Factors influencing hypolipidemic treatment of patients after acute coronary syndrome, ischemic stroke, and transient ischemic attack in cardiological and neurological outpatient care in Slovakia

Czech version

Authors: Štefan Tóth ¹; Lenka Kováčová ²; Martin Selvek ²; Beata Saal ²; Roman Mužik ²; Ivan Tkáč ³
Authors‘ workplace: Klinika gerontológie a geriatrie LF UPJŠ a Univerzitná nemocnica – Nemocnica svätého Michala, a. s., Košice ¹; DÔVERA zdravotná poisťovňa, a. s., Bratislava ²; IV. interná klinika UNLP a LF UPJŠ Košice ³
Published in: AtheroRev 2025; 10(2): 89-104
Category: Reviews

Overview

Introduction: Prompt initiation of lipid-lowering therapy (LLT) after acute cardiovascular events such as acute coronary syndrome (ACS) or ischemic stroke (IS) is crucial for preventing subsequent cardiovascular events. Intensive LLT and the use of novel therapeutic options are essential to achieve target LDL-C levels. The aim of this study was to analyze real-world trends in LLT prescription in patients after ACS or IS in Slovakia and to identify risk factors associated with lower LTT prescription. Methods: A retrospective analysis of reported healthcare services for insured patients of Dôvera health insurance company (1.78 mil. policyholders) was conducted for the period January–December 2024. Patients with a history of ACS (n = 21,257) examined at cardiology outpatient clinic in analyzed period or IS or transient ischemic attack –⁠ TIA (n = 29,829) examined at neurology outpatient clinic were included. The type of LLT was determined with intensified treatment defined as either high-intensity statin therapy or therapy titration (addition of PCSK9i, ezetimibe, etc.). Logistic regression was used to evaluate the influence of age, sex, ACS/IS type, place of residence and interactions between these variables on LLT utilization. Results: LLT was prescribed to 86.9% of ACS patients, of whom 72.9 % received intensified therapy. In IS/TIA patients, the rates were markedly lower: 60.5 % received LLT and 38.5 % received intensified therapy. Significant regional variability was observed in LLT utilization, as well as variability among individual outpatient clinics. Risk factors for absence of LLT and for lower intensification included female sex (both in ACS and IS/TIA), a diagnosis of non-STEMI/NAP or other ACS types, and a diagnosis of TIA. The 60–74-year age group in both cohorts had highest rates of LLT prescription and intensified LLT prescription. Women under 60 years represented a particularly high-risk group, with their chance of receiving LLT being 54 % lower in ACS cases and 44 % lower in IS/TIA cases compared to their male counterparts. Conclusion: In Slovakia, a significant gap remains in LLT adoption between ACS and stroke/TIA patients, with marked differences associated with age, sex, diagnosis type, and their combinations. A portion of Slovak patients following ACS or iCMP/TIA under specialist care does not receive LLT. Regional and provider-level variability in LLT prescription was observed. Absence of treatment is more common among women, particularly those under 60 years of age. Targeted interventions, education of healthcare providers, and protocol-driven strategies could improve the prescription of adequate LLT and thereby enhance achievement of target LDL-C levels among high-risk patients.

Keywords:

statin – risk factors – acute coronary syndrome (ACS) – ischemic stroke (IS)– intensified therapy – lipid-lowering therapy (LLT)

Sources

Visseren FL, Mach F, Smulders YM et al. [ESC National Cardiac Societies; ESC Scientific Document Group]. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021; 42(34): 3227–3337. Dostupné z DOI: <https://doi.org/10.1093/eurheartj/ehab484>. Erratum in Corrigendum to: 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2022; 43(42): 4468. Dostupné z DOI: <http://dx.doi.org/10.1093/eurheartj/ehac458>.

Chong B, Jayabaskaran J, Jauhari SM et al. Global burden of cardiovascular diseases: projections from 2025 to 2050. Eur J Prev Cardiol 2024; zwae281. Dostupné z DOI: <https://doi.org/10.1093/eurjpc/zwae281>.

Patti G, Spinoni EG, Grisafi L et al. Safety and efficacy of very low LDL-cholesterol intensive lowering: a meta-analysis and meta-regression of randomized trials. Eur Heart J Cardiovasc Pharmacother 2023; 9(2): 138–147. Dostupné z DOI: <https://doi.org/10.1093/ehjcvp/pvac049>.

Mach F, Baigent C, Catapano AL et al. [ESC Scientific Document]. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41(1): 111–188. Dostupné z DOI: <https://doi.org/10.1093/eurheartj/ehz455>. Erratum in Eur Heart J 2020; 41(44): 4255. Dostupné z DOI: <http://dx.doi.org/10.1093/eurheartj/ehz826>.

Ray KK, Molemans B, Schoonen WM et al. EU-Wide Cross-Sectional Observational Study of Lipid-Modifying Therapy Use in Secondary and Primary Care: the DA VINCI study. Eur J Prev Cardiol 2021; 28(11): 1279–1289. Dostupné z DOI: <https://doi.org/10.1093/eurjpc/zwaa047>.

Pella D, Pecen L, Müllerova J et al. Sme úspešní pri dosahovaní cieľových hodnôt pre LDL cholesterol u pacientov liečených statínmi? Výsledky prieskumu DYSIS I. –⁠ Slovenská republika. Int Med 2015.

Gitt AK, Lautsch D, Ferrières J et al. Cholesterol target value attainment and lipid-lowering therapy in patients with stable or acute coronary heart disease: results from the Dyslipidemia International Study II. Atherosclerosis 2017; 266 : 158–166. Dostupné z DOI: <https://doi.org/10.1016/j.atherosclerosis.2017.08.013>.

De Backer G, Jankowski P, Kotseva K et al. Management of dyslipidaemia in patients with coronary heart disease: results from the ESC-EORP EUROASPIRE V survey in 27 countries. Atherosclerosis 2019; 285 : 135–146. Dostupné z DOI: <https://doi.org/10.1016/j.atherosclerosis.2019.03.014>.

Ray KK, Haq I, Bilitou A et al. Evaluation of contemporary treatment of high-and very high-risk patients for the prevention of cardiovascular events in Europe–Methodology and rationale for the multinational observational SANTORINI study. Atheroscler Plus 2021; 43 : 24–30. Dostupné z DOI: <http://dx.doi.org/10.1016/j.athplu.2021.08.003>.

Tóth S, Turek M, Pella D. Success in achieving LDL-C target values in a high-risk population in Slovakia: the SlovakLipid retrospective study. Arch Med Sci 2023; 21(3): 738–746. Dostupné z DOI: <http://dx.doi.org/10.5114/aoms/170961>.

Ah-Ram Kim A-R, Han JY, Kim M et al. Cardiovascular Outcomes of Early LDL-C Goal Achievement in Patients with Very-High-Risk ASCVD. Cardiol Ther 2025; 14(1): 101–115. Dostupné z DOI: <http://dx.doi.org/10.1007/s40119–025–00397–6>.

Schubert J, Leosdottir M, Lindahl B et al. Intensive early and sustained lowering of non–high-density lipoprotein cholesterol after myocardial infarction and prognosis: the SWEDEHEART registry. Eur Heart J 2024; 45(39): 4204–4215. Dostupné z DOI: <http://dx.doi.org/10.1093/eurheartj/ehae576>.

Krychtiuk KA, Ahrens I, Drexel H et al. Acute LDL-C reduction post ACS: strike early and strike strong: from evidence to clinical practice. A clinical consensus statement of the Association for Acute CardioVascular Care (ACVC), in collaboration with the European Association of Preventive Cardiology (EAPC) and the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. Eur Heart J Acute Cardiovasc Care 2022; 11(12): 939–949. Dostupné z DOI: <http://dx.doi.org/10.1093/ehjacc/zuac123>.

Kytö V, Rautava P, Tornio A. Initial statin dose after myocardial infarction and long-term cardiovascular outcomes. Eur Heart J Cardiovasc Pharmacother 2023; 9(2): 156–164. Dostupné z DOI: <http://dx.doi.org/10.1093/ehjcvp/pvac064>.

Tóth Š. Kde sa posunuli v dosahovaní cieľových hladín LDL cholesterolu na Slovensku u vysoko-rizikovej populácie pacientov –⁠ štúdia SlovakLipid II. Praktická a preventívna kardiológia. In Press.

Ratz M, Vogel JB, Kührer H et al. 25 years of lipid-lowering therapy: secular trends in therapy of coronary patients. Wien Klin Wochenschr 2025; 137(9–10): 297–306. Dostupné z DOI: <http://dx.doi.org/10.1007/s00508–024–02365-x>.

Massia D, Giovas P, Papadopoulos P et al. Real-world management of hypercholesterolemia in patients after acute coronary syndrome in Greece. Atheroscler Plus 2025 : 60 : 20–26. Dostupné z DOI: <http://dx.doi.org/10.1016/j.athplu.2025.03.002>.

Cinza-Sanjurjo S, Barrios V, Fierro-González D et al. Achievement of LDL-Cholesterol Goals in Patients Receiving LLT in Primary Care: TERESA-AP Study: LDL-Cholesterol Goals in Primary Care. Cardiovasc Ther 2024; 2024 : 4227941. Dostupné z DOI: <http://dx.doi.org/10.1155/2024/4227941>.

Faggiano A, Gualeni A, Barbieri L et al. Therapeutic inertia in dyslipidemia management for secondary cardiovascular prevention: results from the Italian ITACARE-P network. J Clin Med 2025; 14(2): 493. Dostupné z DOI: <http://dx.doi.org/10.3390/jcm14020493>.

Laufs U, Birkenfeld AL, Fraass U et al. Novel insights into the management of patients with very high cardiovascular risk eligible for PCSK9 inhibitor treatment: baseline findings from the PERI-DYS study. Cardiovasc Drugs Ther 2024; 38(1): 119–129. Dostupné z DOI: <http://dx.doi.org/10.1007/s10557–022–07386–0>.

Zheutlin AR, Derington CG., Herrick JS et al. Lipid-lowering therapy use and intensification among United States veterans following myocardial infarction or coronary revascularization between 2015 and 2019. Circ Cardiovasc Qual Outcomes 2022; 15(12): e008861. Dostupné z DOI: <http://dx.doi.org/10.1161/CIRCOUTCOMES.121.008861>.

Minhas AM, Ijaz SH, Javed N et al. National trends in disparities in statin use for ischemic heart disease from 2006 to 2018: Insights from National Ambulatory Medical Care Survey. Am Heart J 2022; 252 : 60–69. Dostupné z DOI: <https://doi.org/10.1016/j.ahj.2022.05.015>.

Thalmann I, Preiss D, Schlackow I et al. Population-wide cohort study of statin use for the secondary cardiovascular disease prevention in Scotland in 2009–2017. Heart 2023; 109(5): 388–395. Dostupné z DOI: <https://doi.org/10.1136/heartjnl-2022–321452>.

Rosenson RS, Farkouh ME, Mefford M et al. Trends in use of high-intensity statin therapy after myocardial infarction, 2011 to 2014. J Am Coll Cardiol 2017; 69(22): 2696–2706. Dostupné z DOI: <https://doi.org/10.1016/j.jacc.2017.03.585>.

Brown CJ, Chang L-S, Hosomura N et al. Assessment of sex disparities in nonacceptance of statin therapy and low-density cholesterol levels among patients at high cardiovascular risk. JAMA Network Open 2023; 6(2): e231047. Dostupné z DOI: <https://doi.org/10.1001/jamanetworkopen.2023.1047>.

Bots SH, Ina JA, Peters SAE. Medication adherence after acute coronary syndrome in women compared with men: A systematic review and meta-analysis. Front Glob Womens Health 2021; 2 : 637398. Dostupné z DOI: <https://doi.org/10.3389/fgwh.2021.637398>.

[Cholesterol Treatment Trialists’ Collaboration]. Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised trials. Lancet 2019; 393(10170): 407–415. Dostupné z DOI: <https://doi.org/10.1016/S0140–6736(18)31942–1>.

Nanna MG, Navar AM, Wang TY et al. Statin use and adverse effects among adults > 75 years of age: insights from the Patient and Provider Assessment of Lipid Management (PALM) registry. J Am Heart Assoc 2018; 7(10): e008546. Dostupné z DOI: <https://doi.org/10.1161/JAHA.118.008546>.

Khatib R, Yeh EJ, Glowacki N et al. Lipid-lowering therapy utilization and dosage among patients with acute coronary syndrome events: a retrospective cohort from 12 community hospitals. Clin Epidemiol 2023; 15 : 547–557. Dostupné z DOI: <https://doi.org/10.2147/CLEP.S400903>.

Cummings DM, Jones S, Bushnell C et al. Disparate statin prescribing following hospital discharge for stroke or transient ischemic attack: Findings from COMPASS. J Am Geriatr Soc 2023; 71(8): 2476–2484. Dostupné z DOI: <https://doi.org/10.1111/jgs.18318>.

Yifan D, Yue M, Yubin Z et al. The impact of early in-hospital use of PCSK9 inhibitors on cardiovascular outcomes in acute coronary syndrome patients: A systematic review and meta-analysis. Int J Cardiol 2024; 399 : 131775. Dostupné z DOI: <http://dx.doi.org/10.1016/j.ijcard.2024.131775>.

Tóth S, Barbierik Vachalcová M, Jarolímková A et al. Lipid lowering with inclisiran: a single-center experience from Slovakia. Klin Farmakol Farm 2025; 39(1): 14–21. Dostupné z DOI: <https://doi.org/10.36290/far.2025.017>.

Briani F, Bagli M, Venturi G et al. Inclisiran: Early LDL-C target achievement in a real-life population. Atheroscler Plus 2025; 59 : 54–58. Dostupné z DOI: <http://dx.doi.org/10.1016/j.athplu.2025.01.001>.

Vrablík M, Seifert B, Parkhomenko A et al. Lipid-lowering therapy use in primary and secondary care in Central and Eastern Europe: DA VINCI observational study. Atherosclerosis 2021; 334, 66–75. Dostupné z DOI: <http://dx.doi.org/10.1016/j.atherosclerosis.2021.08.035>.