Secondary Prevention Measure Use is Suboptimal in US Patients With ASCVD

Due to the high risk for adverse cardiovascular events, increasing the number of patients receiving optimal medical therapy could significantly decrease the morbidity and mortality of atherosclerotic cardiovascular disease.

There has been suboptimal use of secondary prevention methods for patients with atherosclerotic cardiovascular disease (ASCVD) and diabetes in the US health care system, according to study findings published in Diabetes, Obesity, and Metabolism.

Researchers conducted a prospective observational study to develop longitudinal secondary prevention treatment patterns in patients with ASCVD. Study participants were enrolled between December 2016 and July 2018. Participants had ASCVD (ie, coronary artery, cerebrovascular, or peripheral artery disease) and low-density lipoprotein cholesterol levels greater than or equal to 70 mg/dL or were on a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i).

Overall, participants were enrolled at 107 sites (cardiology, 47%; primary care, 41%; and other, 12%). The researchers performed an initial 1-year retrospective chart review upon enrollment and then reviewed every 6 months for 2 years post-enrollment. The primary outcome was the use of optimal medical therapy (OMT), which was defined as receiving all of the following:

  • High-intensity lipid-lowering therapy (ie, high-intensity statin, any statin plus ezetimibe, or a PCSK9i);
  • Antithrombotic therapy (ie, antiplatelet or anticoagulant, excluding triple therapy);
  • Angiotensin-converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or angiotensin receptor neprilysin inhibitor (ARNI) therapy; and
  • Sodium-glucose cotransporter-2 inhibitors or glucagon-like peptide-1 receptor agonist therapy.

A total of 4452 patients were enrolled in the study, of which 1590 had diabetes (type 2 diabetes, 95.7%). At the end of the study, 90.5% of participants were receiving a statin, 51.6%  received a high-intensity statin, 14.0% received ezetimibe, and 3.9% received PCSK9i therapy. Additionally, 70.7% were receiving an ACE-I/ARB/ARNI, and 89.1% received an antiplatelet or anticoagulant agent. Overall, 10.8% of the patients were receiving OMT.

We found suboptimal use of secondary prevention in US patients with ASCVD and diabetes, with minimal improvement over time.

The researchers observed that patients treated by cardiologists experienced lower rates of OMT than patients treated by non-cardiologists (7.8% vs 13.7%, respectively; P <.001), and that older age was associated with a lower odds ratio (OR) of receiving OMT (OR 0.74 per 10-year age increase [95% CI, 0.60-0.90]). Having coronary artery disease increased the odds of receiving OMT (OR 1.62 [95% CI, 1.01-2.61]), as did having private health insurance (OR 1.93 [95% CI, 1.32-2.84]). Overall, the researchers found a modest increase in the odds of OMT use over time.

Limitations of the study include the fact that guidelines for cardiovascular treatments are constantly changing, and the lack of generalizability of the study findings.

The study authors conclude, “We found suboptimal use of secondary prevention in US patients with ASCVD and diabetes, with minimal improvement over time.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Arnold SV, de Lemos JA, Zheng L, et al. Use of optimal medical therapy in patients with diabetes and atherosclerotic cardiovascular disease: insights from a prospective longitudinal cohort study. Diabetes Obes Metab. Published online February 27, 2023. doi:10.1111/dom.15032