High-intensity statins often not prescribed after CHD hospitalization, study finds

Patients who are hospitalized for coronary heart disease (CHD) often don't fill prescriptions for high-intensity statins after discharge, according to a new study.

Researchers used a 5% random sample of Medicare beneficiaries between age 65 and age 74 to conduct a retrospective cohort study examining rates at which high-intensity statin prescriptions are filled after CHD hospitalization. Beneficiaries were included in the study if they filled a prescription for statins after myocardial infarction or coronary revascularization in 2007, 2008, or 2009. The authors defined high-intensity statins as atorvastatin, 40 to 80 mg; rosuvastatin, 20 to 40 mg; and simvastatin, 80 mg. The study results were published in the Jan. 27 Journal of the American College of Cardiology.

A total of 8,762 Medicare beneficiaries who filled statin prescriptions postdischarge were included in the study. Only 27% of first prescription fills after myocardial infarction or coronary revascularization were for a high-intensity statin. This increased to 35% of patients getting high-intensity statins when the window was expanded to 365 days after discharge. Patients who had taken a high-intensity statin before their CHD event were more likely to fill a high-intensity statin prescription afterward than patients who had not been taking statins before their hospitalization or those who had been taking low- or moderate-intensity statins (80.7%, 23.1%, and 9.4%, respectively). Multivariable adjusted risk ratios for filling a high-intensity statin prescription were 4.01 (95% CI, 3.58 to 4.49) for patients taking high-intensity statins previously and 0.45 (95% CI, 0.40 to 0.52) for those taking low- or moderate-intensity statins previously, compared with patients who were not taking statins before their hospitalization.

The authors noted that data on statin prescriptions came from pharmacy claims, that some instances of low- or moderate-intensity statin use could have been appropriate, that their results are not generalizable to younger patients, and that use of high-intensity statins may have increased since 2009 because of the availability of generic atorvastatin. However, they concluded that a majority of Medicare beneficiaries did not receive a prescription for high-intensity statins after CHD hospitalization, contrary to clinical trial evidence and guideline recommendations, and that patients were more likely to fill a high-intensity statin prescription after discharge if they had taken the drugs before their hospitalization. “Future efforts are needed to better understand the causes of this pattern so that interventions can be designed to improve evidence-based care,” the authors wrote.

The author of an accompanying editorial was concerned by the findings. “It is unlikely that most patients after significant cardiac events would have ignored their physician's advice if they were indeed given a prescription for high-intensity statins, so why did most patients end up on lower-dose therapy?” the editorialist asked. He speculated that treating physicians might not know about the guideline recommendations, might not believe in them because of ongoing controversy about cholesterol targets, might not have prescribed the drugs if patients already had low LDL cholesterol levels, or might be concerned about side effects of statins at high doses. “Although not guideline recommended, it is conceivable that treating physicians wanted to evaluate patient response and tolerance to lower-dose therapy before proceeding to high-intensity statin therapy,” the editorialist wrote. “Finally, physician inertia and/or lack of adequate discharge planning could explain the observed gaps in [guideline-directed medical therapy].”

The editorialist called these gaps “worrisome” and called for actions to improve implementation of these therapies in clinical practice. “Future [coronary artery disease] performance measures should include documentation of evidence for guideline-based therapy use by clinicians tied to pay for performance. Such a strategy has worked for heart failure and it is time now to apply it to patients with [coronary artery disease],” he concluded.