Preventing Dropped Balls: Pharmacists Can Catch Missed Opportunities in Lipid Management

In baseball, a towering pop fly draws multiple fielders to the same spot. Without clear communication and coordination, the ball may fall untouched with the batter safely reaching base as fielders hesitate, each unsure of who should take responsibility. Announcers often describe this play using the phrase “I've got it - Wait, no you take it” to show how miscommunication between teammates can turn what should be an easy out into an unearned run. This serves as a reminder that seemingly routine situations can go awry, resulting in missed opportunities and adverse outcomes when accountability is unclear. In this issue of JACCP, Ayers and colleagues describe a far more consequential dropped ball that directly impacts the health and prognosis of patients with atherosclerotic cardiovascular disease (ASCVD) [1]. The link between elevated LDL cholesterol (LDL-C) and recurrent cardiovascular events (e.g., acute coronary syndrome, myocardial infarction, ischemic stroke) in patients with clinical ASCVD is well established as is the impressive risk reduction associated with aggressive LDL-C lowering with high-intensity statins and other lipid-lowering therapies [2, 3]. Despite this, numerous reports identify persistent gaps in achieving LDL-C treatment targets in patients with ASCVD [4-8]. Importantly, prior studies often did not include patients undergoing revascularization procedures, a group at especially high risk for recurrent events. In their retrospective cohort analysis, Ayers et al. address this limitation by focusing specifically on lipid-lowering therapy (LLT) following coronary (PCI or CABG), cerebrovascular (angioplasty, stent, or carotid endarterectomy), or peripheral artery disease (PAD, angioplasty, or bypass graft) revascularization at an urban academic medical center. Their goal was to evaluate attainment of guideline-recommended LDL-C goals, therapy intensification when indicated, and follow-up LDL-C monitoring. Their findings that management of postprocedure lipid-lowering therapy is often suboptimal are both disappointing and not surprising. Patients (n = 119) with a baseline (prerevascularization) LDL-C > 70 mg/dL were included in the analysis. Over the 15 months of follow-up, less than half of the patients had a repeat evaluation of their lipid profile and fewer than 20% achieved an LDL-C < 70 mg/dL. Moreover, the authors identified 269 ambulatory care visits in which providers did not assess lipid profiles, reflecting missed opportunities (the ball was dropped) to optimize care in these high-risk patients. Their results are particularly concerning given the well-documented benefits of early LDL-C reduction in reducing cardiovascular events in patients with ASCVD [9, 10]. The authors are commended for focusing on patients after common revascularization procedures for whom data are limited despite elevated risk [1]. When stratified by revascularization type, important differences in LLT management were found. Patients undergoing coronary revascularization were more likely to receive follow-up lipid testing and to achieve LDL-C < 70 mg/dL compared with those undergoing cerebrovascular or peripheral procedures. Follow-up with cardiology was a strong predictor of obtaining a postprocedure lipid panel. These findings are similar to previous results showing lower use of high-intensity statins, worse rates of target LDL-C attainment, and higher adverse cardiovascular event rates in patients with noncoronary ASCVD [4, 6, 8]. Also of concern is that suboptimal lipid management was more frequent in Black patients, underscoring ongoing disparities in cardiovascular care. Collectively, these findings reveal distinct patterns of care for patients according to race and coronary versus noncoronary revascularization. After coronary procedures, cardiologists typically guide follow-up care, perhaps in conjunction with a primary care provider. In contrast, patients with ischemic stroke or PAD may be managed by multiple specialists including vascular surgery, interventional radiology, neurology, cardiology, and primary care, increasing the likelihood that crucial aspects of care—such as lipid management—will be overlooked. Thus, it is not surprising that these latter patients are at greater risk of falling through the cracks just like dropping the pop fly in baseball—“I've got it - Wait, no you take it”. The authors note several limitations of their study, including those inherent in any retrospective analysis [1]. Although it was clear from their results that LDL-C management was not consistent with current guidelines, the relatively short-term follow-up (15 months) precluded any evaluation of the risk of recurrent cardiovascular events. Social determinants of health were not evaluated and could affect results, since the patient population was from an urban minority-serving medical center. Also, adherence to LLT was not determined, which could affect achievement of LDL-C goals and treatment decisions. Their use of an LDL-C < 70 mg/dL target also likely underestimates contemporary care gaps. Because their cohort underwent revascularization between July 2021 and July 2022, the selected LDL-C target of < 70 mg/dL aligned with the recommendation in place at that time from the 2018 AHA/ACC Guideline on Management of Blood Cholesterol [11]. Recommendations for an LDL-C target < 55 mg/dL from the ACC Expert Consensus Decision Pathway for very high-risk ASCVD were published in late 2022 [12]. Moreover, the 2026 ACC/AHA Multisociety Guideline on the Management of Dyslipidemia now recommends an LDL-C goal of < 55 mg/dL using high-intensity statin and nonstatin therapies in patients with very high-risk ASCVD [2]. Given that the majority of revascularized patients meet criteria for very high risk, the challenge ahead is even more formidable. Another recent analysis reported that only 21% of such patients met the LDL-C goal of < 55 mg/dL [8]. Our patients deserve better than what they are getting. The findings of Ayers and colleagues, coupled with numerous other reports of failure to achieve recommended LDL-C goals in at-risk patients, underscore the critical disconnect between what we know (low LDL-C is good) and what we do (routinely fail to adequately assess, initiate, intensify, or monitor therapy) [1, 6-8, 13]. The reasons for this disconnect are multifactorial and include patient-level (nonadherence, cost, social determinants of health), clinician-level (therapeutic inertia, time, underestimation of cardiovascular risk), and healthcare system-level (care fragmentation between specialties, electronic health record gaps) barriers. Clinical pharmacists are ideally positioned to overcome many of these barriers and ensure that we don't drop the ball in these patients at high-risk for recurrent cardiovascular events. So how can we do better? Team-based care that incorporates clinical pharmacists into multidisciplinary care teams can overcome many of these barriers and substantially improve cholesterol management [14-17]. For example, patients with PAD managed by a vascular care team that included clinical pharmacists were eight times more likely to achieve LDL-C < 55 mg/dL compared to usual care [16]. These impressive results were primarily achieved by obtaining timely lipid profiles and by increasing use of high-intensity statins, ezetimibe, and PCSK9 inhibitors—all important activities that can be performed by clinical pharmacists. In a meta-analysis of 26 randomized trials, Dixon and colleagues also reported that pharmacist intervention yielded significant improvements in LDL-C concentrations [15]. Use of collaborative practice agreements with clinical pharmacists, clinical decision support systems, electronic health record (EHR) alerts to identify and assist follow-up of at-risk patients, artificial intelligence-driven protocols, transition of care strategies, and telehealth initiatives to improve care accessibility are all approaches that can reduce the likelihood that essential, effective, and evidence-based care is overlooked. Ongoing clinical trials evaluating the effect of behavioral nudges to increase referrals to pharmacist-managed lipid evaluation and treatment will further support implementation strategies [18]. Programs should consider prioritizing populations with the lowest rates of optimal therapy—women, racial and ethnic minorities, and patients with noncoronary ASCVD [2, 4, 7, 16]. Finally, while LDL-C is a critical target, it is only one component of comprehensive cardiometabolic care. Many patients in this population have multiple comorbidities—hypertension, diabetes, heart failure, obesity, tobacco use—that are also frequently undertreated. Integrated approaches combining comprehensive medication management with team-based care to optimize management of all risk factors meaningfully and substantially reduces cardiovascular risk [19]. Clinical pharmacists—trained, available, and ready—are the teammates best positioned to “call the ball” in this situation and prevent the next dropped opportunity. Microsoft Copilot was used to assist with developing the title and editing the first draft of the editorial for clarity and conciseness. Robert B. Parker, Pharm.D. is an Associate Editor of the Journal of the American College of Clinical Pharmacy.