Rodriguez discusses her team's recent 300,000-patient cohort analysis on statin adherence, plus advice on managing at-risk patients with ASCVD.
Fatima Rodriguez, MD, MPH
A new cohort study from the Stanford’s Division of Cardiovascular Medicine and Cardiovascular Institute this week found a distinct correlation between low rates of prescribed statin adherence in patients with atherosclerotic cardiovascular disease (ASCVD) and an increased risk of death.
The findings, though alarming, are consistent with what Fatima Rodriguez, MD, MPH, experiences in her practice as a preventive cardiologist. They’re also consistent with the trend of studies to precede hers and her colleague’s: patient at the greatest risk of cardiovascular disease-related mortality are at the greatest need for statins, and sometimes they’re the least likely to adhere to the routine, for-life therapy.
In an interview with MD Magazine®, Rodriguez discussed the most important takeaways from the team’s cohort analysis, what practices physicians and cardiologists should apply to at-risk patients with ASCVD, and why it’s difficult to get patients to commit to statins.
MD Mag: What, from your perspective, were the most surprising or critical findings of the cohort?
Rodriguez: I think of a couple of things. This cohort is unique in the sense that patients actually are very adherent. A lot of the studies that have been done on this topic before have focused on patients right after they have an acute episode, like a heart attack, and focuses on whether they continue taking their medicine.
This is a very stable cohort of patients that overall has a very high adherence, and yet we still found that without perfect adherence, it’s a detriment to mortality. I think the most important finding is that you basically need perfect adherence to have the best outcomes. As clinicians, we really need to make sure we ask our patients about adherence at every visit, even in the patients that are stable and have been on a stable dose of medication for a while. Of course, they could stop taking the medication for a variety of reasons.
The second thing is that there are 2 factors that really matter, and one of them is the intensity of the statin. The higher the intensity of the statin, the better outcomes—and we’ve published studies on that before. But also, adherence. It’s really a combination of telling the patient to take the highest intensity statin they’re able to take regularly, and keeping an adherence level of more than 90% to have the best outcomes.
If you discontinue the statins, it doesn’t matter. You’re going to have worse outcomes. And this is not surprising, but there’s patient groups that need extra attention for this. Women, non-white patients, as well as very young and very old patients, need to be focused on. And again, this is a very high-risk cohort.
What is your perspective on patient statin adherence as a practicing preventive cardiologist?
I deal a lot with both secondary and primary progression of ASCVD, and a lot of patients are reluctant to take statins, especially as a lifelong medication. That’s why this topic came up—because not only are a lot of us prescribing this drug, but we also have recurring bouts with adherence that can be quite significant.
Physicians have told us it’s usually a wide range of issues a patient may have with consistently taking statins. Is there concern that these concerns are just respective to the patient?
Yes. Statins, for whatever the reason, are one of the drugs with the worst press out there. And there’s been interesting studies looking at how bad press is associated with bad patient outcomes. I think part of it is it’s just one of those medications that’s widely prescribed, so that’s why people tend to share deplorable new articles about it, and that people are skeptical.
The other thing is that when you start a patient on a statin, they often want to know when they can get off this medication. For at least high-risk patients, something we recommend is lifelong adherence. So, it’s hard for patients to grip that they’re going to have to take this medication for the rest of their lives.
So, it’s a much more daunting commitment to their health than they’re expecting.
Yes, and people will say they have only known people who have had side effects from statins. In practice, real statin side effects are rare. They happen more than often clinically—or at least are perceived to happen more often—but the incidence of statin-induced myopathy or other serious side effects is rare.
There’s a lot of things you could do to try to help patients tolerate statins. One of them is trying a different statin—a different type, a different potency. For the highest-risk patients, to me, it’s not controversial. They need to be on statins, as opposed to the primary prevention patients, where it’s a little more controversial.
Can you elaborate on the patient groups most at-risk for cardiovascular disease without the help of statins?
The patients who have ASCVD—so, patients who have had a heart attack, a stroke, peripheral arterial disease. Those patients are at extremely high risk, particularly, if they have other comorbidities associated with this or any recurring events. It’s not necessarily about statins, but these patients really need to have their LDL cholesterol lowered. The lower the LDL cholesterol, the better the outcomes. And we’ve seen that not only for statins, but other drugs as well.
The good news is that statins are generic and widely available, so we don’t have the issues we have with other drugs such as PCSK-9 inhibitors. One of the reasons patients are doing so well now after they’ve had a heart attack is because of these medications like statins.
That’s why we focused on this group for this study, because in terms of what the therapy should be, it’s not controversial. And I think there’s a lot less controversy in patients with lower risk. In this population, we need to really push through and find that if patients are really statin-intolerant, we get them on another therapy to get their cholesterol lowered.
What is the follow-up to these findings?
I think there’s 2 metrics that clinicians need to focus on getting patients on the highest-intensity statin, because we saw this adherence issue was even more important for the highest-intensity group—which tend to be the sickest patients. Adherence is really something we need to measure and ask about at every clinical visit. And with visits being shorter, this is maybe something people take for granted. But as a doctor, I know a lot of my colleagues do the same—they ask their patients routinely, “I prescribed you a high dose of statins. Are you still taking them regularly, and are you having any issues with them?”
Regarding next steps, there’s upcoming 2019 cardiovascular care guidelines that will be released. I think it’s going to be important to see how practice changes within those guidelines, because the guidelines exclusively say that adherence should be tracked, and one of the ways to track adherence is through the cholesterol levels.
In addition to those points, just having conversations with patients where we’re making it clear we understand their perceptions and fears about the drugs, and their reasons for inadherence, are really important.
I still don’t think we’ve done a really good job of teasing out why inadherence happens, and that’s certainly a line of research I’m interested in, and a lot of my colleagues in preventive cardiology are as well.