Improving adherence to cholesterol lowering guidelines through an interactive digital tool

Background Statins are the cornerstone of primary and secondary prevention of atheroscleoric cardiovascular disease (ASCVD). Our previous retrospective analysis of 1042 consecutive patient encounters at a large urban academic institution found that one in five patients were not prescribed an appropriate statin therapy. These patients tended to be younger, of Black race, and met statin-eligibility solely via a 10-year ASCVD risk score ≥7.5%. Only one-third of patients had follow-up cholesterol levels ordered to monitor treatment efficacy. Purpose To improve adherence to cholesterol guidelines at our academic institution. Methods We implemented multiple interventions over a four-month period to support clinical decision making of guideline directed statin therapy: a) development of an online interactive tool, b) physician education on updated cholesterol guidelines and utilization of the tool, c) display of guideline summary in the workspace, and d) a documentation reminder in the electronic health record. We randomly selected encounter dates, from which 622 consecutive patient visits were analyzed. The primary outcome measures were: prescription rates of statins, documentation of a 10-year ASCVD risk score, and follow-up cholesterol levels ordered to monitor treatment efficacy. Results Out of the 622 patients, 232 met statin indication. In this post-intervention group, statin prescriptions rates improved when compared to the pre-intervention group (90.5% vs 82.3%, p=0.006). Among the patients who met statin indication solely via a 10-year ASCVD risk score ≥7.5%, there was an increase in documentation of the calculated 10-year ASCVD risk score (72.3% vs 57.8%; p=0.039) and in statin prescription rate (90.8% vs 67.6%; p<0.001). In addition, there was an increase in follow-up cholesterol levels ordered in all patients included in our study who met statin indication (64.1% vs 33.3%; p<0.001). Conclusion Our study showed higher rates of statin prescription, 10-year ASCVD risk score documentation, and treatment monitoring after multiple interventions, including an easily accessible online interactive tool, at a large urban academic institution. Funding Acknowledgement Type of funding sources: None. Statin Prescription Rates

Large-Scale Screening for Monogenic and Clinically Defined Familial Hypercholesterolemia in Iceland

Objective: Familial hypercholesterolemia (FH) is traditionally defined as a monogenic disease characterized by severely elevated LDL-C (low-density lipoprotein cholesterol) levels. In practice, FH is commonly a clinical diagnosis without confirmation of a causative mutation. In this study, we sought to characterize and compare monogenic and clinically defined FH in a large sample of Icelanders. Approach and Results: We whole-genome sequenced 49 962 Icelanders and imputed the identified variants into an overall sample of 166 281 chip-genotyped Icelanders. We identified 20 FH mutations in LDLR , APOB , and PCSK9 with combined prevalence of 1 in 836. Monogenic FH was associated with severely elevated LDL-C levels and increased risk of premature coronary disease, aortic valve stenosis, and high burden of coronary atherosclerosis. We used a modified version of the Dutch Lipid Clinic Network criteria to screen for the clinical FH phenotype among living adult participants (N=79 058). Clinical FH was found in 2.2% of participants, of whom only 5.2% had monogenic FH. Mutation-negative clinical FH has a strong polygenic basis. Both individuals with monogenic FH and individuals with mutation-negative clinical FH were markedly undertreated with cholesterol-lowering medications and only a minority attained an LDL-C target of <2.6 mmol/L (<100 mg/dL; 11.0% and 24.9%, respectively) or <1.8 mmol/L (<70 mg/dL; 0.0% and 5.2%, respectively), as recommended for primary prevention by European Society of Cardiology/European Atherosclerosis Society cholesterol guidelines. Conclusions: Clinically defined FH is a relatively common phenotype that is explained by monogenic FH in only a minority of cases. Both monogenic and clinical FH confer high cardiovascular risk but are markedly undertreated.

Differences in Beliefs About Cholesterol-Lowering Medications Among the Visegrad Group Countries: A Cross-Sectional Study

Background: New cholesterol guidelines highlight more personalized risk assessments and new cholesterol-lowering drugs for people at the highest risk for cardiovascular disease. Adherence due to fear of and lack of trust in medications prevents treatment to provide better health outcomes.Objectives: The aim of our study was to investigate the possible differences in the beliefs about the necessity and concerns regarding lipid-lowering drugs among the Visegrad Group countries.Methods: The Beliefs About Medicines Questionnaire (BMQ-Specific) was used in our research. The responses of 205 Hungarian, 200 Slovak, 235 Czech, and 200 Polish participants, all taking cholesterol-lowering medications, were compared to each other.Results: Hungarian participants' belief in the necessity of cholesterol-lowering drugs was significantly lower compared to the Slovak (P = 0.001), Czech (P = 0.037), and Polish (P &lt; 0.001) participants. While no difference was observed between the Czech and Slovak responses (P = 0.154), both the Czech (P &lt; 0.001) and Slovak (P = 0.006) respondents' belief regarding necessity was lower than that of the Polish. Regarding concerns, the only significant difference was observed between the Czech and the Polish respondents (P = 0.011).Conclusions: While the beliefs about benefits (necessity) are most prominent among the Polish participants, except in comparison to Czech responses, the Visegrad Group countries do not differ considerably regarding their beliefs about the fear (concerns) of the treatment.

Abstract 13117: Incorporation of High-Sensitivity Troponin Along With the AHA/ACC Cholesterol Guidelines for Improved Risk Stratification and Targeted PCSK9 Inhibition in Atherosclerotic Cardiovascular Disease

Introduction: The 2018 AHA/ACC cholesterol guidelines only recommend PCSK9 inhibitors in patients with very high risk ASCVD. However, high-sensitivity troponin (hsTn) can reclassify some lower risk patients as very high risk, identifying a subgroup who may benefit from PCSK9 inhibitors. Methods: We performed a nested prospective biomarker substudy including 22,224 patients enrolled in the FOURIER trial, which tested the PCSK9 inhibitor evolocumab. Per the guidelines, patients were assigned to ASCVD risk categories of “very high risk” or “not very high risk” (lower risk), followed by classification based on hsTnI (Abbott ARCHITECT) using an a priori risk threshold of 6 ng/L. The primary endpoint was a composite of CV death, MI, stroke, unstable angina, or coronary revascularization. The median follow-up was 2.2 years. Results: Clinical ASCVD categories alone identified a gradient of risk from 7.1% to 12.3% (HR 1.83, p<0.0001). Adding hsTnI further risk stratified patients by 1.5- to 2-fold in both the lower and very high risk ASCVD categories (HR 1.73, p=0.017 & HR 1.81, P<0.0001). Among patients with lower risk ASCVD, 25% had an elevated hsTnI and carried a similar risk (10.5%) to patients with very high risk ASCVD and low hsTnI (9.8%). Very high risk ASCVD patients receiving evolocumab had an absolute risk reduction of 1.9% (0.98-2.72). A similar absolute risk reduction was seen in the 25% of patients in the lower risk group with elevated hsTnI (ARR 2.0%, Figure). Conclusions: Either hsTn or ASCVD clinical criteria can identify patients who benefit from evolocumab. Specifically, hsTnI identifies a significant cohort of nominally lower risk ASCVD patients who are actually at greater risk than appreciated and may derive absolute risk reductions on par with very high risk ASCVD patients.