Low-Density Lipoprotein Goals
Despite national guidelines for treatment of hyperlipidemia, significant numbers of individuals with coronary artery disease are not treated to their National Cholesterol Education Program (NCEP) low-density lipoprotein (LDL) goals. The potential benefits of a clinical pharmacist-managed lipid clinic would be to improve rates of success in achieving these goals, improve drug adherence and compliance with therapy, and reduce cardiovascular events. All patients who had a documented history of coronary artery disease and were under the care of one cardiologist were treated in the pharmacist-managed lipid clinic. A second cardiologist provided usual care to a group of patients with coronary artery disease who served as controls. Patients in each arm were followed for a minimum of 6 months. A protocol for therapy changes in clinic patients was developed by the clinical pharmacist and approved by the cardiologist. At the end of 6 months, 69% of patients in the pharmacist-managed clinic achieved their LDL goal, compared with 50% of controls. Compliance with laboratory tests and drug regimens also improved in clinic patients. Compliance with lipid panels went from 8% 2 months before to 89% 2 months after the start of the study. At the end of 6 months compliance with laboratory work and refills was 80%. Thus the clinical pharmacist-managed clinic was highly successful in achieving NCEP goals for secondary prevention.

Chronic disease is often poorly controlled despite extensive education programs aimed at increasing patient and physician compliance with national guidelines. Findings for diseases such as hypertension and diabetes show that only 25% of patients followed nationally recommended guidelines. Hyperlipidemia is also poorly controlled, especially when secondary prevention is involved. Results of the Lipid Treatment Assessment Project (L-TAP) show that only 38.4% of 4888 patients requiring lipid-lowering therapy achieved their target low-density lipoprotein (LDL) level. Of 1460 patients receiving lipid-lowering therapy for secondary prevention after a coronary event, only 18% achieved their LDL goal. Patients who had documented chronic heart disease (CHD) in L-TAP and failed to achieve their National Cholesterol Education Program (NCEP) goal did so by a large margin: their mean LDL level was 40 mg/dl higher than the target level.

Although 93% of investigators in L-TAP indicated that they were aware of NCEP guidelines and followed them in practice, it is apparent that other barriers besides knowledge and attitude impede achieving goals. Problems identified as key reasons for this are lack of patient education on hyperlipidemia, noncompliance with lipid-lowering therapies, lack of follow-up visits and monitoring, and poor physician understanding of the guidelines. Guidelines developed by the NCEP for secondary prevention of ischemic events in patients with coronary artery disease recommend LDL levels below 100 mg/dl. Effective treatment of 100 patients with a statin would prevent three to five strokes and three to nine myocardial infarctions a year.

Several models for lipid management exist, but only a few use pharmacists as the primary health care team member responsible for managing hyperlipidemia. Published results indicate pharmacists' success in increasing patient adherence to NCEP guidelines, with rates for persistence and compliance with drug therapy 93.6% and 90.1%, respectively. Most patients (62.5%) followed by pharmacists achieved their goals. Since pharmacists have a proven record of clinical success and cost-effectiveness in managing chronic disease, a local private cardiology practice decided to establish a pharmacist-managed lipid clinic to improve compliance with NCEP guidelines and patient outcomes.