Dyslipidaemia management in the cardiac rehabilitation clinic of a tertiary referral centre; analysis of the impact of new ESC guidance on LDL-C target achievement
Authors: Mccaughey C , Ranganathan D , Murphy G , Kerins M , Murphy R 
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac rehabilitation (CR) programs provide an opportunity to measure low density lipoprotein cholesterol (LDL-C) levels and optimise lipid lowering therapy (LLT) accordingly. New ESC guidelines released in August 2019 recommend lower absolute LDL-C target levels and an &gt;50% reduction from baseline in those at the highest risk.

Purpose

This study investigated the proportion of those patients who finished CR in 2019 that reached both their absolute and relative reduction in LDL-C levels, before and after the introduction of these new guidelines. We also analysed the choice and appropriateness of LLT. 

Methods

A retrospective chart review of 163 patients who completed CR in 2019. A database was created containing baseline patient characteristics and LDL-C levels both prior and post CR; as well as the patient’s contemporary LLT. Those patients who did not have a previous diagnosis of atherosclerotic cardiovascular disease (ASCVD) were risk stratified as per ESC guidance. 

Baseline LDL-C levels were recorded, where possible, and otherwise calculated using pre-CR LDL profile with an adjustment made based on the projected effects of their LLT.

Results

Mean (SD) patient age was 62 (10) years, 123/163 (75%) were male and 142 (87%) patients had established ASCVD. 90/142 (63%) of very high-risk patients were treated with a high intensity LLT and 5/163 overall (3%) were prescribed ezetimibe.

Overall, 96/163 (59%) patients in 2019 met their absolute LDL-C targets; 62% of applicable patients achieved an &gt;50% reduction in LDL-C levels. 104 (64%) of patients were treated in compliance with their contemporary guidelines.

Both pre (n = 112) and post (n = 51) September 2019 cohorts were well matched. Fewer patients who were treated under the August 2019 guidelines reached their absolute LDL-C (51% v 63%, p &lt; 0.005) targets; achieved a &gt;50% reduction in LDL-C from baseline (48% vs 61%, p &lt; 0.005), or were compliant with the guidelines for their risk category (43% vs 73%, p &lt; 0.005).

Conclusions

Both high intensity statin therapy and ezetimibe are under-prescribed. Fewer patients are meeting the lower absolute LDL-C targets set out in the 2019 ESC guidelines. For those at high risk, determining the reduction in LDL-C from baseline reveals that even those meeting their absolute LDL-C targets may still be undertreated.

LDL-C Target Achievement N Mean LDL Pre-CR (95% CI) Mean LDL-C Post CR (95% CI) Absolute LDL-C Target Met (%) Mean % LDL-C Reduction from Baseline (95% CI) &gt; 50% Reduction (% of applicable patients) Guidelines Achieved Pre-Sept"20 112 2.7 (2.46-2.93) 1.64 (1.49- 1.79) 70 (63) 61 (56-66) 50 (65) 82 (73) Post Sept 20 51 2.83 (2.41-3.25) 1.83 (1.41-2.25) 26 (51) 48 (37-59) 11 (34) 22 (43) Total 163 2.72 (2.52- 2.91) 1.69 (1.57-1.82) 96 (59) 57 (52- 62) 61 (52) 104 (64 LDL-C targets met, stratified by contemporary guidelines followed.

Abstract Figure. Choice of lipid lowering therapy in 2019