Persistent gaps in the implementation of lipid-lowering therapy in patients with established atherosclerotic cardiovascular disease: A French nationwide study.

Background: According to international guidelines, lowering LDL-cholesterol is the cornerstone of atherosclerotic cardiovascular disease (ASCVD) prevention. However, observational studies have identified current gaps in the implementation of lipid-lowering therapy (LLT). This whole-population study aimed to evaluate the prevalence and determinants of LLT use in ASCVD patients.

Methods: Using the national health data system, all French adults with established ASCVD between 2012 and 2021 were identified using specific ICD-10 and/or procedure codes. LLT use was defined as ≥1 dispensing in the last quarter of 2021. Logistic regression was used to identify factors associated with the absence of LLT use.

Findings: In 2021, 2,206,305 individuals (4.89 % among 45,082,270 adults) had established ASCVD (mean age: 72.2 years; 36.9 % women), including 56.1 % with coronary artery disease, 40.4 % with cerebrovascular disease, and 14.5 % with revascularized peripheral artery disease (PAD). Among the 2,056,354 patients alive on 31st December 2021, 32.5 % did not receive any LLT, while 64.8 % received a statin (27.0 % a high-intensity statin), 13.0 % a combination of statin and ezetimibe, and 0.25 % a PCSK9 inhibitor. The absence of LLT use was significantly associated with female sex (adjusted odds ratio [aOR]:1.42, 95 %CI, 1.41-1.43); lowest/highest ages: < 50 years (aOR (/65-74 years): 2.23, 95 %CI 2.20-2.27) and ≥ 85 years (aOR: 2.10, 95 %CI 2.08-2.13); and stroke and PAD, compared to myocardial infarction (aOR: 2.21, 95 %CI 2.19-2.23 and 1.88, 95 %CI 1.86-1.91, respectively).

Interpretation: In real life, one-third of French ASCVD patients was not regularly treated with LLT, highlighting the urgent need to develop implementation strategies for lipid management.