An analysis of the electronic health records (EHRs) of a multidisciplinary healthcare system identified gaps in the treatment of patients with primary severe hypercholesterolemia (SH), including the suboptimal use of high-intensity lipid therapy among primary care providers and specialists, according to a study published in the American Journal of Cardiology.

The researchers found that the use of statins and high-intensity statins was higher in patients with SH but still fell far below the recommended use according to current guidelines, especially for younger patients. “There remains a significant opportunity to improve the use of lipid-lowering therapy for this high-risk population,” reported the researchers.

Participants of the study were enrolled in a clinical query aimed at identifying every patient with low-density-lipoprotein cholesterol (LDL-C ≥ 190 mg/dL) documented in the EHR to assess SH prevalence, characteristics, and treatment. Records were identified as SH (group 1) if the maximum EHR-documented LDL-C or last estimated untreated LDL-C during the timeframe was ≥190 mg/dL. Records of subjects not meeting these criteria were placed in group 2.

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Patient comorbidities, tobacco exposure, and prescribed lipid-lowering therapies were assessed. Comorbidities included coronary artery disease (CAD), diabetes type 1 (T1D) or type 2 (T2D), essential hypertension, congestive heart failure, and obesity. Different lipid-lowering therapies included statins, ezetimibe, and PCSK9 inhibitors.

A total of 289,299 records were screened; after exclusion criteria, 265,220 records were used for the analysis, with 19,695 having LDL-C ≥190 mg/dl (7.4%). Individuals in group 1 were generally 3 to 4 years older than those in group 2 and had a slightly higher prevalence of CAD (5.8% vs 2.7%). Individuals in group 1 had a slightly higher prevalence of obesity and diabetes than those in group 2 but a lower body mass index. More individuals in group 1 were exposed to smoking than group 2. Group 1 had a higher prevalence of hypertension and higher mean blood pressure, systolic blood pressure, and diastolic blood pressure than group 2.

Total mean cholesterol levels were significantly higher in group 1 compared with group 2. Cholesterol-lowering therapy in group 1 included general statins (77%) and high-intensity statins (27%). There was no evidence of differences in statin therapy use in patients with SH in primary care, endocrinology, or cardiology providers. Cardiologists initiated high-intensity statin therapy more frequently than primary care providers but not much more than endocrinologists. Both general statins and high-intensity statins were used less frequently in patients <40 years or >75 years.

No significant difference was found between groups for having established care with a primary care provider; however, a slightly larger proportion of group 1 patients were scheduled for future appointments with a primary care clinician. Incidence of endocrinology consultation did not differ significantly, but more participants in group 1 than group 2 were scheduled for cardiology visits.

“This study will serve as a startup project to optimize lipid treatment for high-risk individuals in primary care settings,” concluded the study authors.


Eid WE, Sapp EH, McCreless T, Nolan JR, Flerlage E. Prevalence and characteristics of patients with primary severe hypercholesterolemia in a multidisciplinary healthcare system. Am J Cardiol. Published online July 12, 2020. doi:10.1016/j.amjcard.2020.07.008