (21%) are more likely to prescribe niacin for their patients than are cardiologists and endocrinologists (9% each).

For the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab (Praluent, Sanofi/Regeneron) or evolocumab (Repatha, Amgen), 25% of cardiologists' patients are on one, compared with around 12% of endocrinologists' patients, the survey found.

Respondents were also asked to assess their likelihood of prescribing a PCSK9 inhibitor for a variety of patient populations.  

About 55% to 65% of survey participants said they are likely to prescribe PCSK9 inhibitors to patients with statin tolerance issues or familial hypercholesterolemia or those needing more than 25% additional LDL-C lowering. More than one quarter are likely to use them for primary prevention and more than half for secondary prevention.

The survey was conducted before Amgen announced it was lowering the cost of its PCSK9 inhibitor (evolocumab), by roughly 60%, as reported by Medscape Medical News. The new list price for the drug is $5850 a year, down from its original list price of more than $14,000 a year.  

Detailed coverage and analysis of the new lipid guidelines will be released at the 2018 AHA Scientific Sessions.


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