Abstract 4370304: Phenotyping Lipid-Lowering Therapies for Patients with ASCVD

Abstract

Background: Statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) are used to lower low-density lipoprotein (LDL) to below 70 mg/dL ("at-goal") in patients with atherosclerotic cardiovascular disease (ASCVD). Identifying ASCVD patients above this goal on suboptimal lipid-lowering therapy (LLT) is critical for addressing guideline-recommended care gaps. In this study, we investigate differences in patients with LDL at-goal and above-goal by phenotyping changes in their LLT throughout the electronic health record (EHR). Hypothesis: Patients with ASCVD with an LDL above-goal are less likely to be on maximal LLT. Methods: In this retrospective cohort study, we identify all patients with a clinician-billed diagnosis code of ASCVD at a Northern California healthcare system from January 1, 2019 through May 15, 2025. We retrieved outpatient encounters from specialties managing ASCVD (e.g., Primary Care, Cardiology) and excluded patients with single encounters. Active prescription data for a statin (by intensity, low/moderate vs. high), ezetimibe, and a PCSK9i were linked to each encounter. LDL values were linked to each encounter if they were obtained within 6 months; if multiple were present, the closest one was used. Univariate statistical analyses were conducted for each patient at the time of their most recent encounter. Results: We identified 28,520 ASCVD patients with ≥2 outpatient encounters and associated LDL values. Only 15,368 (53.9%) were on high-intensity statins and 15,493 (54.3%) had above-goal LDL. Nonstatin LLT use was low (ezetimibe: 4.9%; PCSK9i: 1.2%). Mean LDL in the above-goal group was 129.3±42.9 mg/dL versus 47.0±14.3 mg/dL in the at-goal group. Most patients with above-goal LDL had no LLT adjustment at their most recent encounter (Graphic 1A), and when changes occurred, 72.1% were therapy de-escalations (Graphic 1B). Compared to at-goal patients, above-goal patients were older (70 vs. 69.1 years), more likely to be women (40.1% vs. 35.6%), have recent LLT de-escalation (10.4% vs. 7.9%), and be off statins (16.7% vs. 9.9%) (Graphic 2). Conclusion: In patients with ASCVD, nonprescription rates of high-intensity statins and non-statin LLT remain high, LDL remains above goal for over half of patients, and changes to patient LLT are rarely made. However, identification of these patients and encounters can create a focal point for targeted interventions to reduce care gaps in ASCVD care.