Abstract Background Optimizing low-density lipoprotein cholesterol (LDL-C) is crucial for both primary and secondary prevention in atherosclerotic cardiovascular disease (ASCVD). Clinical guidelines for managing LDL-C recommend lower targets with increasing patient risk level and consideration of appropriate intensification of lipid lowering therapy (LLT). Understanding trends in LLT use can help inform clinical practice and health policy. This study analysed long-term trends in LLT use among patients with ASCVD among the general population within the Maccabi Health Services (MHS, a nationwide payer-provider health plan in Israel, representing one quarter of the population) database. Methods We retrospectively examined deidentified electronic health records and pharmacy data from MHS between 2013 and 2023. We included adults aged 40–79 years with a first non-fatal ASCVD event between January 2006 and December 2023 and assessed annual LLT utilization patterns following index event. Using multivariable logistic regression, we identified factors independently associated with stable LLT utilization at 1, 3, 5, and 8 years of follow-up among patients who experienced their first event in 2013 or later and survived for the corresponding duration. Stable LLT utilization was proxied as the purchase of at least one LLT of any type in each follow-up year. Results Among 44,410 adults experiencing their first ASCVD event, approximately 86% were on any LLT in any of the follow-up years. Among them, we observed a significant decrease in the use of statin monotherapy and increase in combination use of statins and ezetimibe between 2013 and 2023, dropping from 76% to 49% and rising from 4.3% in 2013 to 31.6% in 2023, respectively (p0.001, Figure 1). The utilization of PCSK9 inhibitors has also grown steadily, from 0.02% in 2016 to 3.15% in 2023, mostly in combination with other LLTs. Across all subgroups, consistent LLT use was independently associated (Figure 2) with male sex, higher socioeconomic status (SES), an index event of an MI (compared to ischemic stroke, PAD or carotid endarterectomy), a history of diabetes, hypertension, or LLT use prior to their index event. Younger age was independently associated with less LLT use. Conclusions We observed steady overall LLT use and increasing combination LLT use over the last decade among patients in MHS following an ASCVD event. Observations underscore the need to target certain groups of patients in guideline directed LLT use following ASCVD events, particularly among the younger population, women, those with lower SES, and those experiencing ischemic stroke or PAD. Targeted, innovative interventions may be needed to address barriers to, continued implementation of, and adherence to, guideline recommended LLT. Further research is warranted to explore the underlying causes of LLT non-utilization and develop effective strategies to mitigate this challenge.
Goldberg et al. (Sat,) studied this question.