Sex differences in lipid management among high-risk patients without prior myocardial infarction or stroke: results from the VESALIUS-REAL global study

Background Effective lipid-lowering therapy (LLT) reduces the risk of cardiovascular outcomes in patients at high cardiovascular risk, as well as in those without a history of myocardial infarction (MI) or stroke. The VESALIUS-CV trial demonstrated the benefit of intensive low-density lipoprotein cholesterol (LDL-C) lowering in such patients, reducing the risk of major cardiovascular events.1 However, real-world lipid management in this population remains poorly characterised, and evidence suggests persistent sex disparities, with women less likely to receive intensive LLT or achieve guideline-recommended LDL-C levels.2,3 Purpose To examine lipid management patterns and LDL-C goal achievement in women and men at high cardiovascular risk without prior MI or stroke in 11 databases from North America, Europe, and Asia-Pacific. Methods Patients aged ≥ 50 years with either documented coronary artery disease (CAD), atherosclerotic cerebrovascular disease (CeVD), peripheral artery disease (PAD), or high-risk diabetes mellitus (DM; defined as DM with microvascular complications or chronic insulin use), plus additional cardiovascular risk factors and elevated lipid levels, but no history of MI or stroke, were selected from de-identified claims or electronic medical records (2017–2022).4 Elevated lipids were defined as ≥ 1 measurement of either LDL-C ≥ 2.3 mmol/L, non–high-density lipoprotein cholesterol ≥ 3.1 mmol/L, or apolipoprotein B ≥ 0.8 g/L. The earliest date when all criteria were met was defined as the index. This analysis summarises LLT use, LLT intensification, and LDL-C goal achievement based on local guidelines by sex. Results A total of 576,372 women (70% aged ≥ 65 years) and 550,384 men (63% aged ≥ 65 years) were included (Table). Women compared with men had a lower prevalence of CAD (38% vs 42%) and high-risk DM (30% vs 33%), but a higher prevalence of atherosclerotic CeVD (26% vs 22%) and PAD (13% vs 11%). At index, LLT use was similar in women and men (40% each); however, the use of combination therapy as well as LLT intensification within 1 year was slightly lower in women than men (5% vs 7% and 25% vs 29%, respectively). Among patients not on LLT at index, a smaller proportion of women initiated LLT within 1 year compared with men (8% vs 11%). LDL-C testing within 1 year of follow-up was less frequent in women than in men (50% vs 54%). Achievement of guideline-recommended LDL-C levels was also lower in women (17%) vs men (24%), with differences consistent across countries/regions (Figure). Conclusions In this global real-world study, women at high cardiovascular risk consistently experienced less intensive lipid management and LDL-C goal achievement compared with men. These findings highlight similar sex differences in risk factors and lipid management across regions and underscore the need for targeted strategies to improve implementation of guideline-directed LLT in women at high cardiovascular risk.