Drug therapy for hypercholesterolemia in patients with cardiovascular disease: Factors limiting achievement of lipid goals

PURPOSE: To determine the extent that goal lipid levels derived from the National Cholesterol Education Program (NCEP) are achievable in clinical practice, and to identify factors associated with the achievement of these goals. PATIENTS AND METHODS: We conducted a retrospective cohort study consisting of a consecutive sample of 244 patients with either coronary artery disease or peripheral vascular disease treated for hypercholesterolemia at a large Veterans Affairs medical center. Primary outcomes, recorded prospectively, were lipid levels and lipoprotein cholesterol response, and tolerance and compliance to drug therapy. Goal lipid levels were defined as low-density lipoprotein cholesterol (LDL-C) less than or equal to 130 mg/dL and triglyceride (TG) less than or equal to 200 mg/dL. RESULTS: Lipid-lowering drug therapy reduced LDL-C from 25% to 42% below baseline in patients with hypercholesterolemia varying from mild (130 to 160 mg/dL) to severe (>220 mg/dL), respectively. Approximately 75% of patients with LDL-C less than or equal to 160 mg/dL ultimately achieved their lipid goal with drug therapy; however, less than half of patients with baseline LDL-C >160 mg/dL achieved target lipid values. Multivariate analysis indicated that lower baseline LDL-C and triglycerides, use of combinations of drug therapy rather than monotherapy, and patient adherence to treatment predicted the achievement of goal lipid levels. CONCLUSIONS. Successful implementation of NCEP guidelines frequently requires combination drug therapies, and is limited by poor patient tolerance and acceptance of niacin and the sequestrants.