Clinical consequences of poor adherence to lipid-lowering therapy in patients with cardiovascular disease: can we do better?

There is high-quality evidence demonstrating that early initiation of statin use following an acute coronary syndrome (ACS) and persistent use thereafter reduces the risk of major adverse cardiovascular events (MACE) including mortality. However, despite the overwhelming evidence, adherence remains suboptimal and the medications frequently discontinued.1 Here we discuss the data on lipid-lowering therapy among patients with cardiovascular disease and discuss some potential interventions that address the gap. Among those with established atherosclerotic cardiovascular disease (ASCVD), poor statin adherence has been reported to be 47.2% in real-world registry data.2 Discontinuation rates have been reported ranging from 14%3 to 26.5%4 at 12 months in both large multicentre randomised clinical trial (RCT) data and national registries, with long-term discontinuation being 51% after 7 years in a large-scale RCT involving 39 countries.3 In a systematic review including 28 studies (5 nested case–control and 22 cohort studies), adherence to statin use in patients at high risk of ASCVD and those with established ASCVD was associated with a reduction in subsequent cardiovascular events (OR 1.22–5.26) and improved survival (OR 1.79–5.00).5 The US National Cardiovascular data Registry’s PINNACLE database (data collected at the point of care at cardiology practices) was used in a large study that showed that in 1 029 633 adults with known ASCVD, 27.9% did not receive any lipid-lowering medication.6 Similarly, other registries demonstrate high proportions of patients not receiving lipid-lowering therapy within the first year following an ACS in Australia7 and New Zealand8—22% and 25% respectively. Prescription of statins at the time of discharge after ACS is associated with continued use,7 and a range of data demonstrates significant gaps in use of lipid-lowering drugs among patients with cardiovascular disease. In the CONCORDANCE trial, failure to discharge patients on guideline-recommended therapies was 10 …