Adoption of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline in Cardiology Practices Nationwide

Abstract

Importance: The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline recommends moderate-intensity to high-intensity statin therapy in eligible patients.

Objective: To examine adoption of the 2013 ACC/AHA guideline in US cardiology practices.

Design, setting, and participants: Among 161 cardiology practices, trends in the use of moderate-intensity to high-intensity statin and nonstatin lipid-lowering therapy (LLT) were analyzed before (September 1, 2012, to November 1, 2013) and after (February 1, 2014, to April 1, 2015) publication of the 2013 ACC/AHA guideline among 4 mutually exclusive risk groups within the ACC Practice Innovation and Clinical Excellence Registry. Interrupted time series analysis was used to evaluate for differences in trend in use of moderate-intensity to high-intensity statin and nonstatin LLT use in hierarchical logistic regression models. Participants were a population-based sample of 1 105 356 preguideline patients (2 431 192 patient encounters) and 1 116 472 postguideline patients (2 377 219 patient encounters). Approximately 97% of patients had atherosclerotic cardiovascular disease (ASCVD).

Exposures: Moderate-intensity to high-intensity statin and nonstatin LLT use before and after publication of the 2013 ACC/AHA guideline.

Main outcomes and measures: Time trend in the use of moderate-intensity to high-intensity statin and nonstatin LLT.

Results: In the study cohort, the mean (SD) age was 69.6 (12.1) years among 1 105 356 patients (40.2% female) before publication of the guideline and 70.0 (11.9) years among 1 116 472 patients (39.8% female) after publication of the guideline. Although there was a trend toward increasing use of moderate-intensity to high-intensity statins overall and in the ASCVD cohort, such a trend was already present before publication of the guideline. No significant difference in trend in the use of moderate-intensity to high-intensity statins was observed in other groups. The use of moderate-intensity to high-intensity statin therapy was 62.1% (before publication of the guideline) and 66.6% (after publication of the guideline) in the overall cohort, 62.7% (before publication) and 67.0% (after publication) in the ASCVD cohort, 50.6% (before publication) and 52.3% (after publication) in the cohort with elevated low-density lipoprotein cholesterol levels (ie, ≥190 mg/dL), 52.4% (before publication) and 55.2% (after publication) in the diabetes cohort, and 41.9% (before publication) and 46.9% (after publication) in the remaining group with 10-year ASCVD risk of 7.5% or higher. In hierarchical logistic regression models, there was a significant increase in the use of moderate-intensity to high-intensity statins in the overall cohort (4.8%) and in the ASCVD cohort (4.3%) (P < .01 for slope for both). There was no significant change for other risk cohorts. Nonstatin LLT use remained unchanged in the preguideline and postguideline periods in the hierarchical logistic regression models for all of the risk groups.

Conclusions and relevance: Adoption of the 2013 ACC/AHA Cholesterol Management Guideline in cardiology practices was modest. Timely interventions are needed to improve guideline-concordant practice to reduce the burden of ASCVD.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Pokharel reported being supported by award T32HL110837 from the National Heart, Lung, and Blood Institute. Dr Nambi reported receiving a research grant from Merck (paid to Baylor College of Medicine), reported serving as a consultant to and on an advisory board for Sanofi-Regeneron, and reported holding provisional patent 61721475 entitled “Biomarkers to Improve Prediction of Heart Failure Risk” filed by Baylor College of Medicine and Roche. Dr Bittner reported serving on steering committees (her institution [University of Alabama at Birmingham] was compensated) for the ODYSSEY trial (Sanofi-Regeneron) and for development of the CETP inhibitor (Eli Lilly), reported being national coordinator of the STRENGTH trial (AstraZeneca), reported serving on advisory boards for Eli Lilly and Amgen, reported being coinvestigator on a University of Alabama School of Public Health–Amgen contract related to Medicare analyses, and reported holding the position of past local site principal investigator for a Pfizer Inc Studies of PCSK9 Inhibition and the Reduction of Vascular Events (SPIRE) trial. Dr Chan reported being supported by R01 grant 1R01HL123980 from the National Heart, Lung, and Blood Institute. Dr Borden reported serving as a consultant to the Agency for Healthcare Research and Quality to support evidence-based cardiovascular disease prevention. Dr Spertus reported having a contractual agreement to analyze data from the National Cardiovascular Data Registry. Dr Petersen reported being supported by the Department of Veterans Affairs Health Services Research and Development Service. Dr Ballantyne reported receiving grant and research support (all paid to Baylor College of Medicine) from Abbott Diagnostic, Amarin, Amgen, Eli Lilly, Esperion, Novartis, Pfizer Inc, Otsuka, Regeneron, Roche Diagnostic, Sanofi-Synthelabo, Takeda, National Institutes of Health, American Heart Association, and American Diabetes Association and reported serving as a consultant to Abbott Diagnostics, Amarin, Amgen, AstraZeneca, Eli Lilly, Esperion, Genzyme, Isis, Matinas BioPharma Inc, Merck, Novartis, Pfizer Inc, Regeneron, Roche, and Sanofi-Synthelabo. Dr Virani reported being supported by the Department of Veterans Affairs Health Services Research and Development Service, an American Heart Association Beginning Grant-in-Aid, the American Diabetes Association Clinical Science and Epidemiology Award, and Baylor College of Medicine’s Global Initiatives and reported serving on the steering committee (with no financial remuneration) for the Patient and Provider Assessment of Lipid Management (PALM) Registry at the Duke Clinical Research Institute. No other disclosures were reported.

Figures

Figure 1.. Study Populations Before and After Publication of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline

A, There were 2 431 192 total patient encounters for patients included in the study in the preguideline period. B, There were 2 377 219 total patient encounters for patients included in the study in the postguideline period. ASCVD indicates atherosclerotic cardiovascular disease; ATP III, Adult Treatment Panel III; FRS, Framingham Risk Score; LDL-C, low-density lipoprotein cholesterol; and LLT, lipid-lowering therapy. To convert LDL-C level to millimoles per liter, multiply by 0.0259.

Figure 2.. Observed Trends in the Use of Moderate-Intensity to High-Intensity Statin and Nonstatin Lipid-Lowering Therapy in the Overall Cohort

The dashed line indicates the transition period. There were 2 431 192 total patient encounters before publication of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline. There were 2 377 219 total patient encounters after publication of the 2013 ACC/AHA Cholesterol Management Guideline.

Figure 3.. Overall Use for the Preguideline and Postguideline Periods

ACC/AHA indicates American College of Cardiology/American Heart Association; ASCVD, atherosclerotic cardiovascular disease; and LDL-C, low-density lipoprotein cholesterol.

Figure 4.. Model Estimated Use of Moderate-Intensity to High-Intensity Statin Therapy in the Overall Cohort

Line A to B, Moderate-intensity to high-intensity statin use for the preguideline period. Line C to D, Moderate-intensity to high-intensity statin use for the postguideline period. Line E to F, Projected moderate-intensity to high-intensity statin use for the postguideline period using preguideline data. G, Estimated moderate-intensity to high-intensity statin use at the middle of the postguideline period (ie, September 2014) using preguideline data. H, Estimated moderate-intensity to high-intensity statin use at the middle of the postguideline period (ie, September 2014) using postguideline data. P1 is the P value for difference in the rate of use of statin therapy between the preguideline and postguideline periods (ie, difference in slope). P2 is the P value for difference in the rate of use of statin therapy at the starting point of the postguideline period (ie, February 2014) (ie, difference in intercept). P3 is the P value for difference in the rate of use of statin therapy at the middle of the postguideline period (ie, September 2014) using preguideline vs postguideline data. Line E to F is dashed to show that it is based on projection of preguideline data. The first vertical dashed line indicates the beginning of the preguideline period, and the second vertical dashed line indicates the middle of the postguideline period.