Clinicians need to implement strategies that improve adherence to and greater use of intensive therapies in secondary cardiovascular disease prevention.

Patients with established coronary heart disease (CHD) require targeted risk management strategies and treatments, including lipid‐lowering therapy (LLT), to help reduce their risks for subsequent cardiovascular (CV) events and death. Published studies have demonstrated the benefits of statins when managing patients with CHD, with each 1 mmol/L reduction in LDL cholesterol (LDL‐C) being associated with a 20% relative reduction of major CV events. As such, long‐term adherence to effective LLT is strongly recommended by clinical guidelines.

According to observational studies, many patients with CHD do not receive high‐intensity LLT as first‐line therapy, fail to switch to high‐intensity LLT, and/or have suboptimal adherence rates. “It is possible that suboptimal LLT management can affect cardiovascular disease (CVD) recurrence and LDL‐C goal attainment, but this has not been well studied,” says Faizan Mazhar, PharmD, PhD. Previous research has been limited by fragmented healthcare issues, varied indications for using LLT, a lack of information on LDL‐C levels, and evaluating only fixed periods of adherence.

For a study published in the Journal of the American Heart Association, Dr. Mazhar and colleagues examined 20,490 adults who suffered a myocardial infarction or had coronary revascularization between 2012 and 2018 and subsequently initiated LLT. Specifically, investigators looked at LLT adherence, LLT intensity, and a combined measure of adherence and intensity. At each LLT fill, the study group calculated adherence and intensity during the previous 12 months. The primary outcome was major adverse cardiovascular events (MACE), including nonfatal myocardial infarction or stroke and death. Secondary outcomes included LDL-C goal attainment and individual components of MACE.

Better LLT Adherence Reduces Risks for MACE

The study team found that every 10% increase in 1‐year adherence, intensity, or adherence‐adjusted intensity was associated with a 6% reduction in the risk for MACE, according to investigators (Table). In addition, each 10% incremental increase in adherence was associated with a lower risk for unstable angina and a tendency toward a modest reduction of risk for heart failure. They also observed that every 10% increase in adherence, intensity, or adherence and intensity was associated with higher odds of LDL‐C goal attainment.

Among patients with good adherence—defined as being adherent 80% or more of the time for the year—the risk for MACE was similar with low‐moderate and high‐intensity LLT despite differences in the LDL-C goal attainment with the treatment intensities. Patients with poorer adherence were at higher risk for not achieving the LDL-C goal of less than 1.8 mmol/L than those with good adherence. A similar pattern was observed for patients using low‐moderate intensity LLT versus high intensity LLT. Poorly adherent patients who received low-moderate intensity LLT were less likely to attain LDL‐C goals than those with optimal adherence receiving high‐intensity treatment. Furthermore, patients who discontinued statins at 1 year or later had markedly higher risks for adverse patient outcomes.

Effective Interventions Needed to Improve Adherence

Collectively, findings from the study emphasize the need to implement strategies that improve adherence and greater use of intensive therapies in secondary CVD prevention. “Our results indicate that optimal LLT use can provide a significant prognostic benefit, regardless of treatment intensity, in post-myocardial infarction or revascularized patients with CHD,” Dr. Mazhar says. Notably, good adherence to LLT was more important than LLT intensity or achieved LDL‐C levels for reducing CV risk. The highest CV risk was seen in those who discontinued LLT.

Previous research shows that various strategies have been used to improve statin uptake in patients with hypercholesterolemia, but these interventions have had varying degrees of success. “Although these interventions may improve statin prescribing and adherence, no single strategy or approach has been shown to consistently improve outcomes,” says Dr. Mazhar. “As such, the optimal strategy should be multifaceted and tailored to the patient.” Providing person‐centered secondary prevention care is important to showing patients that their values are being considered. Such efforts can facilitate patient discussions on the risks and encourage treatment adherence for the long term.