Focus on Big Picture to Promote Statin Adherence


MONTREAL, Nov. 27 -- A conversation about a patient's overall cardiovascular risk provided better motivation to adhere to statin treatment, particularly among those at high risk, than reporting cholesterol levels alone, researchers found.
Action Points
Consider calculating and sharing overall cardiovascular risk profiles with patients to improve adherence to hyperlipidemia treatment.
Note that the National Cholesterol Education Program's Adult Treatment Panel III recommends calculating the future risk of cardiovascular events to identify high-risk patients.
Consistent feedback using a risk-profile tool helped patients achieve a greater decline in LDL cholesterol (−3.3 mg/dL) and in total-to-HDL cholesterol ratio (−0.1) than patients receiving standard care, according to results of a yearlong study published in the Nov. 26 issue of the journal Archives of Internal Medicine.
Controlling for baseline between-group differences in cholesterol levels, patients shown their risk profile were 26% more likely to reach lipid targets (95% CI: 7% to 48%), reported Steven A. Grover, M.D., M.P.A., F.R.C.P.C., of McGill University here, and colleagues.
And, the higher a patient's risk, the greater the effect of the risk profile, the researchers said.
Guidelines of the National Cholesterol Education Program's Adult Treatment Panel III already recommend calculating the future risk of cardiovascular events to identify high-risk patients, they said.
The findings provide proof of principle that simply sharing this information with patients may improve the effectiveness of statin therapy, they said.
However, the impact "was disappointingly small, and there was no clear impact in the highest-risk group (those with previous cardiovascular disease)," commented Rod Jackson, M.B.Ch.B., Ph.D., and Sue Wells, M.B.Ch.B., M.P.H., of the University of Auckland in Auckland, New Zealand, in an accompanying editorial.
The study, called Cardiovascular Health Evaluation to Improve Compliance and Knowledge Among Uninformed Patients (CHECK-UP), included 233 primary care physicians and 3,053 patients.
The patients were all likely to have untreated hyperlipidemia at baseline with diabetes, established cardiovascular disease, or multiple risk factors adding up to at least a 10% calculated 10-year Framingham coronary risk.
One group was randomized to discuss their individual coronary risk profile at quarterly office visits whereas the others received standard care, which did not systematically include risk profile assessment.
The profile was a one-page computer printout showing the probability of developing heart disease. It was calculated with the Cardiovascular Life Expectancy Model for heart disease patients. For primary prevention patients, it was calculated with Framingham equations and also showed the "cardiovascular age," the patient's age minus the years of life expectancy they would lose with their current heart risk.
Participants purchased medications from their normal pharmacy out-of-pocket or using private insurance or public drug plans.
Although statin doses were similar between groups, LDL cholesterol levels dropped more in the risk profile group than in the control group (mean change: −51.2 versus −48.0 mg/dL, P=0.02). The same was true for total cholesterol (mean difference: −3.9 mg/dL, 95% confidence interval: −6.4 to −1.4 mg/dL) and the ratio of total cholesterol to HDL cholesterol (−0.1, 95% CI: −0.2 to −0.1).
Among patients with pre-existing cardiovascular disease, the risk profile had a similar magnitude of impact but the difference between groups was not significant (OR: 1.25, 95% CI: 0.89 to 1.75).
"In the presence of symptomatic disease, it seems that a risk profile did not substantially improve the effectiveness of treatment," the researchers said.
One explanation may be that these patients were "already well aware of their high-risk status, which could have neutralized the study intervention," Drs. Jackson and Wells said.
However, the benefit remained for primary prevention patients (OR: 1.26, 95% CI: 1.04 to 1.53) driven primarily by those with diabetes (OR: 1.42, 95% CI: 1.11 to 1.81).
Notably, primary prevention patients with a large gap between their cardiovascular age and their actual age were more likely to reach treatment targets.
Participants with the smallest age gap, ranging from −6.10 to 0.43 years, showed no benefit (OR: 0.92 versus usual care), whereas those in the highest age gap quintile were 69% more likely to hit their cholesterol targets with the profile than with usual care (P=0.04).
"Informing patients of their coronary risk may also increase the effectiveness of primary prevention by identifying individuals most likely to benefit from treatment while reassuring those at low risk," Dr. Grover and colleagues wrote.
The information may also help physicians select treatment, they wrote.
But, cardiovascular risk profiles require more work to calculate and to manage than the simple yes-no definitions for hypertension or high cholesterol, Drs. Jackson and Wells said.
"Risk prediction is not rocket science, but, similar to a tax return, most of us cannot do it in our heads," they said. "Then comes the hard part: discussing the predicted risk and the predicted treatment benefit with the patient."
Furthermore, only 45% to 66% of high-risk cardiovascular patients had reached lipid targets within a year, "and thus, a large treatment gap still persisted," noted Charles B. Eaton, M.D., M.S., of Brown University and Memorial Hospital of Rhode Island in Providence, R.I., in a second accompanying editorial.
The study was funded by Pfizer Canada.
Dr. Grover and two co-authors reported receiving research grants from Pfizer, sanofi-aventis, and AstraZeneca. Dr. Grover also reported receiving speaker honoraria from Pfizer, sanofi-aventis, and Orynx, and has either been a consultant to or participated on an advisory board for AstraZeneca, sanofi-aventis, and Pfizer.
The editorialists reported no conflicts of interest.Additional source: Archives of Internal MedicineSource reference: Grover S, et al "Patient knowledge of coronary risk profile improves the effectiveness of dyslipidemia therapy. The CHECK-UP study: a randomized controlled trial"Arch Intern Med 2007; 167: 2296-2303. Additional source: Archives of Internal MedicineSource reference: Eaton CB, "Using cardiovascular age equivalent to close the treatment gap for dyslipidemia"Arch Intern Med 2007; 167: 2288.
Jackson R, Wells S, "Prediction is difficult, particularly about the future"Arch Intern Med 2007; 167: 2286-2287.