Hypercholesterolemia continues to be one of the primary modifiable risk factors for cardiovascular disease (CVD), yet cholesterol management remains an ongoing challenge for healthcare professionals and patients. In this article, you will learn about strategies and resources to close the gaps in applying current guidelines for lowering low-density lipoprotein cholesterol (LDL-C). Addressing health equity and the costs of medication can help you, your colleagues, and patients in the drive to reduce CVD and improve patient outcomes.

Cholesterol: What We Know

LDL-C is a major causal factor for the development of atherosclerotic cardiovascular disease (ASCVD).[i] Elevated LDL-C is a significant risk factor for CVD; the higher the LDL-C level, the greater the risk.

Elevated LDL-C continues to be an issue for many patients. The American Heart Association (AHA) estimates that 93.9 million American adults have elevated blood cholesterol levels, and almost 30% of U.S. adults ages 20 and older have high LDL-C levels. While evidence-based guidelines have been in place for more than three decades, gaps in applying current guidelines for LDL-C lowering continue to place patients at higher risk for stroke, heart attack, and death.

Cholesterol and Health Equity

Cholesterol continues to affect individuals of all ages and from all backgrounds. Some populations are disproportionately affected by gaps in applying evidence-based treatment guidelines regarding lowering LDL-C.

Hypercholesterolemia often has no symptoms; without screening, the disease may not be identified and treated. Because cholesterol levels can fluctuate over time, periodic screenings are important to ensure patients are identified and treated as their health changes. While current guidelines recommend that low-risk adults receive cholesterol screening at least every five years and those at higher risk or who are older be screened more frequently, it is estimated that 25% of Americans do not meet these screening goals.[ii]

In addition, disparities in screening can put individuals at a higher risk. Compared to Black, Indigenous, and People of Color (BIPOC), individuals in the U.S. who are older and white were more likely to be screened at a higher frequency.[iii]

Impact of Medication Costs on LDL-C

Once high LDL-C is identified, treatment gaps can continue to exacerbate a patient’s risk. Rates of statin use—a first-line treatment for LDL-C—is quite low overall, but particularly low in adults who are Black or Hispanic.[iii] Additional factors, such as lack of health insurance or no routine location for health care, lead to the most significant disparities in care.[iv]

Additional treatments may be warranted for patients unable to tolerate statins or those for whom LDL-C lowering is not optimized with statins.[v] These treatments, while effective, often have a higher price tag than statins, potentially limiting their use by individuals for whom insurance coverage is inadequate, the insurance formulary does not cover the prescribed medications, or out-of-pocket costs are high. A 2017 study found that black women and people without health insurance were at high risk for underutilization of medications for lowering cholesterol despite being prescribed.[vi]

Recent cost-cutting measures for medications for Medicare recipients in the Inflation Reduction Act (IRA) may impact out-of-pocket costs for some patients. Healthcare professionals and patients must carefully consider the best treatment options in a shared decision-making process.

Clinical Implications

• Early diagnosis and treatment can lead to improved patient outcomes.
• Because high LDL-C is often asymptomatic, it may not be front of mind for patients or clinicians.
• Equitable application of guideline-directed screening and medical therapies can reduce the disease burden of elevated LDL-C.
• Regular screening of LDL-C ensures the identification of patients with elevated levels of LDL-C who are at greater risk for stroke, heart attack, and death.
• Clinical attentiveness to equity issues, such as increased risk to certain populations, access to care, medication cost, and other matters, can help lead to collaborative problem-solving and increased access to and adherence to treatments.
• As with any healthcare concern, a patient-centric approach utilizing a shared decision-making process may lead to increased adherence and improved outcomes.

Guidelines-Based LDL-C Resources for Clinicians

• Informational videos on hyperlipidemia management.
  • Hyperlipidemia Management: Treatment Access
  • Hyperlipidemia Management: A Team-based Care Approach
• Lipid Management educational courses

Tools for Patients on LDL-C

• Cholesterol Tools and Handouts for Your Patients, Fact sheets, booklets, and interactive resources on cholesterol, statin side effects, and PCSK9 inhibitors. New and updated tools will be available in fall 2024. Tools include:
  • Fact Sheet: Managing Lipid Disease
  • Booklet: Cholesterol – Your Plan for A Healthy Lifestyle
  • Fact Sheet: Cholesterol – What You Need to Know

What Did You Learn?

We’d love to hear what you learned from this article.

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References

[i] Ference BA Ginsberg HN, Graham I, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2017 Aug 21;38(32):2459-2472. doi: 10.1093/eurheartj/ehx144.

[ii] Kuo WC, Sorensen SL, Johnson HM. Abstract 101015: Health Disparities in Cholesterol Screening Among Older Americans: Longitudinal Analysis of the Health and Retirement Study (2008-2018). Circulation. 2022;146:Number Suppl_1. https://doi.org/10.1161/circ.146.suppl_1.10105

[iii] Jacobs JA, Addo DK, Zheutlin AR, et al. Vulnerabilities to Health Disparities and Statin Use in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study.  JAMA Cardiol.  2023;8(5):443-452. doi:10.1001/jamacardio.2023.0228.

[iv] Schroff P Gamboa CM, Durant RW, et al. JAHA.  2017;6(9) https://doi.org/10.1161/JAHA.116.005449

[v] Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Solution Set Oversight Committee JACC. 2022 Oct, 80 (14) 1366–1418. https://www.jacc.org/doi/10.1016/j.jacc.2022.07.006.

[vi] Centers for Disease Control and Prevention. Underlying Cause of Death, 1999–2020. CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention; 2018. Accessed March 12, 2024. https://wonder.cdc.gov/ucd-icd10.html