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Cholesterol Management and Risk Reduction – Current Guidelines and Barriers to Goal Attainment
(1999–2000) showed that many patients with dyslipidaemia and either
Table 1: World Health Organization Guidelines for
established CHD or high risk of CHD were not treated to their LDL-C goal,
Primary Prevention
which suggested that guidelines were being poorly implemented.
57,58
Researchers from EUROASPIRE II reported that 58.3% of patients did not
All individuals with total cholesterol ≥8mmol/l (≥320mg/dl) should be advised to follow a
lipid-lowering diet and given a statin to lower the risk of cardiovascular disease.
reach the total cholesterol goal of <5.0mmol/l despite the fact that
All other individuals need to be managed according to their cardiovascular risk, as
60.6% of patients were being treated with statins.
58,59
Recently, the
follows: 10-year risk of cardiovascular event <10%, 10–<20%, 20–<30% or ≥30%:
EUROASPIRE III survey (2006–2007) showed that lipid control was
• Risk <10% Should be advised to follow a lipid-lowering diet.
completely inadequate, with most patients not achieving the targets • Risk 10–<20% Should be advised to follow a lipid-lowering diet.
defined in the European guidelines.
60
EUROASPIRE III also showed that
• Risk 20–<30% Adults >40 years of age with persistently high serum
79% of the patients had total cholesterol
cholesterol (>5.0mmol/l) and/or LDL cholesterol >3.0mmol/l,
≥4.5mmol/l, which exceeded
the recommended European targets.
61
Furthermore, the high-risk
despite a lipid-lowering diet, should be given a statin.
• Risk ≥30% Individuals in this risk category should be advised to follow a
individuals in primary prevention programmes were not being managed
lipid-lowering diet and given a statin. Serum cholesterol should
effectively, with too few of these patients following the European
be reduced to <5.0mmol/l (LDL cholesterol to <3.0mmol/l) or
guidelines and more than 80% never having received any advice or
by 25% (30% for LDL cholesterol), whichever is greater.
direction about the importance of following a heart-healthy lifestyle
LDL = low-density lipoprotein.
programme.
60
EUROASPIRE III also showed that statins were
Adapted from WHO, 2007.
4
underprescribed.
60
Other recent surveys have investigated the extent to
Table 2: World Health Organization Guidelines for
which the ATPIII
62
and European guidelines (based on recommendations
Secondary Prevention
by JTF3)
63
were incorporated into clinical practice. These surveys have
shown that the treatment gap still exists, despite the continuing
Treatment with statins is recommended for all patients with established CHD.
improvement in guidelines, with many patients not reaching target
Treatment should be continued in the long term, and probably lifelong. Patients at high
baseline risk are particularly likely to benefit.
cholesterol levels.
Treatment with a statin should be considered for all patients with established CVD,
especially if they also have evidence of established CHD.
Barriers to Goal Attainment
Monitoring of blood cholesterol levels is not mandatory. Total cholesterol <4.0mmol/l
The treatment gap may be due to the presence of certain barriers to goal
(<152mg/dl) and LDL cholesterol <2.0mmol/l (<77mg/dl), or a reduction of 25% in total
attainment. These barriers can be vaguely divided into three categories: cholesterol and 30% in LDL cholesterol, whichever achieves the lower absolute risk level,
physician-related, patient-related and healthcare-system-related.
may be desirable goals.
Other lipid-lowering agents are not recommended, either as an alternative to statins or in
Physician-related Barriers
addition to them.
The Reassessing European Attitudes about Cardiovascular Treatment
CHD = coronary heart disease; CVD = cardiovascular disease; LDL = low-density lipoprotein.
Adapted from WHO, 2007.
4
(REACT) survey identified numerous physician-related barriers,
64
including lack of time, prescribing costs, too many guidelines, lack of to be a valuable tool for physicians in improving the quality of both their
guideline awareness and lack of physician motivation. Lack of time could decision-making and the health of their patients.
69,71–73
However, the
result in physicians not properly informing their patients about their main barrier to thorough implementation of these systems is their cost.
treatment regimen, leading to patient non-compliance due to improper While hospitals can afford expensive IT systems and infrastructure, there
understanding of their therapy.
65
The cost of pharmacotherapy may also are few cost-effective options for small clinics.
be a barrier; however, the effect of this factor on clinical practice has not
been well documented.
66,67
Patient-related Barriers
Patient non-compliance has frequently been reported to be a barrier to
Although physicians have knowledge of hypercholesterolaemia and its goal attainment in cholesterol management.
35,64,74–76
Non-compliance
link to CHD, they are not suitably motivated to implement correct to pharmacotherapy can result in higher LDL-C levels, an increased rate
treatment.
65
This requires a change in behavioural practice and also new of coronary events and poor quality of life.
75
Poor patient compliance is
policies from health services to ensure better physician understanding a contributing factor to failure to reach goal LDL-C levels, even in
and implementation of the guidelines; for example, a payment-by-results patients receiving the most effective of the current therapies for
scheme could give physicians the incentive to implement more wide- lowering LDL-C.
77
It seems that despite the improvement in cholesterol
ranging treatment regimens. management and risk reduction guidelines, drug non-compliance is still
a major barrier to goal attainment.
76
Another strategy to improve guideline implementation is to use powerful
information technology (IT) systems that encompass up-to-date medical Non-compliance could itself be due to a variety of barriers, such as
knowledge and the medical history of patients.
68,69
With some systems, adverse drug effects.
35
Overcoming these barriers could help increase
the physicians can actually input and access the information in patient compliance and, in turn, improve goal attainment. Although the
realtime.
69,70
In this manner, the knowledge management system can currently available statins are generally safe, discontinuation rates of 30%
automatically check the physician’s decision (order of a medicine or after six months have been reported.
78
This emphasises the need for even
laboratory test) against a large clinical database, as well as the patient’s better and safer statins, or modification of existing drugs.
21
own medical record, and make queries or recommendations.
69,70
Thus,
this system helps the physician to provide treatment tailored to the The Global Opinions and Awareness of Cholesterol (GOAL) survey
patient and also considers all of the patient’s health needs at the same assessed the European public’s perception of cardiovascular risk.
65
The
time.
69
Health IT and knowledge management systems have been shown majority of participants had only a vague idea about cholesterol’s role in
ASIA-PACIFIC CARDIOLOGY 17
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