This cross-sectional study aimed to identify actionable factors to improve LDL-cholesterol target achievement and overcome underuse of lipid-lowering treatments in high- or very-high-cardiovascular risk patients. We evaluated healthcare records of 934,332 subjects from North-Italy, including subjects with available lipid profile and being on statin treatments up to December 2018. A 6-month-period defined adherence with proportion-of-days-covered ≥ 80%. Treatment was classified as high-intensity-statin (HIS) + ezetimibe, HIS-alone, non-HIS (NHIS) + ezetimibe or NHIS alone. We included 27,374 subjects without and 10,459 with diabetes. Among these, 30% and 36% were on secondary prevention, respectively. Adherence was high (78–100%) and increased with treatment intensity and in secondary prevention. Treatment intensity increased in secondary prevention, but only 42% were on HIS. 2019-guidelines LDL-cholesterol targets were achieved in few patients and more often among those with diabetes (7.4% vs. 10.7%, p < 0.001). Patients in secondary prevention had mean LDL-cholesterol levels aligned slightly above 70 mg/dl (range between 68 and 73 mg/dl and between 73 and 85 mg/dl in patients with and without diabetes, respectively). Moreover, the differences in mean LDL-cholesterol levels observed across patients using treatments with well-stablished different LDL-lowering effect were null or much smaller than expected (HIS vs. NHIS from − 3 to − 11%, p < 0.001, HIS + ezetimibe vs. HIS—from − 4 to + 5% n.s.). These findings, given the observational design of the study, might suggest that a “treat to absolute LDL-cholesterol levels” approach (e.g., targeting LDLc of 70 mg/dl) was mainly used by physicians rather than an approach to also achieve the recommended 50% reduction in LDL-cholesterol levels. Our analyses suggested that female sex, younger age, higher HDL-c, and elevated triglycerides are those factors delaying prescription of statin treatments, both in patients with and without diabetes and in those on secondary prevention. Among patients on statin treatment and high adherence, only a small proportion of patients achieved LDL-cholesterol targets. Late initiation of high-intensity treatments, particularly among those with misperceived low-risk (e.g., female subjects or those with high HDL-cholesterol), appears as pivotal factors needing to be modified to improve CVD prevention.

中文翻译：

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改善他汀类药物治疗策略以降低 LDL 胆固醇：与 2 型糖尿病患者和非 2 型糖尿病患者达到目标相关的因素

这项横断面研究旨在确定可操作的因素，以提高 LDL 胆固醇目标的实现，并克服对高或极高心血管风险患者降脂治疗使用不足的问题。我们评估了来自意大利北部的 934,332 名受试者的医疗保健记录，其中包括具有可用血脂和接受他汀类药物治疗直至 2018 年 12 月的受试者。 6 个月期间定义的依从性天数比例≥ 80%。治疗分为高强度他汀类药物 (HIS) + 依折麦布、单独使用 HIS、非 HIS (NHIS) + 依折麦布或单独使用 NHIS。我们纳入了 27,374 名没有糖尿病的受试者和 10,459 名患有糖尿病的受试者。其中，30% 和 36% 分别处于二级预防。依从性很高（78-100%），并且随着治疗强度和二级预防的增加而增加。二级预防的治疗强度增加，但只有 42% 的患者使用 HIS。2019 年指南 LDL-胆固醇目标在少数患者中实现，在糖尿病患者中更常见（7.4% 与 10.7%，p < 0.001）。二级预防患者的平均 LDL-胆固醇水平略高于 70 mg/dl（范围在 68 和 73 mg/dl 之间，糖尿病患者和非糖尿病患者的范围​​分别在 73 和 85 mg/dl 之间）。此外，在使用具有良好稳定的不同 LDL 降低效果的治疗的患者之间观察到的平均 LDL-胆固醇水平差异为零或远小于预期（HIS 与 NHIS 从 - 3 到 - 11%，p < 0.001，HIS +依折麦布与 HIS——从 − 4 到 + 5% ns）。鉴于该研究的观察性设计，这些发现可能表明“治疗绝对 LDL-胆固醇水平”方法（例如，70 mg/dl 的目标 LDLc）主要由医生使用，而不是同时实现 LDL-胆固醇水平降低 50% 的推荐方法。我们的分析表明，女性、年龄较小、HDL-c 较高和甘油三酯升高是推迟他汀类药物治疗处方的因素，无论是糖尿病患者还是非糖尿病患者以及二级预防患者。在接受他汀类药物治疗且依从性高的患者中，只有一小部分患者达到了 LDL-胆固醇目标。高强度治疗的晚期开始，特别是在那些被误认为是低风险的患者（例如，女性受试者或高 HDL 胆固醇的患者）中，似乎是需要修改以改善 CVD 预防的关键因素。