UAB researchers, Naman Shetty, M.D., (left) and Pankaj Arora, M.D. (right), from the UAB Cardiovascular Institute.In a collaborative effort led by the University of Alabama at Birmingham Marnix E. Heersink School of Medicine, researchers examining how the evaluation of cholesterol levels, awareness of high cholesterol levels, and lipid-lowering therapy varied between 2011 and 2020 among individuals with severe dyslipidemia found that only one in three individuals with severe dyslipidemia took statins, in a recent study published in the Mayo Clinic Proceedings.
Dyslipidemia refers to unhealthy levels of certain lipids, or fats, in the blood. With dyslipidemia, it usually means that low-density lipoprotein cholesterol levels, also known as bad cholesterol levels, are too high.
“Severe dyslipidemia, or elevated LDL cholesterol levels, affects nearly one in 15 adults living in the United States,” said Naman S. Shetty, M.D., a research fellow in the UAB Division of Cardiovascular Disease and the first author of this manuscript. “Elevated LDL cholesterol levels is one of the strongest risk factors. Patients with elevated LDL cholesterol levels are five times more likely to develop cardiovascular disease. Therefore, identifying the gaps in screening lipid levels and awareness of high cholesterol levels and the treatment rates in the high-risk population of severe dyslipidemia may facilitate strategies that decrease the risk of adverse cardiovascular outcomes.”
Shetty and his team leveraged population-level data from the National Health and Nutrition Examination Survey, or NHANES, between 2011 and 2020 to study approximately 14 million individuals with severe dyslipidemia. More than 5 percent of the population had severe dyslipidemia. Among these individuals, 75 percent had undergone cholesterol evaluation and 50 percent of them were aware of their elevated lipid levels. However, only one in three individuals were receiving statin therapy, which are drugs that lower cholesterol. Researchers examined the number of individuals on newer non-statin lipid-lowering therapies and found that the use of those therapies also remained low. The rates of cholesterol evaluation, awareness of elevated lipid levels and lipid-lowering therapy remained stable across the 10-year-long study period.
Pankaj Arora, M.D., senior author and associate professor in the UAB Division of Cardiovascular Disease, notes that there was a large discordance between the rates of awareness of hyperlipidemia and lipid-lowering therapy in the study. Arora explains this discordance may be attributed to a decrease in statin adherence.
“While prescription rates of statins are reported to be approximately 70 percent, adherence to statins has been found to drop to 50 percent at the end of the first year and 20 percent at the end of the fifth year,” Arora said. “The non-adherence to statin therapy has been attributed mainly to the concern of the side effects of statin therapy. Before initiation and along the course of statin therapy, educating patients about the expected adverse events and providing reassurance may improve long-term adherence to statin therapy to reduce the risk of cardiovascular disease effectively.”
Arora, who also serves as the director of the UAB Cardiogenomics Clinic, highlights that the presence of severe dyslipidemia may indicate an underlying genetic etiology.
“Individuals with severe dyslipidemia are more than 20 times more likely to carry a genetic mutation that increases lipid levels,” Arora said. “Promoting genetic testing in individuals with severe dyslipidemia may allow identification of high-risk individuals and prompt intensive lipid-lowering therapy to reduce their risk of developing cardiovascular disease. Furthermore, the identification of a genetic mutation may also facilitate genetic testing in family members and allow the implementation of preventive measures to reduce their risk of cardiovascular disease. Therefore, genetic testing may help not only individuals with severe dyslipidemia but their family members as well.”
Arora suggests changes at the policy and provider levels to improve statin adherence. At the health policy level, statin adherence may be improved by educating patients and providing them with low-cost insurance options, reducing copays, providing extended supplies of medications, and implementing automatic reminders for medication refills. At the level of the provider, apart from having a transparent discussion of statin therapy, it is important for physicians to actively screen patients for statin intolerance and transition them to non-statin lipid-lowering medication.
This study was conducted in collaboration with physician-scientists from Stanford University and Harvard Medical School.