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

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.