Statin Use in the U.S. for Secondary Prevention of Cardiovascular Disease Remains Suboptimal

Quyen Ngo-Metzger, MD, MPH; Samuel Zuvekas, PhD; Paul Shafer, PhD; Howard Tracer, MD; Amanda E. Borsky, DrPH, MPP; Arlene S. Bierman, MD, MS

Disclosures

J Am Board Fam Med. 2019;32(6):807-817. 

In This Article

Abstract and Introduction

Abstract

Background: Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of mortality in the United States. The purpose of this study is to examine the rates of statin use for secondary prevention of ASCVD events in the United States over the last decade and determine whether disparities in the treatment of ASCVD still persist among women and racial/ethnic minorities.

Methods: We conducted a trend analysis using data from 2008 through 2016 to describe age-adjusted trends in the use of statins for secondary prevention using the Medical Expenditure Panel Survey. We also conducted a multivariable logistic regression analysis to determine whether sociodemographic characteristics are associated with statin use during the 3 years that followed the publication of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline (2014 through 2016).

Results: The prevalence of statin use among those with a history of ASCVD remained unchanged from 2008 through 2016. In 2014 to 2016, more than 40% of those aged 40 years and older with a history of ASCVD did not use statins, corresponding to approximately 9.5 million Americans. Increasing age and having been diagnosed with high cholesterol (odds ratio [OR], 6.22; P < .001) were associated with higher odds of statin use while being female (OR, 0.65; P < .001) or Hispanic (OR, 0.69; P = .011) were associated with lower odds of statin use.

Conclusions: Our study found there was no increase in the national rates of statin use following the ACC/AHA 2013 secondary prevention guideline and the availability of generic statins. Significant gender and ethnic disparities in ASCVD treatment remained in the United States.

Introduction

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of mortality in the United States despite a strong emphasis on prevention, accounting for more than 800,000 deaths in 2017.[1] The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommends statin use for secondary prevention for adults ≤75 years of age with a prior history of ASCVD, specifically recommending that "high-intensity statin therapy should be initiated for those with clinical ASCVD who are not receiving statin therapy" or intensity raised for those already on a lower dose unless contraindicated (eg, history of statin intolerance).[2] The ACC/AHA guideline also recommends moderate-intensity statin use be considered for secondary prevention in those >75 years of age with a history of ASCVD. These recommendations were based on numerous studies showing that statins are effective in reducing low-density lipoprotein cholesterol levels, and the risk of death and recurrent coronary and cardiovascular events in those with a history of ASCVD, even in older adults.[3–7]

However, despite this proven effectiveness and the resulting ACC/AHA guideline, several studies have shown persistent underuse of statins in this high-risk population.[8–14] Of these, we are aware of only a few studies that extend beyond the year that the guideline was published and even then only include narrowly defined populations (eg, only privately insured and/or Medicare patients, those covered by a single insurer, those within 30 days post-myocardial infarction (MI)).[10,11,13,14]

We examined nationally representative data for the years 2008 through 2016 to determine whether there has been an increase in use of statins in persons with a history of ASCVD following the publication of the ACC/AHA guideline in 2013. Prior studies have tended to focus on narrower samples whereas ours contains a nationally representative sample of adults with any history of ASCVD, the wider population targeted by the ACC/AHA guideline. We also assessed whether individual sociodemographic characteristics are associated with statin use for individuals with a history of ASCVD. Given known disparities in ASCVD treatment among women and racial/ethnic minorities,[15–18] we wanted to understand whether these disparities persisted using the most current data available. We also capture those who are on Medicaid (only or dually eligible for Medicare) or uninsured, populations that are often missed in claims-based analyses that typically include only those with Medicare and/or private coverage. This study assesses whether rates of statin use for secondary prevention are improving and examines disparities to identify opportunities for improvement.

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