Vascular disease

Intensive statins insufficient to meet lipid targets in CABG patients

Clinicians should consider adding non-statin therapies to coronary artery bypass graft (CABG) patients’ treatment regimen, Australian researchers suggest after finding statins alone were insufficient to meet lipid-lowering goals.

Their retrospective study of 484 CABG patients found that only 24.4% of patients were meeting LDL-cholesterol targets of <1.4 mmol/L as recommended in European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) guidelines of 2019, despite almost all patients (91%) receiving intensive statin therapy.

And even when assessed against less intensive LDL-cholesterol goals of 1.8 mmol/L as recommended by ESC/EAS in 2016 only half of CABG patients (47.7%)  met the targets, according to clinicians from the Department of Cardiology, Fiona Stanley Hospital, Perth.

Their study found that patients on ezetimibe plus high-intensity statins were more likely to achieve guideline-recommended low- and non-high density lipoprotein cholesterol (LDL-C and HDL-C) levels than individuals on low- or moderate-intensity statins with or without ezetimibe or high-intensity statins alone.

With CABG patients at higher risk of adverse cardiovascular events and their ability to modify that risk with lipid-lowering therapy, the results highlight “a significant gap” to optimal preventative care, the authors wrote.

Published in the Journal of Lipid and Atherosclerosis, the study assessed CABG patients’ lipid levels, management strategies and adherence to the 2019 and 2016 European dyslipidaemia guidelines.

“Compared with patients discharged on high-intensity statin therapy only, or moderate- or low-intensity statin therapy with or without ezetimibe, patients discharged on high-intensity statin therapy plus ezetimibe were more likely to attain the LDL-C target levels of <1.4 mmol/L (54 mg/dL) (p for trend=0.020) and <1.8 mmol/L (70 mg/dL) (p for trend<0.001),” the paper read.

Of 62 ezetimibe patients, 67% had LDL-C levels below 1.8 mmol/L and 30%, under 1.4 mmol/L, while 59% had non-HDL-C levels below the 2.6 mmol/L threshold and 37%, less than 2.2 mmol/L, as per the 2016 and 2019 guidelines, respectively.

Conversely, 48% and 26% of patients on high-intensity statins and 27% and 9% on moderate- or low-intensity statins with or without ezetimibe reached the same LDL-C levels while 51% and 30%, and 27% and 11% achieved target non-HDL-C levels, the authors wrote.

Thirty-eight deaths were recorded by median day 1,254 from CABG surgery; no significant differences in LDL-C levels at follow-up, proportion of patients achieving LDL-C targets at follow-up or proportion of patients on statin plus ezetimibe prescriptions at discharge were seen in patients who died or were alive at time of follow-up, they reported.

“The major finding of this study is that a large proportion of patients who underwent CABG surgery could potentially benefit from the addition of non-statin lipid-lowering therapies, as they are not attaining lipid targets despite the majority being prescribed high-intensity statins at discharge,” they wrote.

Bettering lipid management

Optimising lipid management in CABG patients is critical, with reductions potentially preventing venous graft failure, cardiovascular disease events such as myocardial infarction, and death, the authors wrote.

“Given the results of our study, it is important to identify and address the reasons for suboptimal lipid management,” they noted.

Although pre-CABG treatment with lipid-lowering therapies may account for smaller changes in some patients, medication non-adherence, statin intolerance, undertreatment, insufficient efficacy, uncertainties around guideline recommendations and medication cost may also hinder lipid management.

“The establishment of a new cardiometabolic speciality, with integration into inpatient cardiothoracic units, cardiac units, and outpatient clinics, could potentially bridge the gap in lipid management,” the authors wrote.

The subspecialty could help provide a “more comprehensive approach to managing complex lipid disorders” by facilitating access to preventative therapies, including those in development or undergoing cardiovascular disease outcome trials and “support a more comprehensive, patient-centred approach to cardiovascular risk reduction”, they suggested.

The authors declared that the study did not receive any industry funding.

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