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Adoption of 2013 ACC/AHA Cholesterol Management Guideline in Cardiology Practices
Study Questions:
To what degree have US cardiologists adopted the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline in their practices?
Methods:
Among 161 cardiology practices, trends in the use of moderate-intensity to high-intensity statin and nonstatin lipid-lowering therapy (LLT) were analyzed before (September 1, 2012, to November 1, 2013) and after (February 1, 2014, to April 1, 2015) publication of the 2013 ACC/AHA guideline among four mutually exclusive risk groups within the ACC Practice Innovation and Clinical Excellence Registry. Participants were a population-based sample of 1,105,356 preguideline patients and 1,116,472 postguideline patients with each averaging about two encounters and 0.5 lipid draws postpublication. Approximately 97% of patients had atherosclerotic cardiovascular disease (ASCVD).
Results:
Mean age was about 70 years and 40% were female in each time period. Although there was a trend toward increasing use of moderate-intensity to high-intensity statins overall and in the ASCVD cohort, the trend was already present before publication. The use of moderate-intensity to high-intensity statin therapy was 62.1% (before publication of the guideline) and 66.6% (after publication) in the overall cohort, 62.7% (before publication) and 67.0% (after publication) in the ASCVD cohort, 50.6% (before publication) and 52.3% (after publication) in the cohort with elevated low-density lipoprotein cholesterol (LDL-C) levels (i.e., ≥190 mg/dl), 52.4% (before publication) and 55.2% (after publication) in the diabetes cohort, and 41.9% (before publication) and 46.9% (after publication) in the remaining group with 10-year ASCVD risk of 7.5% or higher. There was a significant increase in the use of moderate-intensity to high-intensity statins in the overall cohort (4.8%) and in the ASCVD cohort (4.3%) (p < 0.01 for slope for both). There was no significant change for other risk cohorts. Nonstatin LLT use remained unchanged in the preguideline and postguideline periods.
Conclusions:
Adoption of the 2013 ACC/AHA Cholesterol Management Guideline in cardiology practices was modest. Timely interventions are needed to improve guideline-concordant practice to reduce the burden of ASCVD.
Perspective:
The results are both disappointing and frustrating considering moderate- and high-intensity statins are now generic. LDL-C levels were missing in 64.7% of the preguideline and 70.8% of the postguideline period. The improvement in the high-risk groups was small. More importantly, before publication, 22% of patients with ASCVD were not taking LLT, which reduced modestly to 19.3% after publication. Considering the frequency of missing LDL-C in the cardiologist office practice and the very small change in practice, I suspect a very large number of patients in the 161 cardiology practices had lipids managed by primary care physicians, for whom there is usually a delay in embracing guidelines.
Keywords: Atherosclerosis, Cardiovascular Diseases, Cholesterol, Cholesterol, LDL, Diabetes Mellitus, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lipids, PINNACLE Registry, Primary Prevention, Risk
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