ASCVD Risk Reduction in Patients with Immune-Mediated Inflammatory Disease: A Retrospective Quality Assessment Study

Abstract

Background/Synopsis

Patients with inflammatory immune-mediated disease (IMID) face a heightened risk of atherosclerotic cardiovascular disease (ASCVD). Current guidelines (2018, Grundy et al.) suggest considering a moderate-intensity statin for primary prevention if the 10-year ASCVD risk exceeds 5% in the presence of risk enhancers like IMID (Class IIb recommendation). However, many patients with IMID are undertreated with lipid-lowering therapies (LLT) as traditional ASCVD risk calculators often overlook this enhanced ASCVD risk. The 2022 ACC Expert Consensus decision pathway recommends a target LDL-C of at least 100 mg/dL and preferably less than 70 mg/dL for higher-risk patients for primary prevention. An LDL-C of less than 55 mg/dL is optimal for secondary ASCVD prevention.

Objective/Purpose

Identify the proportion of patients with IMID at our institution who meet criteria to start LLT (defined as ASCVD risk greater than 5% in the presence of risk enhancers or history of clinical ASCVD), proportion of such patients who are prescribed LLT, and the proportion of patients who meet goal LDL-C for primary and secondary prevention of ASCVD. Additionally, we sought to identify what proportion of those patients underwent coronary artery calcium scoring (CACS) and/or measurement of carotid intima-media thickness (CIMT) to guide decision-making in ASCVD risk management.

Methods

This is a retrospective quality assessment study using data from the Penn Medicine electronic medical records. Patients between 40 and 75 years of age, attending Rheumatology and Dermatology clinics during the calendar year 2022, with the following diagnoses were included: psoriasis, rheumatoid arthritis, systemic lupus erythematosus, gout, vasculitis, systemic sclerosis, antiphospholipid syndrome, mixed connective tissue disease, myositis. Patients with missing covariates to calculate the ASCVD risk score and study outcomes were excluded.

Results

1,907 patients were identified, 29% of which had clinical ASCVD. 69% (1,321) were eligible for LLT. 53% (702) of eligible patients were prescribed LLT, while 47% were not. Among patients who met criteria for LLT, 58% had their most recent LDL-C under 100 mg/dL, while 33% had their most recent LDL-C less than 70 mg/dL. 16% of patients with clinical ASCVD had their most recent LDL-C level less than 55 mg/dL. CACS or CIMT was performed on 10% of our cohort.

Conclusions

This study supports our hypothesis that ASCVD risk management in patients with IMID is suboptimal. With advances in subclinical atherosclerosis imaging and newer non-statin therapies, there is potential to improve cardiovascular outcomes in patients with IMID. Further studies are needed to bridge the management gaps in this patient population.