Inconsistencies in Low-Density Lipoprotein Cholesterol Testing and Treatment After Revascularization

Individuals with atherosclerotic cardiovascular disease (ASCVD), particularly those undergoing revascularization, are at increased risk for future cardiovascular events. Several factors mitigate this risk, including lifestyle modifications, smoking cessation, treatment of comorbidities, and lipid-lowering therapy (LLT). In patients who are 75 years of age or younger with clinical ASCVD, guidelines recommend initiating high-intensity statin therapy, with the aim of achieving a 50% or greater reduction in low-density lipoprotein cholesterol (LDL-C) levels.¹ Data obtained from GOULD, a registry of patients with ASCVD in the United States, suggests clinicians underutilize LLT—ignoring guideline recommendations.²

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A retrospective cohort study published in the European Journal of Preventive Cardiology assessed the rates of LDL-C testing, use of LLT, and whether a goal LDL-C level below 70 mg/dL was achieved.³ The researchers extracted patient-level data from 6405 patients’ electronic health records. All had had myocardial or peripheral artery disease revascularization between 2018 and 2023 at a New York City health system. They included patients aged over 18 years who survived more than 30 days post-procedure and had a follow-up at the health system post-procedure.

The researchers found that 67% of patients had follow-up LDL-C testing at their health system; they subsequently analyzed a portion of these 4319 patients with follow-up LDL-C testing. The median time to follow-up testing was 11 months, with only 35% (1507) of patients having testing performed within 6 months of their index procedure. Patients with earlier follow-up tended to be younger and more likely to have been prescribed a high-intensity statin, ezetimibe, and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) monoclonal antibody during the follow-up period.

Median LDL-C was lower in patients who had follow-up LDL-C testing within 6 months as compared with those with LDL-C testing beyond 6 months. About half of the cohort who had follow-up LDL-C testing (52%) achieved a goal LDL-C level below 70 mg/dL, with 30% of patients achieving an LDL-C of less than 55 mg/dL. The researchers found that being female and non-Hispanic Black were independent predictors of significantly lower likelihood of reaching an LDL-C level below 70 mg/dL at follow-up.

While the literature supports prompt follow-up LDL-C testing and treatment post revascularization in patients with ASCVD, this does not always occur in real-world settings. This cohort study concluded that most LDL-C testing post-revascularization was delayed and identified several disparities in achieving LDL-C goals. Additionally, the study confirmed that early testing was associated with intensification of LLTs and lower follow-up LDL-C levels.

Pharmacists should be sure they monitor LDL-C levels in patients following revascularization and take special consideration as to the benefits of early LDL-C testing. With earlier intensification of statins or other LLTs, patients can more thoroughly reduce their risk for future cardiovascular complications. In their role as front-facing health care providers, pharmacists can counsel patients on the importance of proper lipid monitoring following revascularization.

REFERENCES

1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2019 Jun 25;73(24):3234-3237. doi: 10.1016/j.jacc.2019.05.012.]. J Am Coll Cardiol. 2019;73(24):3168-3209. doi:10.1016/j.jacc.2018.11.002

2. Cannon CP, de Lemos JA, Rosenson RS, et al. Use of Lipid-Lowering Therapies Over 2 Years in GOULD, a Registry of Patients With Atherosclerotic Cardiovascular Disease in the US. JAMA Cardiol. 2021;6(9):1060-1068. doi:10.1001/jamacardio.2021.1810

3. Greenberg GS, Lorenzatti D, Filtz A, et al. Disparities in Achieving LDL-C Goals After Revascularization in a Diverse Real-World Cohort. Eur J Prev Cardiol. Published online April 16, 2025. doi:10.1093/eurjpc/zwaf235