Associate Professor Peter Psaltis

More effort on LDL-cholesterol management and cardiac rehabilitation are the mainstays of an advocacy campaign to ramp up secondary prevention of cardiovascular disease and events.

The Australia’s cholesterol heartache: a simple roadmap for urgent action on cholesterol management report launched in Canberra this week says its solutions would prevent almost 65,000 non-fatal CV events and about 20,000 deaths.

The incremental cost-effectiveness ratio (ICER) was calculated at $26,210 per death or CVD event avoided.

“The outcome is also considered conservative as additional benefits such as reduced patient quality of life associated with non-fatal CVD events and the wider implications of costs borne by patients and carers were not captured,” the report said.

The report, commissioned by Amgen Australia, made five recommendations:

• Ensure all high-risk Australians know their LDL-C level
• Embed annual LDL-C tests for all high-risk Australians
• Standardise lipid profile reporting across Australia
• Update the guidelines to reflect best practice for secondary prevention of CVD
• Enhance the role of quality cardiac rehabilitation across Australia

According to SA cardiologist Associate Professor Peter Psaltis, a member of the report’s advisory committee and president of the Australian Atherosclerosis Society, the fact that 40% of high-risk Australians were falling short of LDL-cholesterol targets was consistent with data from around the world.

“It does alarm me that over the last ten years despite new opportunities to use different medications and combination medications for cholesterol, and despite more and more research showing how important it is to drive cholesterol down after a heart attack or stroke, we haven’t actually improved our rates of getting patients to target,” he told the limbic.

“We’ve done well with primary prevention. Now is the time to properly embrace secondary prevention again.”

Associate Professor Psaltis said the cost savings outlined in the report were very plausible.

“And I think what they emphasise is that it doesn’t take much, given what we know and what we currently have at our disposal, to make major gains.”

“We have known for a long long time that getting the LDL-cholesterol down by 1.1 mmol/L translates to a 22% relative risk reduction of a person’s risk of stroke, heart attack or cardiovascular death.”

“Normally when we start stains we get reductions of at least 1 and often 2 mmol/L. Similarly when we use combination treatment we can get that cholesterol even lower,” he said.

Associate Professor Psaltis, Deputy Program Leader of Heart and Vascular Health at SAHMRI, Adelaide, said PBS prescribing restrictions had limited the ability to introduce combination therapies early in patients with very high LDL-C.

“The current Authority criteria for being able to add in exetimibe require that I try maximum statins for 12 weeks along with lifestyle treatment before I can introduce a second agent.”

“Similarly with the PCSK9 inhibitors, they have been lifting the criteria [to include non-FH patients] but we can only start the PCSK9 inhibitors with authority prescription if the LDL is above 2.6 not 1.8, despite maximum statin and exetimibe – which means we have patients for whom we can’t access those drugs.”

“It really is about leveraging what we have got – to use those agents sensibly to the best of our ability and to always make sure we are individualising treatment.”

He said there was some complacency on the part of cardiologists in not pushing the LDL targets.

“If we look at contemporary studies we know that even when people get discharged from hospital, there are unacceptable rates of not being on appropriate doses of cholesterol lowering medications.”

Standardising the reporting of lipid testing to ensure the full breakdown of total cholesterol, triglycerides, HDL-C, LDL-C and non-HDL-C was available would also be helpful, he said.

“And then it is about engaging the patient and educating them enough so they take ownership of their own treatment.”

He said all five policy solutions had merit.

“For me, the ones I think that can make the biggest difference are the simple task of making sure patients and their treating doctors know the baseline LDL-C level before and after treatment and reviewing that annually…and to follow through and treat to target.”

“Patients want to know the medicines are actually working.”

“The other policy solution that shouldn’t be lost in this is the uptake of cardiac rehabilitation which is an underestimated tool.”

About a third of patients are referred to a program at discharge, the report said.

“The evidence we have for cardiac rehabilitation as a non-pharmacologic treatment continues to be very strong and it comes down to educating patients and empowering them by making sure they are adhering to their medications, questions and concerns can be addressed… that is where the supervised environment of rehab, speaking to other health professionals and to other patients really does help them to understand treatment much better.”