Undertreatment of hyperlipidemia in the secondary prevention of coronary artery disease

OBJECTIVES: To determine adherence to national guidelines for the secondary prevention of coronary artery disease (CAD) using lipid-lowering drugs (LL Ds), by studying the rate of use of LLDs, predictors of use, and the rate o f achieving lipid goals, among eligible patients recently hospitalized with acute myocardial infarction. DESIGN: Cross-sectional analysis of 2,938 medical records, collected from J uly 1995 to May 1996. SETTING: Thirty-seven community-based hospitals in Minnesota. PATIENTS: The 622 patients had previously established CAD and hyperlipidemi a (total cholesterol >200 mg/dL or currently using LLDs), and were eligible for LLDs according to the National Cholesterol Education Program II (NCEP II) Guidelines. MEASUREMENTS: The use of LLDs in eligible patients (primary outcome) and su ccessful achievement of NCEP II: goals (total cholesterol <160 mg/dL) among treated patients (secondary outcome). MAIN RESULTS: Only 230 (37%) of 622 eligible patients received LLDs. In mul tivariate logistic regression, factors independently related to LLD use inc luded age greater than 74 years (adjusted odds ratio [AOR] 0.55; 95% confid ence interval [CI] 0.35, 0.88) and severe comorbidity (AOR 0.60; 95% CI 0.3 8, 0.95), managed care enrollee (AOR 1.56; 95% CI 1.02, 2.39), past smoker (AOR 1.72; 95% CI 0.98, 3.01), prior revascularization (AOR 2.31; 95% CI 1. 51, 3.53), and the use of aspirin (AOR 1.59; 95% CI 1.07, 2.38) or greater than or equal to 4 medications (AOR 2.89; 95% CI 2.19, 3.84). Of the treate d patients who had lipid levels measured (n = 149), 15% achieved the recomm ended goal of a total cholesterol below 160 mg/dL. Of the untreated patient s (n = 392), 89% were discharged from hospital without a LLD prescription. CONCLUSIONS: Lipid-lowering drugs, although proven effective for the second ary prevention of CAD, were used by only one third of eligible patients. Am ong patients receiving LLDs, few achieved recommended lipid goals. Directed quality improvement interventions, such as starting LLDs during hospitaliz ation, may have the potential to substantially reduce CAD morbidity and mor tality in this vulnerable population.