In-hospital initiation of lipid-lowering therapy for patients with coronary heart disease: the time is now.

In the last 2 decades, in-hospital mortality for acute coronary syndromes and percutaneous and surgical revascularization has decreased markedly. To continue to make progress and to meet the goal set by the American Heart Association (AHA) of reducing coronary heart disease (CHD) and stroke by 25% by 2010,1 the focus of treatment in patients hospitalized with CHD must evolve from treating symptoms of the disease to treating the underlying disease process of atherothrombosis. Although dietary therapy is recommended for all patients with CHD, the recommendations for when to initiate lipid-lowering drug therapy have not been as clear, partly because of a lack of data on the benefits, risks, and costs of immediate initiation of therapy versus delayed initiation after a trial of diet and lifestyle modification. Numerous studies have shown that the conventional practice of delaying lipid-lowering medications simply does not work as well as algorithm-guided in-hospital initiation of treatment in regard to patients’ being started on therapy, remaining on therapy for the long-term, and achieving target low-density lipoprotein cholesterol (LDL-C) levels. Is there now enough evidence to adopt in-hospital initiation of lipidlowering therapy in CHD patients as the standard of care? Despite clinical trials demonstrating that lipid-lowering medications reduce mortality in patients with established CHD2 and national guidelines calling for their use, study after study has demonstrated that these therapies continue to be underused. Studies of treatment rates for patients discharged after cardiac hospitalization show a large number of high-risk patients are not receiving lipid-lowering treatment. An analysis of 138 001 patients from 1470 US hospitals in the National Registry of Myocardial Infarction 3 revealed that only 31.7% of patients hospitalized with acute myocardial infarction (MI) were discharged on lipid-lowering medication.3 Similarly, among the 8515 patients hospitalized with an acute coronary syndrome and enrolled in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, only 25.1% were discharged on lipid-lowering therapy.4 In the outpatient setting, this treatment gap persists. The Quality Assurance Project analyzed treatment rates in 48 586 outpatients with CHD from 140 medical practices (80% cardiology).5 Only 39% of these patients were treated with lipid-lowering medications and only 11% were documented to have LDL-C levels ,100 mg/dL. In the third National Health and Nutrition Examination Survey (NHANES III), lipid-lowering medication was used in an estimated 11% of participants with CHD.6 In the Lipid Treatment Assessment in Practice (L-TAP) study, only 18% of outpatients with CHD treated for hyperlipidemia had LDL-C levels ,100 mg/dL.7 This was not due to a lack of provider knowledge, because 95% of the surveyed physicians reported that they were knowledgeable on the National Cholesterol Education Program guidelines and 65% reported that they follow the guidelines on most patients. The American College of Cardiology Evaluation of Preventive Therapeutics (ACCEPT) study, which evaluated 6875 patients from 55 US centers, showed that at 6 months after cardiac hospitalization, despite prospective monitoring, only 28% of patients were at goal for LDL-C.8 These studies demonstrate that conventionally guided management leaves a large number of CHD patients untreated and undertreated. Institution of lipid-lowering therapy in the inpatient setting has a number of potential advantages. Measurement of lipid levels can be systematically integrated into the diagnostic testing performed during cardiac hospitalization through the use of preprinted orders and care maps. It has been demonstrated that measuring lipoprotein levels on admission for acute coronary events or within 24 hours provides a reasonable estimate of baseline lipoprotein levels.9 The structured setting within the hospital can facilitate the initiation of lipid-lowering treatment though the use of physician prompts and reminders, such as preprinted order sets, discharge forms, and involvement of other healthcare professionals. Studies have demonstrated that treatment rates for aspirin and b-blockers in patients with acute MI can be significantly improved though the use of hospital-based programs.10 Such programs would be expected to be similarly effective in improving the use of lipid-lowering medications in hospitalized CHD patients. The Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP) was one of the first programs to demonstrate that a treatment algorithm focused on initiating lipid-lowering medications and other secondary protection measures before hospital discharge could be a more effective The opinions expressed in this editorial are not necessarily those of the editors or the American Heart Association. From Ahmanson–University of California Los Angeles Cardiomyopathy Center, Division of Cardiology, University of California Los Angeles (G.C.F.), and the Section of Atherosclerosis, Department of Medicine, Baylor College of Medicine, Houston, Tex (C.M.B.). Correspondence to Christie M. Ballantyne, MD, Baylor College of Medicine, 6565 Fannin, MS A-601, Houston, TX 77030. E-mail [email protected] (Circulation 2001;103:2768-2770.) © 2001 American Heart Association, Inc.