Many Not Receiving Statins After Lower-Extremity Revascularization

By Linda Carroll

December 08, 2021

NEW YORK (Reuters Health) - More than two-thirds of patients who were not already taking a statin prior to lower-extremity revascularization were not given the cholesterol-lowering medications after the procedure, a new U.S. study shows.

An analysis of data from more than 125,000 patients who received lower-extremity (LE) revascularization between 2014 and 2019 revealed that while rates of statin prescription at discharge improved overall, just 30% of those who did not have a prescription prior to the procedure were discharged with a new prescription, researchers report in JAMA Network Open.

"The take-home message is a simple one," said Dr. Parveen Garg of the University of Southern California, in Los Angeles, who worked on the study.

"It is well-established that the use of statins for symptomatic peripheral-artery disease reduces cardiovascular morbidity and mortality," he told Reuters Health by email. "Despite improvements in statin use for patients following LE revascularization, our study results highlight that substantial under-prescription remains, particularly in those not already taking a statin preprocedurally."

To take a closer look at statin prescriptions after LE revascularization, Dr. Garg and his colleagues examined cross-sectional data from the Society of Vascular Surgery Vascular Quality Initiative, a large, multicenter national registry.

Included in the analysis was demographic information - such as age, gender, race and ethnicity, BMI and insurance status - baseline use of certain medications - antiplatelet therapies, angiotensin converting enzyme inhibitors (ACEIs) , angiotensin receptor blockers (ARBs) and statins - along with clinical variables - such as smoking status, hypertension, diabetes, heart disease, heart failure, chronic obstructive pulmonary disease, kidney impairment, and prior peripheral revascularization.

The researchers focused on more than 172,000 procedures in 125,791 patients with a mean age of 68; 63% were men, 79% were white, 16% were Black and 6% were listed as other race.

In their final regression analysis, Dr. Garg and his colleagues excluded 130,005 procedures because patients were taking pre-procedural statins and another 4,881 because the patients lacked baseline characteristics, which left 37,139 procedures.

Overall, the rates of statin prescriptions improved from 75% in 2014 to 87% in 2019. Still, when the researchers looked at patients not taking a statin prior to revascularization, they found that only 12,790 of 42,020 patients (30%) were newly discharged with a statin medication.

There could be many reasons for this, Dr. Garg said.

"The primary reason may simply be the widespread under-recognition and under-treatment of PAD as compared to coronary-artery disease or stroke," he suggested. "Additionally, proceduralists may defer the responsibility of newly starting a statin to their outpatient providers."

"Patients may have been presumed to not be taking statins due to unwillingness, intolerance, or an inability to afford medications, and operators may have deferred these discussions to their continuity-care professionals," Dr. Garg said.

The rates of new statin prescriptions were substantially lower after endovascular intervention (26%) than after LE bypass (41%). Patients were significantly more likely to receive a new statin prescription after endovascular intervention if they had a BMI of 30 or greater (odds ratio, 1.13), diabetes (OR, 1.22), hypertension (OR, 1.19), coronary heart disease (OR, 1.26) or they currently smoked (OR, 1.32).

Patients were less likely to receive a new prescription if they were female, older, used antiplatelet therapy or had prior peripheral revascularization.

"New-statin-prescription rates were lower in women, which may reflect dismissal of symptoms given their more frequent atypical presentation as well as implicit bias from clinicians. New-statin-prescription rates were also lower in older individuals, which may reflect concerns regarding polypharmacy or a perceived increased risk of side effects," Dr. Garg said.

"There are a couple important steps that we can done beyond increasing provider education," he added. "One priority is to better understand the barriers to physician prescription of statins in this population so they can be overcome. Another one would be to institute clinician- and system-based interventions, such as implementing a 'Get With the Guidelines' check-and-review system that addresses this deficiency, to improve overall compliance."

The new study highlights "the critical gap between the wealth of evidence and guidelines on statins, and their incorporation into day-to-day clinical practice," said Dr. Seth Martin, director of the Advanced Lipid Disorders Program at Johns Hopkins Medicine, in Baltimore, Maryland.

"The study shows that many patients who could benefit from statin therapy are not getting therapy," Dr. Martin told Reuters Health by email. "The big picture here is that underutilization of LDL-cholesterol-lowering therapy is a stubborn and widespread problem. In addition to patients with peripheral-artery disease, it has been well documented in other populations of patients with atherosclerotic cardiovascular disease, such as patients who have suffered heart attacks and strokes."

"We desperately need disruptive innovations in lipid management to implement what we know works," Dr. Martin said. "It could be the difference between spending the holidays home with family or spending it in the hospital. It could be the difference between life and death."

SOURCE: JAMA Network Open, online December 3, 2021.