By Martin S. Lipsky, MD
SYNOPSIS: Following hospital discharge for a heart attack, the majority of Medicare patients do not get recommended high-intensity statin therapy.
SOURCE: Rosenson RS, et al. Underutilization of high-intensity statins therapy after hospitalization for coronary artery disease. J Am Coll Cardiol 2015;65: 270-275.
Following a hospitalization for coronary heart disease (CHD) or acute coronary syndrome (ACS), randomized trials demonstrate that high-intensity atorvastatin is more effective than either placebo or low- to moderate-intensity therapy with either pravastatin or atorvastatin.1-3 Based on this evidence, the American College of Cardiology and the American Heart Association guidelines recommend high-intensity therapy in cases of an acute cardiac event and that therapy be initiated before discharge.
Previous studies indicate that more than 80% of patients receive a statin after a myocardial infarction (MI) or coronary revascularization.4-5 However, few studies examined the percentage of individuals who met guidelines and were prescribed and filled a script for high-intensity statins. One previous study demonstrated that only about one in three filled a high-intensity statin script6 and that the only correlation with taking a high-intensity statin after 1 year was being prescribed a high-intensity statin at discharge.
The authors used a random sample of Medicare beneficiaries between ages 65 and 74 who filled a statin script after being hospitalized for a MI or for bypass surgery from 2007-2009. Of the more than 8000 who filled a statin script, only 27% of the first post-discharge scripts were for a high-intensity statin such as 40-80 mg of atorvastatin or 80 mg of simvastatin. The percentage filling a high-intensity statin post-discharge was 23.1%, 9.4%, and 80.7 % for beneficiaries not taking statins pre-hospitalization, taking low- to moderate-intensity statins, and taking high-intensity before the CHD event, respectively.
Only 11.5% of beneficiaries whose first post-discharge fill was for a low- to moderate-intensity statin eventually filled a high-intensity statin within 365 days of discharge. The authors conclude that the majority of Medicare beneficiaries do not fill high-intensity statin after hospitalization for CHD.
Despite evidenced-based guidelines supporting the use of high-intensity statins in a high-risk population, Rosenson and colleagues found that only about one in four individuals hospitalized for a coronary event receive high-dose statins.
To no great surprise, the greatest predictor of who fills a high-intensity statin was being on one prior to hospitalization. Even though one might argue that physicians are reluctant to use a high dose initially, and prefer to titrate the dose up if tolerated, by year’s end, the percentage on high-intensity therapy only increased to about 35%. Unfortunately, the Medicare dataset used did not allow an analysis of the characteristics, such as liver disease, dose intolerance, or renal disease that might account for such low compliance with the guidelines.
So why are doctors reluctant to use these medicines as recommended? One explanation may be that physicians are unaware of the recommendation, although physicians participating in the care of patients with myocardial infarctions or bypass surgery likely would be familiar with this recommendation. It is possible that despite their physician’s recommendation, patients might be reluctant to fill these scripts. However, in the face of a significant cardiac event, most patients will at least follow their physician’s initial advice.
So what explains such a low level of compliance with a recommended guideline? It likely relates to concerns about the risk of using high-dose statins in an older postulation who are the most vulnerable to side effects. Early on statins may have gotten a bad rap, with some early studies reporting the risk of adverse effects as high as 20%. However, a recent Johns Hopkins review of 20 years of research concluded that the risks linked to statins, including muscle toxicity, diabetes, and dementia, were very low and far outweighed by a statin’s benefits.
The authors found little evidence of significant myalgias and only a modest increase in myositis. Rhabdomyolysis was primarily associated with regimens that are no longer recommended. Regarding blood sugar elevations, this evidence-based review found only a modest increase in the risk of type 2 diabetes with statins. However, this association was found only among people with other risk factors for diabetes, raising the question of whether diabetes might have inevitably developed even without statin use.
Another meta-analysis by Macedo et al found an increase in muscle complaints and creatine phosphokinase (CPK) levels with statin use, but also concluded that the absolute excess risk of side effects with statins is very small compared to its beneficial effects in patients whose risks exceed a certain threshold of cardiovascular risk. The findings by Rosenson suggest that physicians might be underestimating the benefit:risk ratio for high-intensity statins in those with a coronary event.
So what is the take home message for the primary care physician? Consider reviewing how well you adhere to the guidelines recommending high-dose statin therapy. If you are not prescribing these medications as recommended, then perhaps the next step is to determine why not. If it is because of the concern about adverse effects, then I would encourage you to review the cited meta-analyses and decide if you agree with their assessments. If it is because you want to use the strategy in older patients of “start low, go slow,” then consider a tracking system to allow you to remember to increase the dose in patients without significant side effect.
Cannon CP, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004;350:
- LaRosa JC, et al. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 2005;352:1425-1435.
- LaRosa SM, et al. Safety and efficacy of atorvastatin-induced very low-density lipoprotein cholesterol levels in patients with coronary heart disease (a post hoc analysis of the treating to new targets [TNT] study). Am J Cardiol 2007;100:747-775.
- Roe MT, et al. Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. J Am Coll Cardiol 2010;56:254-263.
- Peterson ED, et al. Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J 2008;156:1045-1105.
- Arnold SV, et al. Beyond medication prescription as performance measures: Optimal secondary prevention medication dosing after acute myocardial infarction. J Am Coll Cardiol 2013;62:1791-1801.
- Desai CS, et. al. Non-cardiovascular effects associated with statins. BMJ 2014;349:3743.
- Macedo AF, et al. Unintended effects of statins from observational studies in the general population: Systematic review and meta-analysis. BMC Medicine 2014;12:1741.