O-091 - OPTIMIZING SECONDARY PREVENTION: A 1 YEAR REVIEW OF LIPID LOWERING THERAPY (LLT) AND CHOLESTEROL MONITORING IN PATIENTS UNDERGOING CAROTID SURGERY

TOPIC:
Medical therapies (antithrombotic, anti-hypertensive, diabetes mellitus etc.)
AUTHORS:
Kwan J.Y. (Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust ~ Leeds ~ United Kingdom) , Sood M. (Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust ~ Leeds ~ United Kingdom) , Stocco F. (Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust ~ Leeds ~ United Kingdom) , Orozov N. (Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust ~ Leeds ~ United Kingdom) , Spencer-Jones K. (Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust ~ Leeds ~ United Kingdom) , Bailey M. (Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust ~ Leeds ~ United Kingdom) , Coughlin P. (Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust ~ Leeds ~ United Kingdom) , Scott J. (Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust ~ Leeds ~ United Kingdom)
Introduction:
Stroke is common (100 000 new cases annually in the UK) with carotid atherosclerotic disease a recognised cause (1). In such cases patients may require either surgical or endovascular carotid intervention but they should also receive optimal medical therapy including lipid lowering therapy (LLT) (2). Statins have been shown to reduce the 10- year risk of stroke/death (17.9% vs 7.6%) after carotid endarterectomy (3). Current European Society for Vascular Surgery (ESVS) Guidelines advise high-intensity statin (HIS) treatment with a target LDL-C level of < 1.8mmol/L (2). This study aims to explores trends in titration of lipid lowering therapy and LDL-C levels in patients undergoing carotid intervention prior to, at the time of and 1 year following carotid intervention.
Methods:
This was a 12-month retrospective cohort study from a tertiary vascular surgery unit supported by dedicated two cardiovascular pharmacists. All patients who underwent carotid intervention carotid endarterectomy (CEA) or carotid artery stenting (CAS) from 01/01/19 - 31/12/20 were included in this study. Prescription of LLT and blood lipid profiles were collated from electronic hospital records. HIS therapy was defined as per guidelines (2). Data was collected for the following time points- (i) prior to admission for surgery, (ii) on discharge and (iii) 1 year post discharge. Medication adherence data was extrapolated from primary care records and measured using the adjusted medication possession ratio (MPR). McNemar test was used to assess for differences at baseline and 1 year follow-up.
Results:
There were 138 patients (men n=89, overall median age 72 years IQR (65-78)). 118 patients underwent CEA, and the remaining 20 underwent CAS. Significant increases in the prescription rate of statins and the use of HIS therapy were observed when comparing pre-admission to immediate post carotid intervention discharge (67% vs 93%; p<0.001 and 51% vs 86%; p<0.001 respectively). Ezetimibe was commenced in 4 patients: 2 were statin intolerant, 1 already on maximal HIS therapy, and 1 on medium intensity statin therapy. Only 25% of discharge summaries detailed instructions on the ongoing management of the patients LLT. No difference in either statin prescription or HIS use was observed when comparing immediate to 1 year post discharge (93% vs 91%; p=1 and 86% vs 86%; p=1 respectively). In patients prescribed a statin, 82% were considered adherent with a MPR >80%. The number of patients who underwent at least one LDL-C profile testing remained constant pre-admission and at 1 year (33% vs 27%, p=0.230). Median LDL-C concentration improved from 2.7mmol/L, IQR (1.9-3.4) at baseline pre-admission to 1.6mmol/L, IQR (1.2-2.0) at 1 year follow-up. There was an increase in the number of patients who achieved the ESVS target of <1.8mmol/L, 5% vs 17% (p<0.001). At 1 year, only 46% of patients were on maximum intensity statin therapy (MIS; Atorvastatin 80mg or Rosuvastatin 40mg) with an additional 2 patients on MIS + Ezetimibe.
Conclusion:
Admission to a vascular surgery unit supported by dedicated cardiovascular pharmacists for carotid intervention is associated with a marked increased in guideline directed use of lipid lowering therapy which appears to be maintained out to 1 year. This is associated with significant reduction in LDL-C concentration. Despite this, only a small proportion go on to receive lipid profile monitoring in community and a smaller number achieved LDL-C targets at 1 year. Data also suggests potential for more patients to be up-titrated to HIS and MIS. Detailed discharge advice to general practitioners need to be improved on, and further work is required to ensure adherence, regular monitoring and up-titration in the community.
References:
1. CKS. 2022. What is the prevalence of stroke and TIA in the UK?. [online] Available at: (Accessed 2 April 2022). 2. A.R. Naylor et al., Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS), European Journal of Vascular and Endovascular Surgery 2018;55:3-81. http://dx.doi.org/10.1016/j.ejvs.2017.06.021. 3. Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 2010;376:1074e84.