Treatment patterns and adherence to lipid-lowering therapy, LDL-C control, clinical outcomes, and healthcare resource utilization in treated patients with hypercholesterolemia at high cardiovascular risk in Israel: a retrospective database study

Aims In this retrospective study, we analyzed data from patients with hypercholesterolemia to describe treatment patterns, adherence, low-density lipoprotein cholesterol (LDL-C) control, cardiovascular outcomes, and healthcare resource utilization among treated patients in a real-world setting in Israel. Methods Deidentified data from the medical records of patients with atherosclerotic cardiovascular disease (ASCVD), ASCVD-risk equivalent (ASCVD-RE), and familial hypercholesterolemia (FH) treated with lipid-lowering therapy (LLT) between 2013 and 2019 were analyzed. LDL-C values were based on routine laboratory reporting in Maccabi Healthcare Services and were calculated using the Friedewald equation during the study period. Controlled LDL-C was defined as LDL-C < 70 mg/dL for ASCVD patients and <100 mg/dL for ASCVD-RE and FH patients. Adherence to LLTs was assessed using the proportion of days covered (PDC), and associations with cardiovascular outcomes and healthcare resource utilization were evaluated. Results A total of 15,258 patients with hypercholesterolemia (FH [7.0%], ASCVD [33.3%], and ASCVD-RE [59.7%]) were identified. Most of them (>90%) received statin monotherapy, while 2.9% received a combination of a statin and other LLTs. High adherence to LLTs (PDC ≥ 80%) was achieved by 54.1% of ASCVD patients, followed by 35.3% of ASCVD-RE patients and 17.7% of FH patients. Combination therapy with high-intensity statins (HIS) plus ezetimibe was associated with lower first postinitiation LDL-C levels in the ASCVD and ASCVD-RE groups, with 47.6% and 52.0% of patients, respectively, achieving LDL-C < 55 mg/dL; Among FH patients, 30.8% achieved LDL-C levels of 70–100 mg/dL with HIS monotherapy. A PDC ≥ 80% was significantly associated with a longer time to percutaneous coronary intervention and CABG procedures and a longer time to death in both the ASCVD and ASCVD-RE groups. During the study period, LDL-C targets were achieved by 61.1% of ASCVD patients. LDL-C < 100 mg/dL was reached by 79.9% of ASCVD-RE patients and 33.5% of FH patients. Conclusions In this large, treated real-world cohort, substantial gaps in LDL-C control and treatment adherence were observed across high-risk populations. Higher adherence to lipid-lowering therapy was associated with better LDL-C control and longer time to selected clinical outcomes; however, these findings should be interpreted as associations rather than evidence of causality, given the observational study design. Translational perspective In this real-world cohort, higher adherence to lipid-lowering therapy (PDC ≥ 80%) was associated with better LDL-C control and more favorable cardiovascular outcome patterns. These findings highlight the potential importance of sustained treatment adherence as a key determinant of lipid control in routine clinical practice and suggest that strategies supporting long-term adherence may contribute to improved cardiovascular risk management in high-risk populations.