Effectiveness of Blood Lipid Management in Patients With Peripheral Artery Disease

J Am Coll Cardiol. 2021 Jun 22;77(24):3016-3027. doi: 10.1016/j.jacc.2021.04.060.

Abstract

Background: Low-density lipoprotein cholesterol (LDL-C) is associated with heightened risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in peripheral artery disease (PAD). Lipid-lowering therapies (LLT) that reduce LDL-C decrease this risk.

Objectives: The authors examined LLT use and actual achieved LDL-C in PAD.

Methods: PAD patients in MarketScan from 2014 to 2018 were identified. Outcomes included LLT use, defined as high-intensity (HI) (high-intensity statin, statin plus ezetimibe, or PCSK9 inhibitor), low-intensity (any other lipid regimen), or no therapy, and follow-up LDL-C. Factors associated with LDL-C <70 mg/dl were identified with multivariable logistic regression.

Results: Among 250,103 PAD patients, 20.5% and 39.5% were treated at baseline with HI and low-intensity LLT, respectively; 40.0% were on no LLT. Over a 15-month median follow-up period, HI LLT use increased by 1.5%. Among 18,747 patients with LDL-C data, at baseline, 25.1% were on HI LLT, median LDL-C was 91 mg/dl, and 24.5% had LDL-C <70 mg/dl. Within the HI LLT subgroup, median LDL-C was 81 mg/dl, and 64% had LDL-C ≥70 mg/dl. At follow-up, HI LLT use increased by 3.7%, median LDL-C decreased by 4.0 mg/dl, and an additional 4.1% of patients had LDL-C <70 mg/dl. HI LLT use was greater after follow-up MACE (55.0%) or MALE (41.0%) versus no ischemic event (26.1%). After MACE or MALE, LDL-C was <70 mg/dl in 41.5% and 36.1% of patients, respectively, versus 27.1% in those without an event. Factors associated with follow-up LDL-C <70 mg/dl included smoking, hypertension, diabetes, prior lower extremity revascularization, and prior myocardial infarction but not prior acute or critical limb ischemia.

Conclusions: In PAD, LLT use is suboptimal, LDL-C remains elevated, and LLT intensity is a poor surrogate for achieved LDL-C. Less aggressive lipid management was observed in PAD versus cardiovascular disease, highlighting missed opportunities for implementation of proven therapies in PAD.

Keywords: lipid management; outcomes; peripheral artery disease.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Anticholesteremic Agents / therapeutic use*
  • Cholesterol, LDL / antagonists & inhibitors
  • Cholesterol, LDL / blood
  • Databases, Factual*
  • Disease Management*
  • Dyslipidemias / blood
  • Dyslipidemias / drug therapy*
  • Dyslipidemias / epidemiology
  • Female
  • Follow-Up Studies
  • Humans
  • Hypolipidemic Agents / therapeutic use*
  • Male
  • Middle Aged
  • Peripheral Arterial Disease / blood
  • Peripheral Arterial Disease / drug therapy*
  • Peripheral Arterial Disease / epidemiology
  • Treatment Outcome
  • Young Adult

Substances

  • Anticholesteremic Agents
  • Cholesterol, LDL
  • Hypolipidemic Agents