Real-world LDL-C reduction, treatment persistence and primary prevention impact of bempedoic acid in rural primary care: a mixed-methods evaluation

Abstract Background Achieving LDL-cholesterol (LDL-C) targets in primary prevention remains challenging, with European data consistently demonstrating poor goal attainment despite guideline recommendations. The ESC Primary Prevention Guidelines emphasise absolute LDL-C reduction and sustained adherence as central pillars of ASCVD risk reduction. Bempedoic acid offers a useful non-statin therapy for patients unable to reach targets—supported by CLEAR Outcomes, which demonstrated reduced major cardiovascular events in statin-intolerant patients and meaningful LDL-C lowering. However, real-world data from UK primary care remains limited. Methods This retrospective mixed-methods evaluation assessed 708 adults prescribed bempedoic acid–containing therapies across a rural primary care network. Demographics, serial lipid measurements, adherence, and persistence were extracted, alongside a qualitative review of treatment discontinuation entries. Baseline characteristics included a mean age of 69.2 years (SD 10.2), 53% female, and 94% British or Mixed British ethnicity. Mean adherence was 90.7%, and ~85% of patients remained on therapy. Results Bempedoic acid produced sustained LDL-C reductions consistent with RCT evidence. Mean LDL-C decreased from 2.83 mmol/L (SD 1.08) at baseline to 1.92, 1.80, and 1.71 mmol/L across sequential intervals (median 878 to 311 days). Non-HDL cholesterol fell from 3.71 mmol/L (SD 1.16) to 2.73, 2.60, 2.51, and 2.30 mmol/L, demonstrating broad atherogenic lipid improvement. ESC moderate-risk LDL-C targets (2.6 mmol/L) were achieved by 58% of patients by the median follow-up of 199 days. LDL-C remained stable over time, reflecting strong adherence. Discontinuation occurred in 114/721 individuals, generally due to non-specific symptoms and not biochemically confirmed intolerance. Most who discontinued transitioned to ezetimibe monotherapy, maintaining partial LDL-C control. Discussion: Findings demonstrate that bempedoic acid effectively addresses the persistent gap in LDL-C goal attainment in routine primary care, contributing to improved alignment with ESC 2025 expectations. High adherence and durable lipid improvements reinforce its role in real-world primary prevention strategies, complementing the evidence base established in CLEAR Outcomes. Conclusion Bempedoic acid is a practical, well-tolerated lipid-lowering option for primary ASCVD prevention in rural primary care. Sustained LDL-C reductions, strong persistence and improved goal achievement highlight its value in addressing Europe’s ongoing LDL-C treatment gap. Structured follow-up and enhanced counselling may further optimise long-term outcomes.