A Joint Task Force from the European Atherosclerosis Society and the European Society of
Vascular Medicine recommends a low-density lipoprotein cholesterol (LDL-C) goal reduction
of greater than 50% from baseline and a target of 55 mg/dL in patients with peripheral
artery disease (PAD). An analysis of 1982 provider visits of patients with PAD in
national outpatient databases in the U.S. between 2005-2012 showed that a statin was
prescribed in only 33.1% of patients (Berger JS, Ladapo JA. J Am Coll Cardiol.
2017;69:2293-2300). Data from Europe demonstrates marginally better adherence to
guidelines with 40% of patients with PAD prescribed a statin (Subherwal S, et al.
Circulation. 2012;126:1345).
Explanations for underutilization of LDL-C-lowering therapy in patients with PAD include
clinician knowledge gaps regarding evidence-based clinical practice guideline
recommendations, provider inertia, the need for prior authorization for some agents,
statin intolerance, and statin hesitancy. Statin intolerance is defined as the inability
to tolerate a dose of statin required to sufficiently reduce cardiovascular risk and has
been estimated to affect up to 15% of patients treated with statins (Banach M, et al.
Arch Med Sci 2015;11:1-23 and Banach M, et al. Expert Opin Drug Saf 2015;14:935-55).
While numerous statin options exist and non-statin oral options for LDL-C lowering, such
as ezetimibe and bempedoic acid, are widely available, lack of awareness and inconsistent
implementation contribute to underutilization in patients at high-risk for cardiovascular
events, such as those with PAD. Bempedoic acid, with or without ezetimibe, is a newer
option for LDL-C lowering that offers a lower prevalence of musculoskeletal side effects
than statins (Diabetes Ther. 2021 Jul;12(7):1779-1789). However, familiarity with this
option remains limited outside of Preventive Cardiology and Lipid Clinics.
The failure to achieve guideline-directed LDL-C targets due to clinician knowledge gaps,
provider inertia, the need for prior authorization, statin intolerance, and statin
hesitancy in the PAD population demonstrates similar clinical obstacles to other areas of
cardiovascular medicine in which quality of care was impacted by provider and patient
knowledge gaps. An alert-based computerized decision support (CDS) approach has been
shown to be effective in such circumstances and could be similarly effective for
optimizing lipid management in patients with PAD.
This single-center, 400-patient, randomized controlled trial assesses the impact of a
patient- and provider-facing EPIC Best Practice Advisory (BPA; alert-based computerized
decision support tool) to increase guideline-directed utilization of statin and
statin-alternative oral LDL-C lowering therapies in patients with PAD who are not being
prescribed LDL-C-lowering therapy.