Utilization and adherence to guideline-recommended lipid-lowering therapy at an academic medical center.

original article Utilization and adherence to guidelinerecommended lipid-lowering therapy at an academic medical center Khalid A. Alburikan, Rayah M. Asiri, Abduallah M. Alhammad, Amer A. Abuelizz, Ghada A. Bawazeer, Mohammed H. Aljawadi From the College of Pharmacy, King Saud University, Riyadh, Saudi Arabia Correspondence: Dr. Khalid A. Alburikan · College of Pharmacy, King Saud University, Riyadh 11349, Saudi Arabia · T. +966 11 4677490/ F: +966 11 4678847 · · ORCID: http://orcid.org/0000-0002-4380-3327 Ann Saudi Med 2017; 37(4): 276-281 DOI: 10.5144/0256-4947.2017.276 BACKGROUND: Clinical guidelines for managing blood cholesterol were updated in November 2013. OBJECTIVE: To evaluate the adherence to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations for statin therapy in the treatment of elevated blood cholesterol in high-risk patients. DESIGN: A single-center, retrospective, observational study. SETTING: A tertiary care academic medical center in Riyadh, Saudi Arabia. PATIENTS: Consecutive adult patients discharged with a prescription for any of the statin medications group between 1 June 2015 and 31 December 2015. MAIN OUTCOME MEASURE(S): Adherence to the 2013 ACC/AHA guidelines for management of cholesterol by statin therapy in high-risk patients. RESULTS: Of 1094 patients, 753 (68.8%) met the inclusion criteria of the study. Of these 753 patients, 53.5% had atherosclerotic cardiovascular diseases; 29.2% had diabetes; 0.9% had an LDL-C level >190 mg/dL; 10.8% had an estimated 10-year risk >7.5%; and 4.9% had no risk. Two hundred and eight (27.6%) patients received statin therapy at an inappropriate intensity according to their risk group based on the guideline; 126 (16.7%) received less than the ideal intensity. CONCLUSION: Approximately one-third of patients received statin therapy at an inappropriate intensity according to the guideline recommendation. Wide application of the 2013 ACC/AHA cholesterol guidelines in our practice would optimize the utilization of statin therapy at the ideal intensity in high-risk patients. LIMITATION: Drug-drug interactions and intolerance to statin therapy were not considered when we evaluated adherence among high-risk patients. A therosclerotic cardiovascular diseases (ASCVDs) result from plaques formed in the arterial walls. ASCVDs include coronary artery disease (CAD), peripheral artery disease (PAD), cerebrovascular disease, and aortic atherosclerotic disease.1,2 The risk factors associated with ASCVD can be divided into: modifiable (cigarette smoking, hypertension, diabetes, and hyperlipidemia) and non-modifiable (male sex and advanced age).1,2 ASCVDs are the major cause of mortality worldwide. In Saudi Arabia, the prevalence of CAD and PAD for individuals aged >45 years is 5.5% and 11.7%, 276 respectively.3-12 To decrease the risk of ASCVD, the American Heart Association (AHA) and the American College of Cardiology (ACC) in collaboration with the National Heart, Lung, and Blood Institute (NHLBI) released a new guideline in November 2013. The aim of the treatment recommended in these guidelines focuses on the intensity of statins instead of the target low-density lipoprotein cholesterol (LDL-C).3 The guideline identified four primary patient groups labelled as “high-risk patients” for ASCVD, and for whom statin therapy is indicated.3 The four patient groups that would benefit from statin therapy include ANN SAUDI MED 2017 JULY-AUGUST WWW.ANNSAUDIMED.NET STATIN THERAPY GUIDELINES the following: 1) patients with clinical ASCVD, 2) patients with LDL-C >190 mg/dL, 3) patients aged 40-75 years with diabetes and LDL-C from 70-189 mg/dL but without clinical ASCVD, and 4) patients aged 40-75 years with a 10-year ASCVD risk of >7.5% but without clinical ASCVD or diabetes.3 High-intensity statin therapy was defined in accordance with the 2013 ACC/AHA guidelines as atorvastatin 40-80 mg and rosuvastatin 20-40 mg. Foody and colleagues studied the cardiovascular outcomes in patients without cardiovascular diseases in which simvastatin or atorvastatin was used initially for primary prevention. In their study, 168 973 patients received atorvastatin (10 or 20 mg) and 50 658 patients received simvastatin (20 or 40 mg); both patient groups were followed up for 1.5 years. They found that atorvastatin significantly reduced the risk of cardiovascular disease compared with simvastatin among patients without cardiovascular diseases.4 Data have shown that statin monotherapy is better in terms of reducing the risk of fatal and non-fatal cardiovascular diseases in patients with type 2 diabetes at high risk for cardiovascular diseases than a combination therapy (statin plus fibrate).5 Another RCT has shown that a high-intensity statin therapy reduces the all-cause mortality after acute coronary syndrome (ACS) compared with low-dose statin therapy.6 All of these findings indicate a beneficial effect of statin therapy for primary or secondary prevention. Although previous randomized control trials have shown the benefit of high-intensity statin therapy, registry data show significant underutilization and nonadherence to these treatment recommendations.7 In the United States (US), the National Health and Nutrition Examination Survey reported that only 50% of 1 029 633 high-risk patients received statin therapy.7 Moreover, Hirsh and colleagues found that although 88% of 6748 patients from 31 U.S. hospitals were prescribed a statin at discharge after ACS, only 30% received a high-intensity statin.8 There are no studies in Saudi Arabia that have examined this issue despite its importance. Thus, we sought to evaluate adherence to the guideline-recommended lipid-lowering strategy and the utilization of statin therapy in high-risk patients in a large academic hospital in Saudi Arabia. Moreover, we explored predictors for the utilization of high-intensity statin therapy in high-risk patients. PATIENTS AND METHODS This study was a single-center, retrospective, observational study carried out at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia. KKUH is ANN SAUDI MED 2017 JULY-AUGUST WWW.ANNSAUDIMED.NET original article a 900-bed tertiary teaching hospital at King Saud University. After ethical approval (KSU, NO. E-151662), patients were identified using data from electronic medical records. The data were extracted from patient charts from all adult patients who were discharged with a prescription of any statin medication. A standard data collection sheet was created to capture detailed baseline demographics, including age, sex, medical history, cigarette smoking, and 10-year ASCVD risk; clinical data, including medications and dose, duration, and intensity of statin therapy; laboratory data during hospitalization; medications; and procedural data. We matched the clinical data to the guideline-recommended statin therapy to determine adherence to the guidelines. Between 1 June and 31 De (...truncated)