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Cardiovascular (CV) risk management for high-risk patients is often provided by primary care physicians (PCPs). We surveyed Canadian PCPs regarding their awareness and implementation of the 2021 Canadian Cardiovascular Society (CCS) lipid guideline recommendations for patients following an acute coronary syndrome (ACS) or for those with diabetes but without CV disease.
Methods
A committee of PCPs and specialists with lipid expertise, including some 2021 CCS lipid guideline co-authors, designed a survey to probe PCP awareness and practice patterns regarding CV risk management. From a national database, a total of 250 PCPs completed the survey between January and April 2022.
Results
Almost all (97.2%) PCPs concurred that a post-ACS patient should be seen by their PCP within 4 weeks of hospital discharge (81.2% within 2 weeks). Almost half (44.4%) responded that discharge summaries provided inadequate information, and 41.6% felt that lipid management post-ACS was the primary responsibility of specialists. 58.4% articulated challenges when seeing a post-ACS patient, related to inadequate discharge information, complexities of polypharmacy and duration of therapies, and managing statin intolerance. 63.2% and 43.6% correctly identified low-density lipoprotein cholesterol (LDL-C) intensification thresholds of 1.8 mmol/L in post-ACS patients and 2.0 mmol/L in diabetes respectively, while 81.2% incorrectly thought that PCSK9 inhibitors were indicated in for patients with diabetes but without CV disease.
Conclusions
One year following publication of the 2021 CCS lipid guidelines, our survey reveals knowledge gaps amongst responding PCPs regarding intensification thresholds and treatment options for patients post-ACS or those with diabetes. Innovative and effective knowledge translation programs would be desirable.
Atherosclerotic cardiovascular disease (ASCVD) including cerebral, cardiac, and peripheral arterial disease, remains a leading cause of death and disability in Canada.
ASCVD can be effectively prevented with evidence-based therapies, including therapies to reduce low-density lipoprotein cholesterol (LDL-C), such as statins, ezetimibe, and more recently, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.
Globally, guidelines for lipid management have been recently revised; the new guidelines in Canada have been updated with newer data, and notably, with the introduction of PCSK9 inhibitors. According to these guidelines, in patients with existing ASCVD receiving maximally tolerated statins with LDL-C levels above threshold, adding ezetimibe and/or PCSK9 inhibitors should be considered. Despite this, managing LDL-C levels remains challenging worldwide and within Canada
Low density lipoprotein cholesterol control status among Canadians at risk for cardiovascular disease: Findings from the Canadian Primary Care Sentinel Surveillance Network Database.
. Indeed, Aref-Eshghi et al. found that 68.6% of high-risk patients (including patients with atherosclerosis, most patients with diabetes, and those with a Framingham Risk Score ≥ 20%) in Canadian primary care settings had LDL cholesterol levels in excess of guideline-recommended thresholds.
Low density lipoprotein cholesterol control status among Canadians at risk for cardiovascular disease: Findings from the Canadian Primary Care Sentinel Surveillance Network Database.
Similarly, Rodenas et al. conducted a study in a primary care outpatient setting in Spain and found that only one third of outpatients with a previous MI were maintaining LDL-C levels below threshold.
Given the large proportion of high-risk patients with LDL-C levels above threshold, it is important to characterize practice patterns and physician knowledge in managing lipid-related risk in this patient population. Characterizing the awareness of the CCS 2021 lipid guidelines acts as a first step in identifying knowledge gaps and barriers to care. We thus undertook a Canada-wide survey of primary care providers (PCPs) to evaluate their uptake and understanding of current CCS lipid guidelines as they pertain to high-risk patients.
Methods
Questionnaire development
The Canadian Collaborative Research Network (CCRN) is an academic physician organization devoted to advancing knowledge through the development of continuing medical education programs for physicians from various specialties. A committee of seven PCPs and specialists with lipid expertise, including several co-authors of the 2021 CCS lipid guidelines, conducted a comprehensive needs assessment in the area of lipid guidelines and management. They then designed an online questionnaire to probe PCP awareness of the guidelines as well as practice patterns related to LDL-C thresholds, and to identify potential gaps and barriers to achieving guideline recommendations in high-risk patients. The questionnaire (Supplemental Appendix S1) consisted of 13 multiple-choice questions targeted to explore the specific domains, such as management of patients at particularly high risk, including those with diabetes or those following an acute coronary syndrome (post-ACS). Questions and correct answers, where applicable, were directly tied to the 2021 CCS lipid guidelines.
Participants
Between January and April 2022, we invited PCPs from a national database to complete the survey on lipid management in high-risk patients using SurveyMonkey. CCRN has maintained and grown a database of physicians (primary care and specialists) since 2008. The database includes all physicians who have participated in prior CCRN continuing medical education programs, research activities, and needs assessments. Physicians voluntarily opt in to join CCRN’s database and self-identify as having specific areas of clinical interest or expertise. For the purposes of this study, CCRN’s database was queried to select only primary care physicians who had self-identified as having expertise or clinical interest in cardiovascular medicine. Similar methodology has been used previously by CCRN in completing and publishing other surveys of physician awareness and knowledge in the area of lipids and heart failure.
The final database therefore consisted of 2095 PCPs who had previously expressed experience and/or interest in the management of ASCVD. PCPs from the database were distributed across provinces as follows: British Columbia 305, Alberta 292, Saskatchewan 123, Manitoba 91, Ontario 714, Quebec 355, New Brunswick 56, Nova Scotia 100, Prince Edward Island 13, Newfoundland 45, and Northwest Territories 1. The survey was closed after a pre-specified total of 250 PCPs had completed the survey. Participants were offered a modest stipend for providing complete responses.
Results
Physician demographics
A total of 250 PCPs completed the survey, representing most provinces and territories in Canada. The majority of respondents practiced in Ontario (45.2%), followed by British Columbia (14.8%), with approximately equal distribution across remaining provinces and territories. (Figure 1).
Figure 1Map of Canada showing distribution of survey participant location of practice. Numbers (%) of respondents from each province and territory are shown.
To gauge PCP opinion regarding patients achieving guideline-recommended LDL-C levels, we asked what percentage of post-ACS patients in their practices achieve LDL-C <1.8 mmol/L. The majority of PCPs felt that no more than 30-40% of their post-ACS patients achieve guideline-recommended LDL-C levels. (Figure 2A) We also asked PCPs their opinions as to how soon following discharge should post-ACS patients be seen by their PCP. The overwhelming majority of PCPs (97.2%) felt that such patients should be seen within 4 weeks of hospital discharge; with 81.2% believing this first visit should actually be within 2 weeks (Figure 2B). More than half of PCPs (58.4%) indicated that they faced significant challenges when managing the post-ACS patient. These challenges included inadequate hospital discharge information, complexities of polypharmacy, confusion regarding duration of therapies, and managing perceived or real statin intolerance (Figure 3). 44.4% of PCPs stated that hospital discharge summaries provided inadequate information for them to properly manage their post-ACS patients. Importantly, a significant proportion of PCPs (41.6%) stated that specialists, rather than PCPs, should hold primary responsibility for lipid management in the post-ACS patient.
Figure 2(A) Proportion of patients with acute coronary syndrome that achieve LDL-C levels below 1.8 mmol/L according to surveyed primary care physicians. (B) Surveyed primary care physician opinions on when a patient should be seen by a primary care physician following hospital discharge for an MI.
Awareness of 2021 CCS guidelines on lipid management in secondary prevention
PCPs were asked to identify the LDL-C intensification threshold (despite maximally tolerated statin therapy) in a post-ACS patient. Less than two thirds of PCPs (63.2%) correctly identified the threshold value of ≥1.8 mmol/L, with 28% selecting a threshold of 2.0 mmol/L and 6.4% a threshold of 1.4 mmol/L (Figure 4A). Regarding indications for PCSK9 inhibitor therapy in this patient population, only 19.6% of PCPs correctly stated that these agents were indicated for LDL-C > 1.8 mmol/L despite maximally tolerated statin therapy. The vast majority (81.4%) believed that PCSK9 inhibitors were only indicated for patients who were already receiving statins and ezetimibe (rather than statins alone) or who had substantially elevated LDL cholesterol levels, well above the intensification threshold of 1.8 mmol/L. The 2021 guidelines also identified additional high-risk clinical features that would guide the selection of a PCSK9 inhibitor rather than ezetimibe in the ASCVD population. Just over half of PCPs (53.6%) were able to correctly identify these clinical features associated with greatest absolute benefit of PCSK9 inhibitors in the ASCVD patient based on the major outcomes trials.
Figure 4LDL-C threshold for add-on therapy to a statin identified by surveyed primary care physicians for patients with (A) a recent acute coronary syndrome (ACS) and (B) diabetes and additional risk factors.
Awareness of 2021 CCS guidelines on lipid management in patients with diabetes but without ASCVD
To further assess knowledge of the 2021 CCS lipid guidelines, we explored the management of patients with diabetes with additional risk factors but without clinical ASCVD. Less than half (43.6%) of PCPs were able to correctly identify the LDL-C intensification threshold of 2.0 mmol/L in this patient population (Figure 4B), with 44.8% and 6.4% of PCPs claiming intensification thresholds of 1.8 mmol/L and 1.4 mmol/L respectively. Four out of five PCPs (81.2%) incorrectly believed that PCSK9 inhibitors were guideline-indicated for LDL-C intensification in patients with diabetes but without ASCVD (or familial hypercholesterolemia).
Barriers to implementation of non-statin LDL-C lowering therapies
Less than one quarter of PCPs (23.6%) in this survey had ever prescribed a PCSK9 inhibitor, despite describing themselves as having experience or interest in managing patients with ASCVD. When asked about barriers to PCSK9 inhibitor prescription amongst those who have never prescribed, 32.8% stated that formulary coverage/access was their primary limitation, whereas 35.2% felt that ezetimibe was adequate for the majority of their ASCVD patients.
Discussion
We found that a substantial portion of participating PCPs were unaware of appropriate LDL-C intensification thresholds in both post-ACS patients and in those with diabetes but without ASCVD. While PCPs seem to be aware of the urgency regarding lipid management in post-ACS patients, many encounter challenges in managing this patient population, including limited familiarity with the identification of patients deriving the greatest absolute benefit from PCSK9 inhibitors. Importantly, over 40% of PCPs felt that lipid management in the post-ACS population was not their primary responsibility, deferring to specialists. Familiarity with the appropriate indications for PCSK9 inhibitors in both post-ACS patients and those with diabetes but without ASCVD was also limited. For example, the CCS guidelines only recommend PCSK9 inhibitors in patients with diabetes if they have concomitant ASCVD or HeFH, yet a substantial proportion of PCPs felt that these agents were indicated in patients with diabetes without these other conditions. While provincial formulary coverage for PSCK9 inhibitors is currently limited to HeFH, private payers will cover for ASCVD, but not for diabetes alone, congruent with the CCS guidelines recommendations.
Thus, approximately one year following publication of the 2021 CCS lipid guidelines, our survey identifies knowledge gaps regarding intensification thresholds and treatment options for high-risk patient subgroups. Innovative and effective knowledge translation programs are recommended for PCPs who find application of the latest lipid guidelines challenging in their practices. Furthermore, we have identified other barriers to implementing care, such as limited drug coverage and inadequate discharge summaries post-cardiovascular events; therefore, these barriers are also areas for potential improvement.
LDL-C lowering is fundamental to risk reduction in high-risk patients including those ASCVD or diabetes, yet, lipid management in high-risk patients remains challenging in Canada and beyond.
The 2021 CCS lipid guidelines included stronger recommendations for combination LDL-C lowering therapies in patients with ASCVD, based on clinical trials that were published since the previous 2016 CCS lipid guidelines, including randomized trials and subgroup analyses of PCSK9 inhibitor therapy.
Clinical efficacy and safety of achieving very low LDL-cholesterol concentrations with the PCSK9 inhibitor evolocumab: a prespecified secondary analysis of the FOURIER trial.
A previous study assessed specialist knowledge of the 2016 CCS lipid guidelines for ACS patients, but those guidelines offered limited guidance in selecting between ezetimibe and PCSK9 inhibitors.
The 2021 CCS lipid guidelines have since evolved to reinforce the role of PCSK9 inhibitors in patients with ASCVD and to include specific algorithms for the selection of PCSK9 inhibitors based on easily identifiable patient characteristics.
We have identified gaps in knowledge of thresholds for management and for appropriate clinical action to escalate intensity of LDL cholesterol reduction. This appears to be the result of a relative lack of physician education and perhaps inadequate communication between PCPs and specialist care providers. These findings highlight opportunities to improve the lipid management and clinical outcomes of high-risk patients (Figure 5).
Figure 5Opportunities for addressing care gaps in patients requiring lipid management. Potential areas for improvement identified through surveying primary care physicians include continuing physician education regarding guidelines, collaboration across specialties, as well as improving patient access to various drug options.
Ongoing clinical research on lipid management inevitably impacts guidelines and recommendations, which in turn can pose challenges for PCPs to remain up to date, especially given the wide bandwidth of knowledge required in primary care. Furthermore, the addition of PCSK9 inhibitors to the treatment of ASCVD in recent years has potentially introduced new complexity into patient stratification and drug treatment algorithms. Another complicating factor is inconsistency between international guidelines, such as those from the American Heart Association/American College of Cardiology and the European Society of Cardiology/European Atherosclerosis Society,
which may contribute to variable practice patterns of Canadian physicians.
Knowledge gaps exist amongst responding PCPs regarding the CCS 2021 guidelines, highlighting the need for educational initiatives that meet their specific learning needs. According to our findings, areas for improvement on physician education include LDL cholesterol intensification levels, clinical features associated with the benefit of PCSK9 inhibitors in post-ACS patients, how to handle statin intolerance, and when to prescribe PCSK9 inhibitors in patients with diabetes. Efforts to disseminate information to PCPs focusing on these knowledge gaps could help improve the care of many patients and increase the proportion of patients with LDL-C levels below threshold. In addition to physician education, continuous patient education may facilitate implementation and adherence to guideline recommendations aimed at reducing LDL cholesterol.
Ferhatbegović, L., Mršić, D., Kušljugić, S. & Pojskić, B. LDL-C: The Only Causal Risk Factor for ASCVD. Why Is It Still Overlooked and Underestimated? Curr Atheroscler Rep (2022) doi:10.1007/s11883-022-01037-3.
Patients with ASCVD often have comorbidities and are managed by multiple physicians; therefore, communication across multidisciplinary teams is essential for patient care. Indeed, communication between healthcare providers has been recognized as a cause of poor patient outcomes in healthcare.
To ensure that cross-disciplinary communication meets the needs of healthcare providers involved in patient care, physicians should ensure the usage of standardized communication methods that are understandable by all team members.
Improved communication methods may improve patient care and increase the number of patients with controlled LDL levels. Furthermore, clear communication on which healthcare providers are involved in lipid management of patients is useful, as our survey showed that respondents had varying opinions on who the responsibility falls to.
Limitations and future directions
There are some limitations of this study. First, the sample size is relatively small and the geographic distribution of PCP respondents is not completely representative of the geographic distribution of all practicing PCPs in Canada; for example, nearly half the respondents (45.2%) were from Ontario, while Nunavut, Prince Edward Island, and the Yukon had no representation in this survey. Quebec was relatively underrepresented. Furthermore, while efforts were made to minimize selection bias in PCP participant recruitment, this may not have been completely avoided and should be considered when interpreting the results. However, given that participating PCPs self-identified as having specific interest or expertise in cardiovascular care, it seems likely that similar knowledge gaps might exist in the PCP population at large, though this would require a much larger study to confirm. Future work will also need to consider patient factors and perspectives that may pose challenges to implementation of evidence strategies to control LDL cholesterol levels. Such information could help elucidate barriers that patients face in lipid management.
Conclusion
Managing LDL cholesterol levels in high-risk patients remains challenging. Our survey of Canadian PCPs treating dyslipidemia has identified key knowledge gaps as well as barriers that may contribute to suboptimal patient management. Our findings highlight the importance of physician education and interdisciplinary communication in facilitating lipid management in high-risk populations, especially in a rapidly moving clinical field in which new data and treatment guidelines are frequently updated.
Low density lipoprotein cholesterol control status among Canadians at risk for cardiovascular disease: Findings from the Canadian Primary Care Sentinel Surveillance Network Database.
Clinical efficacy and safety of achieving very low LDL-cholesterol concentrations with the PCSK9 inhibitor evolocumab: a prespecified secondary analysis of the FOURIER trial.
Ferhatbegović, L., Mršić, D., Kušljugić, S. & Pojskić, B. LDL-C: The Only Causal Risk Factor for ASCVD. Why Is It Still Overlooked and Underestimated? Curr Atheroscler Rep (2022) doi:10.1007/s11883-022-01037-3.
Z.T. has received support from the Schulich School of Medicine and Dentistry Summer Research Training Program.
R.A.H. is supported by the Jacob J. Wolfe Distinguished Medical Research Chair, the Edith Schulich Vinet Research Chair, and the Martha G. Blackburn Chair in Cardiovascular Research. R.A.H. holds operating grants from the Canadian Institutes of Health Research (Foundation award), the Heart and Stroke Foundation of Ontario (G-21-0031455) and the Academic Medical Association of Southwestern Ontario (INN21-011).
M.G. received a grant from Amgen Canada to support the development and distribution of the physician survey.
Disclosures
Z.T. has no disclosures.
N.N. has received honoraria from Amgen
V.B. has received honoraria from Amgen and Sanofi
P. L. has received honoraria from Amgen and Sanofi
M.P. has no disclosures
M.G. has received honoraria from Amgen and Sanofi
R.A.H. reports consulting fees from Acasti, Aegerion, Akcea/Ionis, Amgen, HLS Therapeutics, Novartis, Pfizer, Regeneron, Sanofi and Ultragenyx.
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