Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real life evidence of Under-treatment from the EPHESUS registry

Abstract

Background and aims Effective treatment of high low‐density lipoprotein cholesterol (LDL‐C) levels has been shown to improve cardiovascular outcomes of patients with diabetes mellitus (DM). Herein, we aimed to provide insight to the real‐life management of patients with DM in terms of LDL‐C goal attainment and adherence to lipid management recommendations. Our objective was also to reveal the reasons of poor LDL‐C goal attainment by assessing the perceptions of both physicians and patients.

Methods We compared the diabetic and non‐diabetic patients from the database of a nation‐wide registry conducted in cardiology outpatient clinics with regard to the demographic characteristics, educational status, comorbidities, medications, laboratory parameters, and LDL‐C goal attainment. Also, both the patients and attending physicians were surveyed to analyze perceptions and awareness of hypercholesterolemia.

Results Of the 1868 consecutively enrolled patients, 873 (47%) had DM. Proportion of patients on statins was significantly lower in patients with DM (67.8% vs 55.3%; p<0.001). The proportion of patients who attained LDL‐C targets were lower among the diabetic patients (17.8% vs 15%; p=0.06). The most common causes of the discontinuation of statin therapy were negative media coverage about statins (32.1%), and recommendations of physicians to stop the lipid lowering therapy (29.6%). Analysis of the physician survey revealed that the physicians could determine the off‐target patients accurately (negative predictive value 98.4%) while the positive predictive value (48.8%) was low. The reasons for not attaining the LDL‐C goals in diabetic patients were not prescription of statins (38%) and inadequate (e.g., low‐dose, non‐adherent) statin (28.3%) dosages. Conclusions In real‐life clinical cardiology practice, diabetic patients are far below the recommended LDL‐C treatment goals. High intensity statin treatment in diabetic population is still avoided because of the concerns about polypharmacy and drug interactions. Also, the inertia of physicians and even cardiologists is probably a major cause of refraining of prescription of optimal statin dosages.