Improving Statin Noncompliance: If You Build It, Will They Come?

Abstract

See article by Chen et al., pages 884e891 of this issue. Few things are as certain in cardiology as the knowledge that statins reduce cardiovascular (CV) events in at-risk individuals. Statins have significantly reduced the risk of death, myocardial infarction, stroke, and the need for coronary revascularization in dozens of high-quality clinical trials. 1 Risk reduction is proportional to low-density lipoprotein cholesterol (LDL-C) lowering; specifically, each 1 mmol/L reduction in LDL-C lowers CV events by 22%. 1 Other drugs that reduce LDL-C, including ezetimibe 2 and proprotein convertase subtilisin-kexin type 9 inhibitors, 3 have also been shown to reduce CV events, albeit with less impressive clinical trial evidence. Although guidelines in this area often differ with respect to details, they all endorse statin therapy for subjects at intermediate or high risk of a CV event. 4 On the basis of this information, one might expect that most patients with atherosclerotic CV disease (ASCVD) would be treated with a statin, perhaps 90%. As shown in the report from Chen et al. 5 in this issue of the Canadian Journal of Cardiology, reality falls far short of this expectation. These investigators linked 5 large databases in the province of Alberta to identify 281,665 patients with a new ASCVD diagnosis from 2011 to 2015. Only 77.9% of these patients had an LDL-C measurement, and of those with a measurement, only 65.9% were treated with a statin. Among those treated who had a follow-up LDL-C measurement, 36.6% did not achieve the modern Canadian target of either < 2 mmol/L or a 50% LDL-C reduction. Goal achievement improved from low to moderate to high-intensity statin use. Adherence, defined as taking at least 80% of medication, was similar across the 3 statin intensities and averaged 60.2%. Chen et al. characterize their findings as "a remarkable treatment gap," and we certainly agree. They detail how this gap is not unique to Alberta, but extends to the rest of Canada, 6 as well as to the United States, Europe, and most other places that have been studied. Differences among geographic locations might result from differences in patient populations studied (primary vs secondary prevention), differences in methods, differences in practice patterns, differences in the culture of therapy compliance, and variations in guideline implementation. On the basis of these findings, approximately one-third of ASCVD patients are untreated, one-third are treated but do not achieve their LDL-C targets, and one-third are treated to goal. If we assume that the patients not treated to goal obtain approximately half of the potential event reduction from treatment, then overall, approximately half of the potential CV event reduction from statins is being forfeited. Over the lifetimes of our patients with ASCVD, this is a huge missed opportunity. Is there anything that we can do to narrow this gap? Approaches to Improving Statin Compliance Thankfully, a number of options are available. Statinprescribing initiatives can be broadly categoriz...

Evaluating Readability, Understandability, and Actionability of Online Printable Patient Education Materials for Cholesterol Management: A Systematic Review

“…To improve actionability, educational materials should aim to address known barriers to statin adherence such as cost and patient apprehension regarding adverse effects. 58 , 59 , 60 As per the PEMAT, 43 other general strategies for improving actionability are to (1) address the user directly, (2) provide tangible tools such as planners or checklists to help users track their progress, and (3) explain how to use charts and diagrams included in the material to help the user take action.…”

Making Informed CHOICES: The Launch of a “Big Data” Pragmatic Trial to Improve Cholesterol Management and Prevent Heart Disease in Ontario

“…Statins are a class of medications commonly used to reduce the level of low-density lipoprotein, sometimes referred to as "bad" cholesterol, and have been shown to reduce the risk of first (i.e., primary prevention) and recurrent (i.e., secondary prevention) cardiac events in high-risk middleaged adults by about 25% (Cholesterol Treatment Trialists' Collaborators 20052010. Despite the well-established benefit of cholesterol-lowering statin therapy and frequently touted reputation as the "wonder drug" for CVD prevention, therapeutic cholesterol management by means of statin prescribing and adherence remains suboptimal in both Canada and the United States (Hennessy et al 2016;Sparrow et al 2019aSparrow et al , 2019b. For instance, patients who are eligible for statin therapy often report never being offered statins by their physician or report discontinuing their therapy due to perceptions and fear of side effects (Bradley et al 2019).…”

The Case for Patient-Centred Approaches in Addressing Statin Nonadherence

“…We read the important work by Chen et al, 1 which reported that 40% of patients in Alberta prescribed statins were considered nonadherent. Like the editorial published in the same issue, 2 we would like to expand this discussion by highlighting patient-focused approaches to address statin nonadherence.…”