Elsevier

Atherosclerosis

Volume 285, June 2019, Pages 135-146
Atherosclerosis

Management of dyslipidaemia in patients with coronary heart disease: Results from the ESC-EORP EUROASPIRE V survey in 27 countries

https://doi.org/10.1016/j.atherosclerosis.2019.03.014Get rights and content

Highlights

  • Most patients with established coronary artery disease have suboptimal lipid management.

  • More professional strategies are needed aiming at lifestyle changes and LLT adapted to the need of the individual patient.

  • The striking variability between countries and centers with several examples of well managed patients illustrates that the present conditions can be improved.

Abstract

Background and aims

One of the objectives of the ESC-EORP EUROASPIRE V survey is to determine how well European guidelines on the management of dyslipidaemias are implemented in coronary patients.

Methods

Standardized methods were used by trained technicians to collect information on 7824 patients from 130 centers in 27 countries, from the medical records and at a visit at least 6 months after hospitalization for a coronary event. All lipid measurements were performed in one central laboratory. Patients were divided into three groups: on high-intensity LDL-C-lowering-drug therapy (LLT), on low or moderate-intensity LLT and on no LLT.

Results

At the time of the visit, almost half of the patients were on a high-intensity LLT. Between hospital discharge and the visit, LLT had been reduced in intensity or interrupted in 20.8% of the patients and had been started or increased in intensity in 11.7%. In those who had interrupted LLT or had reduced the intensity, intolerance to LLT and the advice of their physician were reported as the reason why in 15.8 and 36.8% of the cases, respectively. LDL-C control was better in those on a high-intensity LLT compared to those on low or moderate intensity LLT. LDL-C control was better in men than women and in patients with self-reported diabetes.

Conclusions

The results of the EUROASPIRE V survey show that most coronary patients have a less than optimal management of LDL-C. More professional strategies are needed, aiming at lifestyle changes and LLT adapted to the need of the individual patient.

Introduction

Despite significant progress in secondary prevention of coronary heart disease (CHD) over the past decades, the incidence of recurrent events remains a problem for many patients and the society. In a Swedish national registry with more than 100,000 patients, post acute myocardial infarction (AMI) recurrent events were observed in 18% of the cohort during the first year following the index event and in 20% during the following three years among those who remained free of recurrent events during the first year [1].

The consequences are high numbers of premature mortality, of disability adjusted life years (DALYs) and of avoidable health care costs. More efforts to improve secondary prevention of CHD are needed. Evidence that an efficient risk factor control has great potential in avoiding unnecessary cardiovascular events has recently been documented in a large Swedish cohort study [2].

The European Society of Cardiology has since 1994 a comprehensive program of cardiovascular disease (CVD) prevention by developing and updating guidelines and implementation strategies. All this is regularly evaluated through the European Society of Cardiology – Eurobservational Research Programme (ESC-EORP) EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) surveys. The EUROASPIRE IV survey incorporated the EuroHeart Survey on Diabetes to create the first European Survey of CVD prevention and diabetes. The aim of the prevention guidelines and the results from the EUROASPIRE I-IV surveys have been extensively communicated [[3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]]. The most recent survey (EUROASPIRE V) in coronary patients took place in 2016–17 in 27 countries and the overall results have been reported [17].

In recent guidelines on CVD prevention in clinical practice [8] it is recommended to treat all patients with established CHD using lifestyle changes and cardio-protective drug therapies. Regarding the control of dyslipidaemia, achieving a low-density-lipoprotein cholesterol (LDL-C) level of <1.8 mmol/L (70 mg/dL) is recommended or a reduction of at least 50% if the baseline LDL-C level is between 1.8 and 3.5 mmol/L (70–135 mg/dL). Non-HDL-cholesterol (Non-HDL-C) is regarded as a secondary target with a treatment goal of <2.6 mmol/L (100 mg/dL). Trials have provided evidence that high-intensity LDL-C-lowering drug therapies (LLT) are more effective than low-intensity LLT at reducing recurrent events in coronary patients [[18], [19], [20]]. In an observational study a graded association was observed between the intensity of statin therapy and total mortality in patients with atherosclerotic CVD [21]. The safety and efficacy of the use of high-intensity LLT to achieve low levels of LDL-C in patients with CHD has been well documented [22].

The objectives of this report is to describe the lipid profile of coronary patients from 27 countries, the management of elevated LDL-C levels, the change that occurred in LLT between hospital discharge and what was actually taken at the time of the interview. Reasons for reducing the dosage or for stopping the LLT were enquired as well. Finally, the management of dyslipidaemia in these coronary patients was looked after according to patient characteristics.

Section snippets

Materials and methods

The hospital arm of the EUROASPIRE V surveys patients with documented CHD. National coordinators of 27 countries (Belgium, Bosnia & Herzegovina, Bulgaria, Croatia, Czech Republic, Egypt, Finland, Germany, Greece, Ireland, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, the Netherlands, Poland, Portugal, Romania, Russian Federation, Serbia, Slovenia, Spain, Sweden, Turkey, Ukraine and the United Kingdom) identified within their country one to three geographical areas, each with a population of

Results

Overall 16,208 patients were identified from consecutive lists of hospitalized patients of whom 8261 (56%) took part in the interview. For the purpose of this analysis on the management of dyslipidaemia full results were available in 7824 patients from 130 centers in 27 countries. They were on average 63.6 years of age (SD: 9.6 years) and 25.7% were females. Smoking was prevalent in 18.5% of these patients; 38% were obese and 35% did not engage in regular physical activity. The median time

Discussion

The EUROASPIRE V survey clearly shows that the overall lipid control was unsatisfactory in a large proportion of patients as reflected by elevated levels of TC, LDL-C, non-HDL-C and TG and low levels of HDL-C. Unfortunately, other fractions such as apo B and Lp(a) were not measured. This situation was on average worse in women and in young patients. Moreover, there was a substantial variation in these lipid profiles between patients from different participating countries and between patients

Conflicts of interest

No competing interests for G. De Backer, D. De Bacquer, E. Mirrakhimov and D. Wood. P. Jankowski has received honoraria, research and conference grants from, KRKA, MSD, Pfizer, SanofiAventis, Servier, Zentiva. Ž Reiner has received honoraria for lectures from Sanofi Aventis and from Akcea. L.Tokozoglu has had financial interests, arrangements or affiliations with Actelion, Amgen, Sanofi, Pfizer, Novonordisk, MSD, Recordati, Kowa, Abbott, Novartis, Mylan, Bayer, Servier and Sanovel. L Rydén has

Financial support

The EUROASPIRE V survey was carried out under the auspices of the ESC –EORP. Since the start of EORP, the following companies have supported the programme: Amgen, Eli Lilly, Pfizer, Sanofi, Ferrer and Novo Nordisk. The sponsors of the EUROASPIRE surveys had no role in the design, data collection, data analysis, data interpretation, decision to publish, or writing the manuscript.

Acknowledgements

The EUROASPIRE Study Group is grateful to the administrative staff, physicians, nurses, and other personnel in the hospitals in which the survey was carried out and to all patients who participated in the surveys.

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