Most patients with cardiovascular disease do not see a provider before having a STEMI

Fewer than half of patients with cardiovascular disease saw a primary care provider and fewer than 40 percent saw a cardiovascular provider during the two years before they had a ST-segment elevation MI (STEMI), according to a prospective cohort study.

The analysis also found that among the patients not taking statins before a STEMI, 38.7 percent were statin eligible under the ATP III guidelines and 79 percent would have been statin eligible under the 2013 guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA).

In addition, most patients did not have significantly elevated low-density lipoprotein (LDL) cholesterol levels before their STEMIs.

Lead researcher Michael D. Miedema, MD, MPH, of the Minneapolis Heart Institute, and colleagues published their results online in the Journal of the American Heart Association on April 12.

“The data on statins clearly shows that individuals with normal cholesterol levels can also reduce their risk of heart attacks,” Miedema said in a news release. “The more recent cholesterol guidelines are clearly a big step in the right direction, but we need to have better systems and incentives in place to get patients the assessment and treatments that could potentially be life-saving.”

Approximately one-third of MIs are STEMIs, which the researchers noted are among the most costly and morbid presentations of cardiovascular disease and are often complicated by cardiogenic shock or cardiac arrest. They added that statins help treat elevated cholesterol and lower the risk of MI.

Whereas the ATP III guidelines relied heavily on measuring LDL cholesterol levels, the ACC/AHA guidelines from 2013 focused on absolute cardiovascular disease risk when recommending statins.

This study analyzed 1,062 STEMI patients who were part of the Minneapolis Heart Institute Level 1 MI program from Jan. 1, 2011 until Dec. 31, 2014. The patients presented to the PCI center or community hospitals without PCI capability.

Each site has standardized protocols and predetermined transfer plans, and patients are enrolled in a comprehensive, prospective database and followed for five years.

The mean age was 63.7 years old, while 72.5 percent of patients were male and 71.7 percent did not have known cardiovascular disease before STEMI. Patients with prior cardiovascular disease were more likely to have hypertension and dyslipidemia before STEMI compared with those without known cardiovascular disease. The rates of current smoking were 36.8 percent and 25.6 percent, respectively.

The researchers found that only 62.5 percent of patients with prior cardiovascular disease and 19.3 percent of patients without prior cardiovascular disease took a statin before experiencing a STEMI.

For patients without prior cardiovascular disease, the median LDL cholesterol levels were 83 mg/dL for those taking statin therapy and 110 mg/dL for those not taking statin therapy. For patients with prior cardiovascular disease, the median LDL cholesterol levels were 108 mg/dL for those not taking a statin and 77 mg/dL for those taking a statin.

Among the patients who were not taking statins before STEMI, 38.7 percent had LDL cholesterol levels that made them statin eligible under ATP III guidelines and 79 percent had LDL cholesterol levels that made them statin eligible under ACC/AHA guidelines.

Of the patients with known cardiovascular disease before STEMI, only 48.5 percent saw a primary care provider and 37.9 percent saw a cardiovascular provider in the two years before their STEMI. Meanwhile, of the patients without known cardiovascular disease before STEMI, only 34.8 percent saw a primary care provider and 3.2 percent saw a cardiovascular provider in the two years before their STEMI.

The researchers acknowledged the study had a few limitations, including that it only had data from one regional STEMI system, so the prevalence of cardiovascular disease, diabetes and other determinants might not be generalizable to other systems. They also could not measure compliance or adherence to preventive medications before STEMI, and they did not evaluate patients’ history of statin intolerance or adverse reactions to preventive medications. In addition, they did not measure cardiovascular disease risk factors and instead used a electronic health record data to track risk factors.

“Our results suggest that implementation of the ACC/AHA guidelines may result in a substantial increase in statin usage in individuals otherwise destined to experience STEMI,” the researchers wrote. “However, we also found that access to and utilization of health care, a necessity for guideline implementation, was suboptimal prior to STEMI, with less than half of those with and without prior [cardiovascular disease] seeing a primary care provider over the 2 years prior to STEMI.”