Persistent gaps in the implementation of lipid-lowering therapy in patients with established atherosclerotic cardiovascular disease: A French nationwide study

Abstract

Background

According to international guidelines, lowering LDL-cholesterol is the cornerstone of atherosclerotic cardiovascular disease (ASCVD) prevention. However, observational studies have identified current gaps in the implementation of lipid-lowering therapy (LLT). This whole-population study aimed to evaluate the prevalence and determinants of LLT use in ASCVD patients.

Methods

Using the national health data system, all French adults with established ASCVD between 2012 and 2021 were identified using specific ICD-10 and/or procedure codes. LLT use was defined as ≥1 dispensing in the last quarter of 2021. Logistic regression was used to identify factors associated with the absence of LLT use.

Findings

In 2021, 2,206,305 individuals (4.89 % among 45,082,270 adults) had established ASCVD (mean age: 72.2 years; 36.9 % women), including 56.1 % with coronary artery disease, 40.4 % with cerebrovascular disease, and 14.5 % with revascularized peripheral artery disease (PAD). Among the 2,056,354 patients alive on 31st December 2021, 32.5 % did not receive any LLT, while 64.8 % received a statin (27.0 % a high-intensity statin), 13.0 % a combination of statin and ezetimibe, and 0.25 % a PCSK9 inhibitor. The absence of LLT use was significantly associated with female sex (adjusted odds ratio [aOR]:1.42, 95 %CI, 1.41–1.43); lowest/highest ages: < 50 years (aOR (/65–74 years): 2.23, 95 %CI 2.20–2.27) and ≥ 85 years (aOR: 2.10, 95 %CI 2.08–2.13); and stroke and PAD, compared to myocardial infarction (aOR: 2.21, 95 %CI 2.19–2.23 and 1.88, 95 %CI 1.86–1.91, respectively).

Interpretation

In real life, one-third of French ASCVD patients was not regularly treated with LLT, highlighting the urgent need to develop implementation strategies for lipid management.