3052 — Prescription of Cholesterol-lowering Medications in Patients Admitted with an Acute Coronary Syndrome

Neugaard BI (James A Haley VAMC), Zoble RG (James A Haley VAMC), Moadhadi S (James A Haley VAMC), Larsen G (Portland VAMC), Pineros S (Seattle VAMC), Rumsfeld J (Denver VAMC), Morris K (Durham VAMC), McFalls E (Minneapolis VAMC), Fihn S (Seattle VAMC)

Objectives:
The objective of the study was to evaluate the quality of care provided to veterans with an acute coronary syndrome (ACS).

Methods:
The sample consisted of patients admitted with an ACS to nine geographically diverse VA medical centers (five tertiary academic centers and four rural referral centers) from April 2005 to December 2006. Hospital-based chart abstractions were performed once providers confirmed the ACS diagnosis. We analyzed the prescription of cholesterol-lowering medications in those having a guideline-indicated low density lipoprotein (LDL) goal of < 100mg/dl.

Results:
Mean values at admission for the overall group of 832 ACS patients were (in mg/dL): total cholesterol (TC)=174.4, LDL=99.5, HDL=39.7, and triglycerides (TG)=187.0, whereas in the subset of 659 patients with a history of CAD, diabetes mellitus (DM) or chronic kidney disease (CKD) in their admitting record, admission values were: TC=168.8, LDL=94.2, HDL=38.6 and TG=193.5. In the overall ACS group, prescription of a cholesterol-lowering medication increased from 72.8% prior to admission to 92.0% at discharge. Of the 659 known to have CAD, DM, or CKD prior to admission, almost three-fourths were at their target of LDL < 100 mg/dL prior to admission (70.2%, 70.9% and 72.5%, respectively). The mean creatinine in the CKD group was 2.2 mg/dL and all CKD patients had a creatinine > 2.0 mg/dL. In the subset of these high-risk patients who were not at LDL target, prescription of a lipid-lowering agent increased from 80.5%, 76.9% and 74.4% prior to admission to 91.2%, 93.5% and 84.2% at discharge.

Implications:
Greater than 70% of those known to be at high risk for adverse cardiovascular events (based on CAD, DM, or CKD prior to admission) were at their LDL target of < 100 mg/dL prior to admission. After an ACS admission, use prescription of cholesterol-lowering medications increased to 92% of the overall population (but only to 84% in those ACS patients with CKD).

Impacts:
Veterans admitted with an ACS had high utilization of cholesterol-lowering medications at discharge, but CKD patients may be under-treated and warrant further study.