Introduction: Severe elevations of LDL-Cholesterol (LDL-C) ≥190mg/dl in adults, representing the familial hypercholesterolemia (FH) phenotype, have been associated with increased risk of cardiovascular disease (CVD). The 2013 AHA/ACC guidelines recommend high intensity statin therapy to reduce LDL-C by ≥50%. We identified patients with FH phenotype in the Veterans Health Administration (VHA) who were statin-naive and determined the degree of LDL-C reduction over one year after statin initiation and the efficacy of statin intensity on ≥50% reduction.
Methods: Patients receiving care at the VHA from 2002-2007, ≥21 years of age, with baseline LDL-C measurement of ≥190 mg/dl (LDL-C0), and statin-naïve were included. Statin initiation was required within 90 days of LDL-C0, and a follow up level (LDL-C1) had to be collected within one year ± 90 days.All participants were free of clinical CVD at baseline. Baseline characteristics were ascertained from patient charts. LDL-C reduction was defined as the difference between LDL-C0and LDL-C1. Multivariable logistic regression models, adjusted for age, sex, race, diabetes, kidney disease, hypertension, and hypertension treatment were constructed to determine the odds of goal LDL-C (≥50%) reduction by statin intensity. We defined statin intensity per the 2013 AHA/ACC guidelines. High intensity statins included Simvastatin 80mg, Atorvastatin 40-80mg, and Rosuvastatin 20-40mg.
Results: We included 35,894 Veterans (Men: N= 33,049 (92.1%), Age=55±10 years; Women: N=2845 (7.9%), Age=50±11 years). The mean duration between LDL-C0and LDL-C1was 52±7 weeks. The population was predominantly white (78.1%). Mean LDL-C0 was 210±22 mg/dl, triglycerides were 175±126 mg/dl. At baseline, 0.3% had kidney disease, 14.1% diabetes, and 52.8% hypertension. Mean absolute LDL-C reduction in the population was 70.2±41.9 mg/dl. A total of 6718 (18.7%) patients achieved an LDL-C reduction of ≥50%. Among these patients, 5.2% were on low, 62.2% were on moderate, and 32.6% were on high intensity statins. In multivariable-adjusted logistic regression models using moderate intensity statins as the comparator, high intensity therapy resulted in 97% higher odds of achieving goal LDL-C reduction (Odds ratio [OR]=1.97; 95% Confidence Interval [CI]=1.85-2.09), and low intensity statins resulted in 42% lower odds of achieving goal LDL-C reduction (OR= 0.58; 95%CI= 0.52-0.65).
Conclusions: In a large veteran population with the FH phenotype, though there was a marked reduction in LDL-C with statin therapy, most patients did not achieve goal LDL-C reduction of ≥50%. This may be related to statin intensity, individual response to statin therapy, or lack of adherence to treatment. In multivariable-adjusted logistic regression models, patients on high intensity statins had 2-fold odds of goal LDL-C reduction compared to moderate intensity statins.