Abstract Background A substantial proportion of individuals labelled as "primary prevention" in routine general practice actually fulfil ESC high or very-high-risk criteria due to multimorbidity, end-organ vulnerability, and chronic inflammatory conditions. These patients require intensive LDL-cholesterol (LDL-C) lowering, yet real-world evidence suggests that treatment targets are often unmet across Europe. Bempedoic acid is a non-statin oral therapy for patients unable to optimise statin-based regimens, but its effectiveness in multimorbid high-risk primary prevention populations is incompletely characterised. Methods A retrospective mixed-methods review was conducted using anonymised records from 708 adults prescribed bempedoic acid–containing therapies in a rural English general practice. Quantitative data included demographics, comorbidities, adherence, and serial lipid profiles; qualitative review explored brief discontinuation notes. The cohort comprised 336 males and 372 females, with a mean age of 69.2 years (SD 10.2). Mean adherence was 90.7%, with approximately 85% persisting on therapy. Results Multimorbidity was striking: 86% had ≥1 comorbidity known to elevate ASCVD risk. High-prevalence comorbidities included diabetes (27%), CKD (37%), hypertension (65%), pre-diabetes (21%), COPD (12%), psoriasis (8%), rheumatoid arthritis (3%), and heart failure (7%). These conditions reclassified the majority of patients into ESC high or very-high-risk categories, despite being treated as primary prevention. Bempedoic acid produced a mean LDL-C decrease from 2.83 mmol/L (SD 1.08) at baseline to a mean of 1.76 mmol/L (SD 0.96) across sequential follow-up periods. Goal attainment over a median of 199 days improved by: - 315 in "high-risk" group (1.8 mmol/L) (271% improvement) - 187 in "very-high-risk" group (1.4 mmol/L) (325% improvement) Discontinuation was infrequent and predominantly due to non-specific symptoms; most individuals who discontinued remained on ezetimibe monotherapy. Discussion: This real-world analysis demonstrates that a rural primary prevention cohort was predominantly composed of multimorbid, high and very-high-risk individuals, consistent with ESC-defined risk modification. Bempedoic acid delivered clinically meaningful LDL-C reductions and substantial ESC goal attainment in precisely the group where achieving targets is historically most challenging. High adherence underscores its acceptability within complex multimorbidity. These findings support bempedoic acid as a valuable adjunct in delivering guideline-aligned prevention, helping bridge Europe’s persistent LDL-C treatment gap. Conclusion Bempedoic acid supports robust LDL-C lowering and meaningful attainment of ESC targets in high- and very-high-risk multimorbid primary prevention patients. Structured follow-up, enhanced counselling and multimorbidity-aware prescribing may further optimise outcomes in rural primary care.
Deaney et al. (Mon,) studied this question.
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