Optimizing Secondary Prevention: A 1-Year Review of Lipid Lowering Therapy (LLT) and Cholesterol Monitoring in Patients Undergoing Carotid Surgery

Objectives: Patients undergoing surgical or endovascular carotid intervention should receive optimal medical therapy, including LLT . Statins reduce the 10-year risk of stroke/death (17.9 vs. 7.6%) after carotid endarterectomy (1). Current guidelines advise high-intensity statin (HIS) treatment and achieve a target LDL-C level of < 1.8mmol/L (2). This study aims to explores trends in titration of lipid lowering therapy and LDL-C levels in patients undergoing carotid intervention prior to, at the time of and 1 year following carotid intervention.

Methods: This was a 12-month retrospective cohort study from a tertiary vascular surgery unit supported by two cardiovascular pharmacists. CEA or CAS patients from 01/01/19–31/12/20 were included. Prescription of LLT and blood lipid profiles were collected (i) prior to admission for surgery, (ii) on discharge and (iii) 1 year post discharge. Medication adherence data was measured using the adjusted medication possession ratio. McNemar test was used to assess for differences at baseline and 1 year follow-up.

Results: There were 138 patients (men n = 89, overall median age 72 years). 118 patients underwent CEA.

Significant increases in the prescription rate of statins and the use of HIS therapy were observed when comparing pre-admission to immediate post carotid intervention discharge (67 vs. 93%; p <0.001 and 51 vs. 86%; p <0.001, respectively). Only 25% of discharge summaries contain instructions on the ongoing management of LLT. No difference in statin prescription or HIS use was observed when comparing immediate to 1 year post discharge (93 vs. 91%; p = 1 and 86 vs. 86%; p = 1 respectively). In patients prescribed a statin, 82% were considered adherent with a MPR >80%.

The number of patients who underwent at least one LDL-C testing remained constant pre-admission and at 1 year (33 vs. 27%, p = 0.230). Median LDL-C concentration improved from 2.7mmol/L, IQR (1.9-3.4) at baseline pre-admission to 1.6mmol/L, IQR (1.2-2.0) at 1 year. Number of patients who achieved the target of <1.8mmol/L significantly increased (5 vs. 17%, p <0.001). At 1 year, 46% of patients were on maximum intensity statin (MIS).

Conclusion: Admission to a vascular surgery unit supported by dedicated cardiovascular pharmacists is associated with an increased in guideline directed use of LLT and reduction in LDL-C concentration. However, only a small proportion underwent lipid profile monitoring in community and achieved LDL-C targets at 1 year. There is potential for more patients to be up-titrated to MIS. Further work is required to ensure adherence, regular monitoring and up-titration in the community.

References

1. Naylor AR, Ricco JB, de Borst GJ, et al; Esvs Guidelines Committee; Esvs Guideline Reviewers. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018;55(1):3–81 10.1016/j.ejvs.2017.06.021 PubMed

2. Halliday A, Harrison M, Hayter E, et al; Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 2010;376(9746):1074–1084 PubMed

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
10 June 2022