Background: Patients with phenotypic severe hypercholesterolemia (SH), low-density lipoprotein-cholesterol (LDL-c) ≥ 190 mg/dl, atherosclerotic cardiovascular disease (ASCVD) or adults 40-75 years with diabetes with risk factors or 10-year ASCVD risk ≥20% benefit from maximally tolerated statin therapy. Rural patients have decreased access to specialty care, potentially limiting appropriate treatment.
Hypothesis: Prior visit with cardiology will improve treatment of severe hypercholesterolemia.
Methods: We used an electronic medical record-based SH registry defined as ever having an LDL-c ≥ 190 mg/dl since January 1, 2000 (n = 18 072). We excluded 3205 (17.7%) patients not alive or age 20-75 years. Patients defined as not seen by cardiology if they had no visit within the past 3 years (2017-2019).
Results: We included 14 867 patients (82.3%; mean age 59.7 ± 10.3 years; 58.7% female). Most patients were not seen by cardiology (n = 13 072; 72.3%). After adjusting for age, sex, CVD, hypertension, diabetes and obesity, patients seen by cardiology were more likely to have any lipid-lowering medication (OR = 1.46, 95% CI: 1.29-1.65), high-intensity statin (OR = 1.81, 95% CI: 1.61-2.03), or proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor (OR = 5.96, 95% CI: 3.34-10.65) compared to those not seen by cardiology. Mean recent LDL-c was lower in patients seen by cardiology (126.8 ± 51.6 mg/dl vs. 152.4 ± 50.2 mg/dl, respectively; p < .001).
Conclusion: In our predominantly rural population, a visit with cardiology improved the likelihood to be prescribed any statin, a high-intensity statin, or PCSK9 inhibitor. This more appropriately addressed their high life-time risk of ASCVD. Access to specialty care could improve SH patient's outcomes.
Keywords: atherosclerotic cardiovascular disease; guideline adherence; low-density lipoprotein cholesterol; rural healthcare; severe hypercholesterolemia.
© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.