Statin use and low-density lipoprotein cholesterol target achievement for primary prevention of atherosclerotic cardiovascular disease in patients with type 2 diabetes mellitus: a multicenter cross-sectional study in Sri Lanka
Authors: De Zoysa P.D.W.D. , Weerarathna T.P. , Darshana I.L.A.N. , Wasana K.G.P. , Piyasekara B. , Jayasekara M.M.P.T. , Sujanitha V. , Silva S. , Mettananda C. , Ramadasa G.U. , Pathirage L.P.M.M.K. 
Published: February 2025

Background
Statin therapy serves a crucial role as a primary preventive strategy against atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes mellitus (T2DM). Even though diabetes poses a significant and growing health concern in Sri Lanka, there is a lack of information regarding the prevalence and intensity of statin prescriptions and the achievement of recommended LDL-C targets in diabetic patients for the primary prevention of ASCVD within the nation. We aimed to assess the prevalence and intensity of statin prescriptions, target LDL-C achievement, and factors associated with target LDL-C achievement for the primary prevention of ASCVD in T2DM patients across several tertiary care facilities in Sri Lanka.

Methods
A multi-centered, cross-sectional study was conducted among T2DM patients without clinical ASCVD attending six tertiary care medical clinics in Sri Lanka. Data on ASCVD risk factors and statin prescription were collected using an interviewer-administered questionnaire. ASCVD risk was calculated using the WHO charts. Atorvastatin 20 mg/ rosuvastatin 10 mg was defined as high-intensity statins and target LDL-C was defined as < 70 mg/dL for moderate to high and < 100 mg/dL for low-risk groups of ASCVD according to the NICE guideline. The independent sample t test, one-way ANOVA and chi-square test were used for data analysis as appropriate. Factors linked to achieving LDL-C targets were determined through multiple logistic regression analysis. Level of significance was considered as 0.05.

Results
Of the 2013 participants studied, 46.7% were at moderate-high risk and the rest were at low risk of ASCVD. All were eligible for statin therapy, and 84.1% were prescribed statins. High-intensity statins had been prescribed only for 38.5% of moderate-high-risk patients. Nonetheless, high-intensity statins have also been prescribed for 30.7% of low-risk patients. LDL-C target achievement was studied in a randomly selected subsample of 683 and 65.4% (70.7% in low-risk patients and 60.3% in moderate-high-risk patients) achieved LDL-C targets. Of moderate-high-risk patients, 46.3% had not achieved target LDL-C even with high-intensity statin therapy. Female gender (OR = 1.52, 95% CI 1.03-2.24, p = 0.036), poor adherence to statins (OR = 1.67, 95% CI 1.18-2.37, p = 0.004), poor glycemic control (OR = 2.27, 95% CI 1.41-3.65, p = 0.001), and inadequate physical activity (OR = 1.48, 95% CI 1.04-2.10, p = 0.031) were significantly associated with failing to achieve LDL-C targets.

Conclusion
Only about one third of diabetes patients with moderate-high ASCVD risk received high-intensity statins. Even with high-intensity statin therapy, nearly half of the treated patients failed to meet recommended LDL-C targets.