Boston—Adults with severely elevated cholesterol, including likely familial hypercholesterolemia (FH), tended to be well aware that their levels were high, yet most of them still weren’t on cholesterol-lowering drugs, according to a new report.

The nationally representative study, published in Circulation, notes that just 38% of those patients were being prescribed appropriate drug treatment. Least likely to be on therapy to lower their cholesterol were patients who were younger, had no health insurance, and/or were without a regular source of healthcare.

“Young adults may be less likely to think that they are at risk of cardiovascular disease, and clinicians may be less likely to initiate statin therapy in this population,” writes lead author Emily Bucholz, MD, PhD, MPH, Department of Medicine at Boston Children’s Hospital. “It is possible that lifestyle modifications continue to be prescribed as an initial treatment prior to initiating statin therapy.”

Bucholz and her colleagues used data from the 1999–2014 National Health and Nutrition Examination Survey to estimate prevalence rates of self-reported screening, awareness, and statin therapy among adults in the United States aged 20 years and older with severely elevated LDL or “bad cholesterol” levels of 190 mg/dL or higher. Study authors also focused on a subgroup of that population—patients with FH who face increased risk of early cardiovascular disease because of a genetic disorder that causes extreme elevations in cholesterol.

Results indicate very high frequency of cholesterol screening and awareness—more than 80%—in those with extremely high cholesterol. At the same time, however, the researchers found that only 38% of them were using statins and, of that group, only 30% had been prescribed a high-intensity statin.

Specifically, the estimated prevalence of definite/probable FH was 0.47% (standard error, 0.03%); for severe dyslipidemia, it was 6.6% (standard error, 0.2%) in the U.S. The prevalence of statin use in adults with severe dyslipidemia increased over time (from 29.4% to 47.7%), study authors report, but at no higher rate than the general population—from 5.7% to 17.6%.

In addition to older age, health insurance status, and having a usual source of care, a diagnosis of diabetes mellitus and/or hypertension, as well as having a personal history of early atherosclerotic cardiovascular disease, all were associated with higher statin use.

That such a low percentage of patients received treatment for severely high cholesterol is contrary to clinical guidelines; both the original 2002 National Cholesterol Education Program’s Adult Treatment Panel III and the current American College of Cardiology and American Heart Association cholesterol guidelines recommend initiation of statin therapy in patients with LDL cholesterol at or above 190 mg/dL.

“Markedly elevated levels of ‘bad’ cholesterol put you at increased risk of developing heart disease and developing it earlier in life,” pointed out Circulation Editor-in-Chief, Joseph A. Hill, MD, PhD. “If your ‘bad’ cholesterol is over 190 you should work with your physician regarding optimal drug treatment, in addition to lifestyle changes and management of other risk factors.”

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