One of our Cardiologists, Jossef Amirian, MD, gave his perspective to Healio Promary Care on patients at risk for atherosclerotic CVD face ‘remarkable treatment gap’.

He was quoted saying: 

“Chen and colleagues’ multi-centered retrospective observational study highlights the underutilization of statin therapy in patients with established atherosclerotic CVD. Based on this study, approximately two-thirds of the patients receiving low-intensity statin therapy failed to achieve recommended LDL cholesterol levels based on the 2016 Canadian Cardiovascular Society guideline recommendations. Even more alarming, more than one-third of patients with atherosclerotic CVD were not prescribed lipid-lowering drugs. If these trends were to hold true in the United States, we as physicians would have to make drastic changes in our treatment of the patients who would benefit most from lipid-lowering agents.

In order to see an improvement over time, we must first direct our attention to the definition of atherosclerotic CVD, which not only includes patients with established coronary artery disease, but also individuals with neurovascular and peripheral vascular disease. Once we establish a patient has clinical atherosclerotic CVD, then we must emphasize the recommendations noted in the American College of Cardiology 2018 Guideline on the Management of Blood Cholesterol, which recommends that we initiate high-intensity or maximally tolerated statin therapy. The guideline notes that the greater the LDL cholesterol reduction on statin therapy, the greater the subsequent risk reduction.

The 2018 guidelines go even further and categorize patients into another category called “very high-risk ASCVD,” which includes patients who have had a history of multiple major atherosclerotic CVD events (acute coronary syndrome within the past 12 months, history of myocardial infarction, history of ischemic stroke, symptomatic peripheral arterial disease) or one major atherosclerotic CVD event and multiple high-risk conditions.

In these “very high-risk ASCVD” patients, the treatment should not be limited to statin therapy alone. If LDL cholesterol levels remain 70 mg/dL (1.8 mmol/L) or higher despite maximally tolerated statin therapy, it is reasonable to add ezetimibe. Another medication which has shown favorable LDL reduction especially in this subset of patients are proprotein convertase subtilisin/kexin type 9 protease (PCSK9) inhibitors, which play an important role in cholesterol metabolism by regulating LDL receptor degradation.

Chen and colleagues’ study sheds light on an area within our field that requires a great amount of attention. I am confident that putting emphasis on the use of guidelines to assist providers in making treatment strategies for their patient will lead to excellent patient care and overcome the underutilization of lipid-lowering agents over time.”


View the original piece placement on Healio Promary Care.

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