Half of those at risk of heart attack not treated adequately, research says

In Europe, only half of those at high risk of heart disease are given correct targets for lowering their cholesterol levels.  It’s the outcome of a recent study on 25,250 patients in Germany published online in the European Heart Journal [1].

The study investigated the way primary care doctors assessed their patients’ risk factors and other health problems when deciding on cholesterol-lowering targets. Though focused on German doctors and their patients, the research results are thought to mirror similar pictures in the rest of Europe. They say that approximately 50-80 fewer heart attacks, strokes and heart disease-related deaths per 1000 patients over a 10-year period could be avoided if all doctors followed the guidelines of best practices on cholesterol-lowering targets.

Cholesterol is a fatty substance known as a lipid and it is carried in the blood on proteins called low-density lipoproteins (LDL). Having high cholesterol levels (hyperlipidaemia) is a major risk factor for the development of blocked arteries (atherosclerosis) and heart disease, and, therefore, lowering cholesterol via drugs, diet and other lifestyle measures, is an important preventative measure.

The researchers found that in a survey of 907 doctors, involving 25,250 patients, just over half of male patients (55%) and less than half (49%) of female patients were assigned correct LDL targets. Patients were more likely to be given correct targets if they had a history of heart attacks, coronary artery disease, with or without bypass surgery, and diabetes. However, doctors were more likely to underestimate women’s risk and assign them incorrect targets. For instance, despite an identical history of a recent heart attack, nearly 68% of men and only 60% of women were given correct treatment targets for LDL lowering.

The average level of cholesterol in the German adult population is approximately 140 mg/dl. For patients with heart disease, 140 mg/dl is already higher than it should be, and they require treatment, for instance with statins, to bring cholesterol levels down. The higher the patient’s risk of heart disease, the lower the LDL cholesterol targets should be. LDL targets are supposed to be less than 100 mg/dl for patients with a history of heart attacks, coronary artery disease, coronary artery bypass grafting, peripheral artery disease, stroke, diabetes, transient ischaemic attacks or a greater than 20% 10-year risk of a heart disease-related event. LDL targets of less than 130 mg/dl apply to patients with two or more vascular risk factors such as diabetes, stroke or peripheral artery disease; and LDL targets of less than 160 mg/dl apply to patients with no, or only one, vascular risk factor and a 10-year risk of heart disease of less then 10%.

The research found that the highest percentage of patients with correctly assigned cholesterol-lowering targets were to be found in the group with LDL targets of less than 100 mg/dl (57.4% correct out of a total of 17,227 patients). Men who had previously suffered heart attacks were the most likely to be assigned a correct target of less than 100 mg/dl (77.1%). For patients assigned a target of less than 130 mg/dl or less than 160 mg/dl, only 41.7% were correct out of a total of 5,551 and 2,472 patients respectively.

The study may highlight similar scenarios in other European countries and those around the world. In fact, similar data were reported from Italy. The core question involves the perception of patient risk: for example, women are often perceived as having a lower cardiovascular risk compared to their real risk, and this may lead to insufficient treatment. This aspect has also been reported in other regions of the world.

There might be a number of reasons why doctors failed to follow guidelines correctly. Women are simply overlooked by their physicians, when it comes to cardiovascular risk. Moreover, not all physicians believe in the concept of risk reduction by LDL modification, although the evidence is overwhelming. Their reasons may be multifactorial: some might be confused by different, changing and frequently updated guidelines and some may simply lack time to spend on their patients in primary care. Physicians may need more assistance in determining the risk of their patients, for instance with nurse practitioners or computer programs calculating the risk from the patients’ electronic file notes.

Guidelines should be made simpler and easier to understand and follow; instruments to identify high-risk patients more easily should be developed; and special attention should be paid to women and patients without known cardiovascular disease, but with an accumulation of risk factors, since both groups appear frequently to escape the notice of doctors for aggressive cholesterol-lowering treatment.

[1] “Physicians’ perception of guideline-recommended low-density lipoprotein target values: characteristics of misclassified patients.” European Heart Journal. doi:10.1093/eurheartj/ehq026.


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