Physician-reported reasons for not intensifying lipid-lowering therapy in patients with recent myocardial infarction

Abstract

Funding

This study was funded by Amgen.

Background/Synopsis

Clinical practice evidence indicates that patients with high risk of a secondary event after a recent myocardial infarction (MI) often do not receive guideline-recommended lipid-lowering therapy (LLT), leaving them at unnecessary cardiovascular risk. We implemented a quality initiative to evaluate and improve LLT prescribing according to the 2018 AHA/ACC/Multisociety guidelines that recommend LDL-C lower than 70 mg/dL for patients with very high ASCVD risk.

Objective/Purpose

This study assessed the reasons cardiologists selected for not following AHA/ACC/Multisociety LLT guidelines for patients with recent MI when alerted to best practice recommendations at the point of care.

Methods

From August 2020 to February 2021, our practice group (96 cardiologists, 35 locations) implemented a ‘hard stop’ best practice alert in the electronic health records (EHR) of patients with MI history within 12 months and elevated LDL-C (70 mg/dL or greater) or no LDL-C values within 6 months of the index visit. If the patient had no LDL-C within 6 months, clinicians were prompted to order an LDL-C test and schedule a follow-up visit. If LDL-C was current and elevated, clinicians received stepwise prompts to prescribe guideline-recommended LLT (high-intensity statin, ezetimibe, and PCSK9i) or provide a reason for not doing so. Reasons for not intensifying LLT were summarized by the type of intensification recommended.

Results

In 42% (244/587) of patients for whom the best practice alert was triggered, treatment was not intensified. In 53/244 (22%) of these patients, treatment was not intensified because the LDL-C was not current, and the physician was prompted to order an LDL-C test. LLT intensification was not followed in 86 patients when high-intensity statin was recommended, 16 patients when ezetimibe was recommended, and 142 patients when PCSK9i was recommended. The most common reasons physicians gave (Figure) for not adding high-intensity statins were intolerance (n=62/86, 72%) and patient refusal (n=14/86, 16%); the most common reasons for not adding ezetimibe were past intolerance (n=8/16, 50%) and no current LDL-C available (n=5/16, 31%); and the most common reasons for not adding PCSK9i were no current LDL-C available (n=42/142, 30%) and patient refusal (n=31/142, 22%).

Conclusions

For patients with an MI in the last 12 months, opportunities to intensify LLT and monitor LDL-C were frequently missed. In addition to a ‘hard-stop’ best practice alert in the EHR, additional strategies need to be explored to overcome common reasons for not intensifying LLT, including addressing adverse events/intolerance and better routine monitoring of LDL-C.