title: Clinical determinants and treatment gaps in familial hypercholesterolemia: Data from a multi-ethnic regional health service.
abstract: Background Familial hypercholesterolemia is characterized by markedly increased low-density lipoprotein cholesterol and risk for premature atherosclerotic cardiovascular disease. Models of care vary and reflect differing health policies and resources. The availability of electronic databases may enable better identification and assessment of familial hypercholesterolemia in the community. Methods A regional healthcare database was utilized to identify patients with a high probability of familial hypercholesterolemia, clinically defined by age-dependent-peak low-density lipoprotein cholesterol cutoffs and exclusion of secondary causes of severe hypercholesterolemia. Clinical characteristics, low-density lipoprotein cholesterol goal attainment, and treatment gaps were investigated. Results Probable familial hypercholesterolemia was diagnosed in 1932 of 685,314 individuals (1:355; median age 47 years). Atherosclerotic cardiovascular disease was present in 16.3% of adults (38% in males aged 50-74 years). Median peak low-density lipoprotein cholesterol was 264 mg/dl (interquartile range 252-288). Statins and/or ezetimibe were prescribed to 83% of patients and high-intensity statins to 53%, whereas prescriptions were filled in 57% and 40% cases respectively over the last six months, p < 0.001. Treatment gaps were wider among ethnic minorities, younger individuals, and those without atherosclerotic cardiovascular disease. Low-density lipoprotein cholesterol < 100 mg/dl was attained in 10.1% overall and 28.7% of those with atherosclerotic cardiovascular disease. Predictors of low-density lipoprotein cholesterol goal attainment included recent issue of high-intensity statins, presence of atherosclerotic cardiovascular disease, diabetes, older age and lack of smoking. Conclusions The population with high probability for familial hypercholesterolemia was characterized by low attainment of low-density lipoprotein cholesterol treatment goals despite high prescription rates of lipid-lowering medications. Low utilization of intensified therapies, non-adherence, and ethnic disparities were contributing factors. These findings emphasize the need to improve awareness and quality of care of familial hypercholesterolemia in the community.
authors.affiliation: 1 Department of Cardiology, Lady Davis Carmel Medical Center, Israel.
authors.forename: Barak
authors.initials: B
authors.lastname: Zafrir
authors.affiliation: 1 Department of Cardiology, Lady Davis Carmel Medical Center, Israel.
authors.forename: Ayman
authors.initials: A
authors.lastname: Jubran
authors.affiliation: 2 Department of Medicine, Lady Davis Carmel Medical Center, Israel.
authors.forename: Gil
authors.initials: G
authors.lastname: Lavie
authors.affiliation: 1 Department of Cardiology, Lady Davis Carmel Medical Center, Israel.
authors.forename: David A
authors.initials: DA
authors.lastname: Halon
authors.affiliation: 1 Department of Cardiology, Lady Davis Carmel Medical Center, Israel.
authors.forename: Moshe Y
authors.initials: MY
authors.lastname: Flugelman
authors.affiliation: 3 Clalit Health Services, Haifa and Western Galilee District, Israel.
authors.forename: Chen
authors.initials: C
authors.lastname: Shapira
mesh_terms: D000293:Adolescent; D000328:Adult; D017668:Age of Onset; D000368:Aged; D000924:Anticholesteremic Agents / Q000627:therapeutic use*; D050197:Atherosclerosis / Q000097:blood / Q000208:ethnology / Q000517:prevention & control*; D015415:Biomarkers / Q000097:blood; D002648:Child; D002675:Child, Preschool; D008078:Cholesterol, LDL / Q000097:blood; D016208:Databases, Factual; D057286:Electronic Health Records; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D006938:Hyperlipoproteinemia Type II / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000208:ethnology; D007223:Infant; D007231:Infant, Newborn; D007557:Israel / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D017064:Process Assessment, Health Care / Q000592:standards; D000071836:Professional Practice Gaps / Q000592:standards; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000924:Anticholesteremic Agents; D015415:Biomarkers; D008078:Cholesterol, LDL
keywords: Familial hypercholesterolemia; adherence; low-density lipoprotein cholesterol