†The Role of Structured Inpatient Lipid Protocols in Optimizing Non-Statin Lipid Lowering Therapy: A Review and Single-Center Experience

IF 3.6 3区 医学 Q2 PHARMACOLOGY & PHARMACY
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引用次数: 0

Abstract

Background/Synopsis

Dyslipidemia is a leading contributor to atherosclerotic cardiovascular disease (ASCVD). There has been a significant improvement in the treatment of dyslipidemia in the past 10 years with the development of new pharmacotherapies. However adherence to guidelines and patients being prescribed appropriate therapy can be improved.

Objective/Purpose

The intent of this review is help enhance clinicians understanding of non-statin lipid lowering therapies in accordance with the 2022 American College of Cardiology Expert Consensus Clinical Decision Pathway (ECDP) on the Role of Non-statin Therapies for LDL-Cholesterol Lowering. We also present a single-center experience implementing a systematic inpatient protocol for lipid lowering therapy (LLT) for secondary prevention of ASCVD.

Methods

We review the clinical trials for ezetimibe, evolocumab, alirocumab, inclisiran, bempedoic acid and summarize how the medications are implemented for use in the 2022 American College of Cardiology Expert Consensus Clinical Decision Pathway. We conducted a quality improvement retrospective chart analysis study to assess the proportion of patients admitted with non-ST-elevation myocardial infarction or ST-elevation myocardial infarction who underwent percutaneous coronary intervention and were prescribed LLT at discharge from 1/1/2018 to 08/20/2021. A structured inpatient lipid protocol was implemented with the aim of identifying very-high-risk patients, standardizing the initiation and escalation of LLT, and ensuring appropriate monitoring and follow-up. We identify patients admitted with ASCVD event, and obtain baseline LDL-C level. Our pharmacist reviews the patients in the cardiology units and will make recommendations for next step in management. For patients on statin with an LDL-C above 70mg/dL or not on a statin with an LDL-C above 150mg/dL, we maximize the statin and add a PCSK9 inhibitor on discharge. For patients on statin with an LDL-C below 70mg/dL or not on a statin with an LDL-C below 150mg/dL, we maximize the statin and add either ezetimibe or bempedoic acid. The inpatient case manager determines cost and coverage and communicates with the care management specialist to ensure follow up on authorization for medications. For very high risk patients, a referral is placed in the electronic medical record to our advanced lipid management program and the office calls patient to ensure follow up visit is scheduled with repeat lipid panel checked in 4-12 weeks. Cases are reviewed with the lipidologists, care managers, and nurses during a weekly lipid board to discuss treatment plans for the patients scheduled for the upcoming week.

Results

Prior to implementation, review of patients from 1/1/2018 to 08/20/2021, our analysis found that 92% of these patients were prescribed statin therapy, but only 66.2% of them had an LDL-C level below 70 mg/dL at their subsequent follow-up appointment. Frequent reassessment of the data is done to see compliance rate with medication and adherence to guidelines with hope to see improvement in percentage of patients with LDL-C at target.

Conclusions

The 2022 ACC ECDP on the role of non-statin therapies for LDL-C lowering recommends aggressive combination therapy to lower LDL-C in very-high-risk patients. To effectively manage very-high-risk patients and ensure that they receive appropriate lipid-lowering therapy, it may be necessary to implement a structured inpatient protocol involving a multi-disciplinary approach in both the inpatient and outpatient setting.

结构化住院患者血脂方案在优化非司他汀类降脂疗法中的作用:回顾与单中心经验
背景/简介血脂异常是导致动脉粥样硬化性心血管疾病(ASCVD)的主要因素。过去 10 年中,随着新药物疗法的开发,血脂异常的治疗有了明显改善。本综述旨在根据 2022 年美国心脏病学会专家共识临床决策路径(ECDP)中关于非他汀类降脂药物在降低低密度脂蛋白胆固醇中的作用的规定,帮助临床医生更好地了解非他汀类降脂药物。方法我们回顾了依折麦布、埃沃洛库单抗、阿利曲库单抗、伊曲西兰、贝美多酸的临床试验,并总结了如何在 2022 年美国心脏病学会专家共识临床决策路径中使用这些药物。我们开展了一项质量改进回顾性病历分析研究,以评估 2018 年 1 月 1 日至 2021 年 8 月 20 日期间,因非 ST 段抬高型心肌梗死或 ST 段抬高型心肌梗死入院并接受经皮冠状动脉介入治疗的患者中,出院时处方 LLT 的比例。我们实施了结构化住院患者血脂方案,旨在识别极高风险患者,规范 LLT 的启动和升级,并确保适当的监测和随访。我们对入院时发生 ASCVD 事件的患者进行识别,并获得基线 LDL-C 水平。我们的药剂师会在心脏病科对患者进行复查,并就下一步的管理提出建议。对于服用他汀类药物但 LDL-C 超过 70 毫克/分升或未服用他汀类药物但 LDL-C 超过 150 毫克/分升的患者,我们会尽量延长他汀类药物的疗程,并在出院时添加 PCSK9 抑制剂。对于服用他汀类药物但 LDL-C 低于 70 毫克/分升或未服用他汀类药物但 LDL-C 低于 150 毫克/分升的患者,我们会最大限度地使用他汀类药物,并添加依折麦布或贝贝多酸。住院病人个案经理会确定费用和承保范围,并与护理管理专家沟通,确保跟进药物授权情况。对于风险极高的患者,电子病历中会将其转介至我们的高级血脂管理计划,办公室会致电患者,确保在 4-12 周内安排复诊,并重复检查血脂组合。在每周的血脂委员会上,血脂专家、护理经理和护士会对病例进行审查,讨论下周安排的患者治疗计划。结果在实施之前,我们对 2018 年 1 月 1 日至 2021 年 8 月 20 日的患者进行了审查,分析发现这些患者中有 92% 接受了他汀类药物治疗,但其中只有 66.2% 的患者在随后的复诊时 LDL-C 水平低于 70 mg/dL。结论 2022 年 ACC ECDP 关于非他汀类药物在降低低密度脂蛋白胆固醇中的作用的报告建议采用积极的联合疗法来降低极高风险患者的低密度脂蛋白胆固醇。为了有效管理极高风险患者并确保他们接受适当的降脂治疗,可能有必要在住院和门诊环境中实施一种涉及多学科方法的结构化住院方案。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
7.00
自引率
6.80%
发文量
209
审稿时长
49 days
期刊介绍: Because the scope of clinical lipidology is broad, the topics addressed by the Journal are equally diverse. Typical articles explore lipidology as it is practiced in the treatment setting, recent developments in pharmacological research, reports of treatment and trials, case studies, the impact of lifestyle modification, and similar academic material of interest to the practitioner. While preference is given to material of immediate practical concern, the science that underpins lipidology is forwarded by expert contributors so that evidence-based approaches to reducing cardiovascular and coronary heart disease can be made immediately available to our readers. Sections of the Journal will address pioneering studies and the clinicians who conduct them, case studies, ethical standards and conduct, professional guidance such as ATP and NCEP, editorial commentary, letters from readers, National Lipid Association (NLA) news and upcoming event information, as well as abstracts from the NLA annual scientific sessions and the scientific forums held by its chapters, when appropriate.
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