How optimal is the treatment for patients using statin for coronary artery disease? "Epidemiological study"

Introduction and Aim: The positive effects of antilipidemic therapy on cardiovascular outcomes in patients with a history of coronary artery disease have been demonstrated by long-standing studies. Again, the issue that was especially emphasized in these studies and had a great impact on outcomes was whether the target low-density lipoprotein (LDL) values for the disease were achieved. It has also been shown in various studies that patients are not able to reach the target LDL values, which are recommended to be reduced more aggressively over the years.The aim of our study is to determine whether statins, which have antiatherogenic, pleiotropic, anti-inflammatory and antioxidant effects, are used in CAD patients prescribed by cardiologist doctors according to current guidelines and whether target LDL values are achieved. Also, patient or drug-based factors that limit reaching the target dose, if any, in patients who do not take the appropriate dose of medication and cannot reach the target LDL values, will be revealed and what can be done to ensure that more patients receive antilipidemic treatment at the target dose and in a way that will reach the target LDL levels will be discussed. Material and Method: The study is a survey study conducted at Dicle University Hospital. Our study included 664 patients over the age of 18 who were admitted to the hospital as an outpatient or inpatient, and who had been receiving statin therapy for at least three months for coronary artery disease. Demographic data of the patients were recorded. The patients were asked for what purpose they received the statin treatment. It was also noted how long and at what dose range the treatment was continued. Cholesterol panel and other parameters were evaluated by examining the routine laboratory tests of the patients. ECGs of the patients were taken and rate and rhythm evaluations were made. Ejection fractions (EF) and left ventricular diameters (LV), as well as valve structure and functions, were evaluated by 2D transthoracic ECHO evaluation of the patients. Findings: A total of 664 patients using statins for CAD were included in the study. 60.2% (400) of the patients were male and 39.8% (264) were female. The mean height was found to be 166.4 ± 8.4 and the mean weight was 79.5 ± 11.9. All 664 patients were married. When we look at the residence areas, 51.5% (342) resided in the province, 27.1% (180) in the district and 21.4% (142) in the village. When we look at the distribution by income level, 54.2% (360) of the patients had an income of <2000 TL, 40.4% (268) had an income of 2000-5000 TL, and 5.4% (36) had an income of 5000-10000 TL. Considering the indications for statin taking of the patients included in the study, 24.1% (160) STEMI, 18.7% (124) NSTEMI, 5.6% (40) USAP, 41.6% (276) SAP and 9.6% (64) of patients were receiving treatment for CAD (noncritical stenosis). The duration of patients receiving statin therapy was as follows: 4.8% (32) 3-6 months, 10.5% (70) 6-12 months, 19% (126) 1-3 years, 17.2% (114) 3-5 years, 25.3% (168) 5-10 years, 16.9% (112) 10-15 years, 3.9% (26) 15-20 years, 2.4% (16) > 20 years. In vital evaluation, mean heart rate was 78.4±16.4, systolic blood pressure was 128.2±18.1 mmHg, diastolic blood pressure was 76.0±10.3 mmHg. When we look at the comorbidities present in the patients, HT 66.3% (440), DM 49.7% (330), smoking 56.6% (376), AF 5.1% (34), family history of CAD 15.4% (102), CKD 6.6% (44), COPD was found with a rate of 10.5% (70). The majority of the patients included in the study, such as 93.4% (620), were in sinus rhythm. 5.1% (34) were in AF and 1.5% (10) were in pace rhythm. While no branch block was observed in 96.4% (640), 2.4% (16) had LBBB and 1.2% had RBBB morphology. The mean EF of the patients was 52.6±10.3%. LVDD value was 48.3±5.7 mm, LA diameter was 38.7±5.1 mm, and systolic pulmonary artery pressure (PASP) was 31.8±12.1 mmHg. When we look at valve regurgitations, 8.1% of the patients had moderate MR, 1.8% had advanced MR, 0.9% had moderate AR, 4.2% had moderate TR, and 1.2% had advanced TR. The mean total cholesterol value of the patients was 186.7±53.4 mg/dl, LDL value was 112.4±43.0 mg/dl, triglyceride value was 148.4±101.6 mg/dl, and HDL value was 43.1±10.1 mg/dl. Mean GFR rate was 80.8±24.5 ml/min, and creatinine value was 1.01±0.72 mg/dl. The mean glucose was 158±79 mg/dl. 76.5% (508) of the patients were taking Atorvastatin, 18.7% (124) Rosuvastatin, 4.2% (28) Pitavastatin and 0.6% (4) Pravastatin. Patients who needed additional antilipidemic agents in addition to statin therapy were 2.7% of all patients. Of all patients, 1.8% (12) were treated with a combination of Statin + Fenofibrate, and 0.9% (6) of them were treated with a combination of Statin + Ezetimibe. When we look at the other treatments that the patients received in addition to statin therapy, we observed that 72.9% (484) of the patients were taking beta-blockers, 58.2% (386) ACEi/ARB, 8.2% (55) MRA, 20.4% (135) CCB, 1.5% (10) SGLT-2i, 93.4% (620) antiaggregant and 6.6% (44) anticoagulant. When the study data are examined, it is observed that only 6.3% (42) of the patients reached the LDL<55 mg/dl target value recommended for CAD patients in the 2019 ESC Dyslipidemia Guidelines. Patients reaching 55-70 mg/dl for LDL are 12% (80) of all patients. In this context, considering the rate of all patients with LDL <70 mg/dl, it is 18.3% (122). The percentage of total patients with LDL value <100 mg/dl is 45.7% (304). LDL level remained above 100 mg/dl in 54.2% (360) of the patients. Reasons for not increasing the statin dose despite these high LDL levels; The doctor's disapproval in 46.7% of the patients, the dose reduction made by the doctor due to side effects in 20.2%, the unwillingness of the patients to take high doses due to the negative news in the media against cholesterol drugs in 25.3% and the patients not going to regular check-ups in 7.8% specified as. Conclusion: As a result of the study, it was seen that a significant part of the patients could not reach the target LDL level recommended for CAD patients in the current dyslipidemia guidelines. There were several reasons why LDL control was so poor. The most important reason was that the bad image about statins had a place in doctors as much as it did in patients. Keywords: Optimal antilipidemic therapy, coronary artery disease, statin, LDL, HDL