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©2003 by Excerpta Medica, Inc. All rights reserved. 0002-9149/03/$–see front matter 79
The American Journal of Cardiology Vol. 92 July 1, 2003 doi:10.1016/S0002-9149(03)00474-0
TABLE 1 Patient Demographics and Baseline Characteristics TABLE 2 Adjusted (multivariate) Odds Ratios for Association
(n ⫽ 2,829) of Patient and Provider Characteristics With Titration of the
Statin Dose in 1,464 Patients Not at their LDL Cholesterol
Patient Characteristic % or Mean Goal of 100 mg/dl With Initial Statin Dose
Men 72.3% Adjusted
Mean age ⫾ SD 63.6 ⫾ 11.9 Odds 95% Confidence
Age ⱖ65 yrs 50.4% Ratios Intervals
Caucasian 86.7%
African-American 5.8% Baseline lipid profile
Hispanic 5.2% HDL Cholesterol 0.981 0.962–1.000
Coronary heart disease only 62.3% Follow-up lipid profile*
Diabetes only 17.9% LDL Cholesterol between 1.360 1.039–1.780
Coronary heart disease and diabetes 19.8% 130–159 mg/dl
Mean LDL cholesterol (⫾ SD) 149.6 ⫾ 31.2 LDL Cholesterol ⱖ160 mg/dl 1.597 1.067–2.391
HDL cholesterol (⫾SD) 36.9 ⫾ 5.6 Triglycerides 1.002 1.000–1.004
Mean non–HDL cholesterol (⫾) 186.7 ⫾ 34.8 Physician characteristics*
Median triglycerides* 171 (126–230) Midwest Region 1.472 1.019–2.125
Initial statin Family or General Practice 0.305 0.188–0.495
Simvastatin 55.4% Baseline statin and dose*
Atorvastatin 29.0% Simvastatin 1.574 1.139–2.176
Pravastatin 10.2% Atorvastatin 1.642 1.145–2.355
Other statin 5.4% Above recommended starting 0.491 0.359–0.672
dose
*Triglycerides are reported as medians and interquartile ranges.
*Follow-up lipid profiles are taken as the lipid profile just before titration for
patients and as the final lipid profile for those whose statin dose was not
titrated. The reference group for the interim LDL cholesterol variables includes
patients with LDL cholesterol ⬍130 mg/dl. The reference group for practice
region variables includes physicians in the south. The reference group for the
specialty variables includes cardiologists. The reference group for the statin
variables includes patients on pravastatin, cerivastatin, fluvastatin, or lova-
statin.
ment rates as low as ⱕ25%.10 –12 Only 48% of patients efficacy of atorvastatin in treating patients with hypercholesterolaemia to target
LDL-cholesterol goals: the LIPI-GOAL trial. Acta Cardiologica 2001;56:109 –
in our study achieved LDL cholesterol goals with their 114.
initial starting dose. Of those who did not reach their 8. Garmendia F, Brown AS, Reiber I, Adams PC. Attaining United States and
European guideline LDL-cholesterol levels with simvastatin in patients with
goals with their initial dose, less than half had the dose coronary heart disease (the GOALLS study). Cur Med Res Opin 2000;16:208 –
titrated despite the allowance of 6 months, which was 219.
believed to be a sufficient amount of time to titrate the 9. Hunninghake D, Bakker-Arkema RG, Wigand JP, Drehobl M, Schrott H, Early
JL, Abdallah P, McBride S, Black DM. Treating to meet NCEP-recommended
statin dose. Thus, lack of titration may contribute to the LDL cholesterol concentrations with atorvastatin, fluvastatin, lovastatin, or sim-
previously reported low rate of success in achieving vastatin in patients with risk factors for coronary heart disease. J Fam Pract
1998;47:349 –356.
LDL cholesterol treatment goals.10 –12 Examination of 10. Sueta CA, Chowdhury M, Boccuzzi S, Smith SC, Alexander CM, Londhe A,
the factors associated with titration suggests that physi- Lulla A, Simpson RJ. Analysis of the degree of undertreatment of hyperlipidemia
cians are more likely to titrate dosages for patients with and congestive heart failure secondary to coronary artery disease. Am J Cardiol
1999;83:1303–1307.
the highest LDL cholesterol and triglyceride values and 11. Pearson T, Laurora I, Chu H, Kafonek S. The Lipid Treatment Assessment
that patients started on a dose above the recommended Project. Arch Intern Med 2000;160:459 –467.
starting dose are less likely to have the statin dose ti- 12. Fonarow G, Gawlinksi A, Moughrabi S, Tillisch J. Improved treatment of
coronary heart disease by implementation of a Cardiac Hospitalization Athero-
trated. Physicians appear to use the highest doses spar- sclerosis Management Program (CHAMP). Am J Cardiol 2001;87:819 –822.
ingly even among these high-risk patients. 13. Pearson T, Feinberg W. Behavioral issues in the efficacy versus effectiveness
Factors not captured in this study may play a role of pharmacological agents in the prevention of cardiovascular disease. Ann Behav
Med 1997;19:230 –238.
in whether patients obtain goal. Lack of patient ad- 14. Black N. Why we need observational studies to evaluate the effectiveness of
herence to statin treatment, and to diet and exercise health care. BMJ 1996;312:1215–1218.
BRIEF REPORTS 81