Elsevier

American Heart Journal

Volume 182, December 2016, Pages 97-102
American Heart Journal

Clinical Investigation
Use of high-intensity statins for patients with atherosclerotic cardiovascular disease in the Veterans Affairs Health System: Practice impact of the new cholesterol guidelines

https://doi.org/10.1016/j.ahj.2016.09.007Get rights and content

Background

The November 2013 American College of Cardiology/American Heart Association cholesterol guidelines recommend the use of high-intensity statins for patients with atherosclerotic cardiovascular disease (ASCVD). We sought to determine how these guidelines are being adopted at the Veterans Affairs (VA) Health System and identify treatment gaps.

Methods

We examined administrative data from the VA 12 months prior to the index dates of April 1, 2013, and after April 1, 2014, to identify patients ≤75 years of age with ≥2 codes for ASCVD. We identified those on high-intensity statin therapy (atorvastatin 40 mg or 80 mg, rosuvastatin 20 mg or 40 mg, and simvastatin 80 mg) during the 6 months after the index date.

Results

The study sample included 331,927 and 326,759 eligible adults with ASCVD before and after the release of the new guidelines, respectively. Overall, high-intensity statin use increased from 28% to 35% after guideline release. High-intensity statin use was lowest in Hispanics and Native Americans, although all groups showed an increase over time. Among those on low- or moderate-intensity statin therapy, 15.6% were intensified to a high-intensity statin after guideline release. Groups less likely to undergo statin intensification were older adults (odds ratio = 0.78 for each 10-year increase, 95% CI 0.76-0.81), women (odds ratio = 0.86, 95% CI 0.75-0.99), and certain minority groups. Academic teaching hospitals and hospitals on the West Coast were more likely to intensify statins after release of the new guidelines.

Conclusions

High-intensity statin use increased in the VA following release of the American College of Cardiology/American Heart Association cholesterol treatment guidelines, although disparities persist for certain patient groups including older adults, women, and certain minority groups.

Section snippets

Background

The 2013 cholesterol treatment guidelines by the American College of Cardiology (ACC) and American Heart Association (AHA) have shifted away from low-density lipoprotein cholesterol (LDL-C) targets and instead recommend high-intensity statin therapy for patients based on risk profiles ≤75 years of age1 because of growing evidence from large clinical trials that higher-intensity statins decrease risk more effectively than lower-intensity statins.2., 3., 4. This paradigm shift provides a

Study population

We created partially overlapping cohorts of patients at quarterly intervals beginning in 2013 (index dates April 1, 2013; July 1, 2013; October 1, 2013; January 1, 2014; and April 1, 2014). Each cohort included all outpatients within the VA Health System ≥21 and ≤75 years of age with at least 1 atherosclerotic cardiovascular disease (ASCVD) code on 2 different dates during the 12 months prior to the index date. ASCVD was defined as coronary artery disease (CAD, International Classification of

Results

Overall statin use (any intensity) remained comparable from 78.4% among 331,927 patients with ASCVD before the release of the cholesterol guidelines to 77.7% among 326,759 patients after the release. Prior to the release of the new guidelines only 28.2% of ASCVD patients were on a high-intensity statin; this increased to 34.9% after the guideline release (P < .0001). Table I compares the characteristics of ASCVD patients on high-intensity statins before and after the release of the new guideline.

Discussion

In this national study of VA patients with established ASCVD, we found that 78% of high-risk patients were on any statin therapy and only 28% were receiving a high-intensity statin just prior to the release of the ACC/AHA cholesterol treatment guidelines. Despite this, evidence continues to show that statins are underused even in the highest-risk patient groups.7., 8., 9., 10., 11., 12. Although well below recommendations, this rate of statin use is higher than data from community settings.14

Conclusions

Although high-intensity statin use has increased significantly within the VA system for all ASCVD and racial/ethnic groups following release of the ACC/AHA cholesterol treatment guideline, the frequency of use remains disappointingly low. Furthermore, disparities persist, with lower use of high-intensity statins among older adults, women, certain racial and ethnic minorities, PAD and cerebrovascular disease patients, and patients not cared for at academic facilities. Our findings highlight the

Disclosures

The authors have no relevant disclosures or relationships with industry to report.

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