We have great drugs to lower cholesterol, but most with heart disease are not adequately treated

July 19, 2023

Source: Aggarwal, et al JAMA July 3, 2023 LINK   

Researchers reviewed 2015-2020 data from the National Health and Nutrition Examination Survey (NHANES), a large government study of about 25,000 Americans. They found that among the 472 adults who reported having cardiovascular disease and had fasting blood tests, over two thirds (68%) were on statin drugs, which is good news. However, even among those on statins, most continued to have LDL cholesterol above the target for those with cardiovascular disease, meaning that we could prevent more heart disease with either better drug adherence or higher doses of these medications, which are effective and low cost.

Most healthy adults should have their lipids checked every 4-6 years (CDC). The US Preventive Services Task Force recommends that individuals who are 40- 75 years old with one or more cardiovascular risk factor (i.e. high lipids, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater (calculator) be on a statin drug.

High LDL cholesterol rates among those treated with statins might lead some physicians to move to prescribing PCSK9 inhibitors (Repatha, Praluent), which are self-injected every other week and Leqvio, which limits PCSK9 production, self-injected once every 6 months. These drugs are even more effective at lowering cholesterol than statins, but cost about $7000 a year (compared to about $50 a year for atorvastatin, the generic of the statin initially marketed as the brand name Lipitor).

Implications for employers:

• Heart disease rates declined rapidly from 1980 until about 2010, but have not continued to decline.  This study shows that there is still a real opportunity to decrease premature vascular disease.

• Many who are on statins likely are not adherent. Employers should be aware that the pharmacy benefit managers reporting on “medication possession ratio,” likely overstates adherence, since medications delivered but never taken don’t prevent heart attacks.

• Health plans can implement provider quality metrics for adequate treatment of cholesterol for those with known heart disease.

• We should encourage full use of less-expensive effective generic medications before shifting patients to especially high-cost alternatives.

• Employers can promote adherence to lipids by putting statins on the preventive medicine list, so patients have no cost sharing. 

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