Lipid management among very-high-risk patients with atherosclerotic cardiovascular disease and type 2 diabetes

Abstract Background Patients with established atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (DM2) often meet very-high-risk (VHR) criteria for recurrent ASCVD events and are recommended for aggressive low-density lipoprotein-cholesterol (LDL-C) lowering in guidelines. Purpose Our study aimed to evaluate the proportion of patients achieving guideline-based lipid goals and identify factors associated with achieving these goals among VHR patients with established ASCVD and DM2. Methods Electronic health record data were used to identify VHR patients with established ASCVD and DM2 across 14 large US healthcare systems between 1/1/2022-12/31/2022 with an available LDL-C measurement. We examined the percentage of patients achieving guideline-based lipid goals based on the 2018 AHA/ACC Multisociety Guideline, defined as either having an LDL-C <70 mg/dL or receiving maximal lipid-lowering therapy (i.e., on a PCSK9i monoclonal antibody (mAb)) at the time of the last LDL-C test, and performed multivariable logistic regression to evaluate factors associated with the achievement of those goals. Results Among 213,380 eligible VHR patients with ASCVD and DM2 (mean age 70.2 years, 42% women), 51.8% (110,452) patients achieved guideline-based lipid goals. This included 50.9% with an LDL-C <70 mg/dL and 1.7% on a PCSK9i mAb. Female sex (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.61-0.66), Black race (OR, 0.67; 95% CI, 0.63-0.72), Medicaid insurance (OR, 0.92; 95% CI, 0.86-0.97), and non-coronary artery disease forms of ASCVD including peripheral artery disease (OR, 0.67; 95% CI, 0.65-0.69) and cerebrovascular disease (OR, 0.80; 95% CI, 0.77-0.83) were associated with a lower likelihood of achieving guideline-based lipid goals. Conversely, having undergone percutaneous coronary intervention (OR, 1.31; 95% CI, 1.19-1.43) or coronary artery bypass graft (OR, 1.24; 95% CI, 1.06-1.45) in the previous year, and comorbidities including dialysis (OR, 1.38; 95% CI, 1.23-1.55), atrial fibrillation or flutter (OR, 1.09; 95% CI, 1.06-1.12), and systolic heart failure (OR, 1.11; 95% CI, 1.08-1.14) were associated with a higher likelihood of achieving these goals. Overall, 24.0% of patients were on no statin, 27.2% were on a low- or moderate-intensity statin, and only 5.8% were on a statin in combination with ezetimibe or a PCSK9i mAb. Conclusion Large gaps in care exist for VHR patients with ASCVD and DM2, particularly among women, Black individuals, and those with Medicaid. Targeted interventions are needed to improve the uptake of evidence-based secondary prevention therapies in these patients.