Adherencija i propisivanje statina u primarnoj prevenciji unutar primarne zdravstvene zaštite

Juraj Jug, Valentina Juraga, Ivor Jelavić

Cilj: Uz slabo dijagnosticiranu porodičnu hiperkolesterolemiju, sekundarna hiperkolesterolemija vrlo je čest i zanemaren problem u svakodnevnoj kliničkoj praksi. Cilj ove studije je prikazati stvarno stanje korištenja statinske terapije u praksi jedne ordinacije primarne zdravstvene zaštite te istražiti razloge zbog kojih bolesnici ne koriste statine u primarnoj kardiovaskularnoj prevenciji. Materijali i metode: Analizirani su rezultati laboratorijskih nalaza LDL-k, non-HDL kolesterola u serumu, koncentracija triglicerida te kreatinina u serumu 1608 pacijenata jedne od ordinacija u sklopu Doma zdravlja Zagreb – Zapad kroz lipanj 2019. godine. Ukoliko je bolesnik koristio statinsku terapiju prilikom uzimanja uzoraka krvi, dobivena laboratorijska koncentracija serumskog kolesterola množila se s odgovarajućim korekcijskim faktorom za vrstu i dozu statina. Uključeni su bolesnici čije su vrijednosti LDL-k izvornom ili korigiranom vrijednošću prelazile 5 mmol/L. Bubrežna funkcija izračunata je po CKD-EPI formuli. Isključeni su svi bolesnici sa svim jetrenim i/ili bubrežnim bolestima kao i oni s nereguliranim vrijednostima glukoze u plazmi, perifernom arterijskom bolesti te preboljelim srčanim ili moždanim infarktom u osobnoj anamnezi. Rezultati: Od 1608 pacijenata ordinacije, njih 40 (26 žena i 14 muškaraca, ukupno 2,5%) imalo je vrijednosti LDL kolesterola iznad 5 mmol/L (max 10,2 mmol/L). Razlika između spolova nije bilo. 38 pacijenata (95%) bili su hipertoničari te 8 (20%) dijabetičari s dobro reguliranim vrijednostima glukoze u plazmi. Unatoč vrijednostima LDL kolesterola, samo 10 pacijenata imalo je propisanu statinsku terapiju (25%). Vrijednosti non- HDL kolesterola u ovih bolesnika varirale su između 5,3 i 12,1 mmol/L. U 13 pacijenata postojali su dokazi u prilog miješane hiperlipidemije. Starost bolesnika je iznosila između 52 i 89 godina. Unatoč normalnom padu bubrežne funkcije sa starenjem (Spearman r=–0,71, p<0,01), vrijednosti LDL i non-HDL kolesterola nisu pokazale korelaciju s njome. Ukupno 13 bolesnika bilo je starije od 70 godina. Zaključak: Hiperkolesterolemija u primarnoj prevenciji kao jedan od neovisnih rizičnih čimbenika za razvoj kardiovaskularnih bolesti i dalje je vrlo podcijenjen problem. Usprkos čvrstim dokazima te visokim vrijednostima kolesterola u serumu, sumnjičavost liječnika u učinkovitost statinske terapije i slaba suradljivost bolesnika dovode do razočaravajućih rezultata u korištenju hipolipemičkih lijekova u primarnoj prevenciji kardiovaskularnih bolesti.

Aim: Apart from underdiagnosed familial hypercholesterolemia, idiopathic hypercholesterolemia in Croatian population is one of the most common and ignored problems in everyday clinical practice. This study aimed to present the situation of statin use in primary prevention in the average Croatian primary care unit, and to reveal the main reasons why patients do not take statins in primary cardiovascular prevention. Materials & Methods: We analyzed lab test results (LDL cholesterol and non-HDL cholesterol, triglyceride, and creatinine levels in serum) of 1608 patients in one primary care unit from the Health Center Zagreb – West during June 2019. If a patient took statin therapy his LDL cholesterol was calculated by multiplying with the corresponding correction factor. We included all
patients whose LDL cholesterol , corrected or measured, exceeded 5mmol/L. Kidney function was calculated by the CKD-EPI formula. All patients with any liver and kidney disease were excluded, as well as uncontrolled diabetic patients. Patients with previous myocardial infarction and/or cerebrovascular insult were also excluded. Results: Out of 1608 patients, 40 (26 female, 14 male, total 2.5%) presented with LDL-cholesterol above 5 mmol/L (max. 10.2 mmol/L). There were no gender differences. Thirty-eight patients (95%) were hypertensive, and eight (20%) had controlled diabetes mellitus type 2. Despite LDL cholesterol levels, only ten patients had prescribed statin therapy (25%). The levels of non-HDL cholesterol in these patients showed a range from 5.3 to 12.1 mmol/L. In 13 patients we found evidence of mixed hyperlipidemia. The age of patients varied from 52 to 89 years. Kidney function deteriorated with aging (Spearman r=–0.71, p<0.01), but LDL cholesterol and non-HDL cholesterol values didn’t depend on those changes. Thirteen analyzed patients were over 70 years old. Conclusion: In primary prevention hypercholesterolemia, as one of the independent risk factors for cardiovascular disease development, is still an underestimated problem. Despite the obvious evidence and very high serum cholesterol levels, doctors’ disbelief in statin efficacy and patients’ low compliance lead to disappointing results in prescribing lipid-lowering drugs in primary prevention.