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Half of patients aged 40 years or older in Canada have dyslipidemia, and prevalence among patients aged 65 years or older, men, and those with obesity or other chronic conditions is even higher, according to a new study.

Although dyslipidemia is a modifiable risk factor for cardiovascular disease (CVD), treatment in primary care settings is suboptimal, the study authors suggested, particularly among patients who have high or intermediate Framingham risk scores.

"CVD is the first leading cause of death in men and second in women, and we have good evidence that we can reduce this risk with appropriate management, including addressing dyslipidemia," coauthor Alex Singer, MB, BAO, BCh, director of research and quality improvement in family medicine at the University of Manitoba in Winnipeg, Manitoba, Canada, told Medscape Medical News.

"We also know this is something that primary care providers frequently encounter and manage, so using the data we have to better understand these trends and where we are doing well and where we can improve is crucial to improving overall outcomes," he said.

The study was published in the March issue of Canadian Family Physician.

Tracking Dyslipidemia

The 2021 Canadian Cardiovascular Society guidelines recommended screening patients aged 40 years or older for dyslipidemia (or lipid profile abnormalities). They also recommended screening patients of any age who have clinical conditions that increase their CVD risk.

The investigators conducted a retrospective cohort study to estimate the prevalence of dyslipidemia and understand its management in Canadian primary care practices. They analyzed data for patients aged 40 years or older who saw a Canadian Primary Care Sentinel Surveillance Network contributor in 2018 or 2019. They also identified the presence of dyslipidemia and treatment with a lipid-lowering agent (LLA).

Among the 773,081 patients included in the study, 50% met the case definition for dyslipidemia. The condition was more prevalent in patients aged 65 years or older (61.5%), men (56.7%), and those living in urban areas (50%). By contrast, rates were lower in patients aged 40-64 years (42.9%), women (44.7%), and patients living in rural areas (45.2%).

In addition, 43.3% of patients were classified as having obesity or a body mass index (BMI) of 30 kg/m² or higher. Patients with obesity had a higher prevalence of dyslipidemia (64.9%) than those with a normal BMI (42.2%).

A higher prevalence of dyslipidemia was also found among patients with hypertension (66.3%), diabetes (57.5%), and four or more comorbidities (67.9%).

Among patients with documented dyslipidemia, 42.8% had evidence of treatment with an LLA, and 97% of the LLAs prescribed were statins. Among those with other LLA-indicated conditions, treatment was given to 70.1% of patients with diabetes, 71.8% of patients with CVD, 74.9% of patients with abdominal aortic aneurysm, 63.2% of patients with chronic kidney disease, and 61% of patients with genetic dyslipidemia.

Based on Framingham risk scores, patients with high risk were more likely to have an LLA prescription (65%) than those with intermediate (48.7%) or low risk (22.8%).

Sex and BMI

The strongest determinants of receiving LLA treatment were sex and BMI. Men had a 1.95-times higher likelihood of being treated, and patients with obesity were about 1.36 times more likely to receive treatment.

"We weren't particularly surprised by the findings, but the size of our cohort certainly confirmed many of the things that, as family doctors and primary care researchers, we expected to find," Singer said. "For example, we anticipated the high frequency of dyslipidemia and the overall appropriateness of who was being treated: Generally older patients who were more likely to be obese or have other chronic conditions."

Primary care practices can improve equity in dyslipidemia management by reducing unnecessary retesting of patients with known disease and instead focusing on screening more people who may be at risk, said Singer. For instance, physicians can target high-risk patients who aren't receiving treatment.

In addition, future studies can examine the reasons why patients may not receive treatment (such as cost, side effects, or other aspects of the shared clinical decision-making process) and how primary care physicians can offer the right resources to help, Singer said.

Considering Next Steps

Commenting on the findings for Medscape Medical News, Michael Allan, MD, professor of family medicine at the University of Alberta in Edmonton, Alberta, Canada, and director of programs and practice support at The College of Family Physicians of Canada, said, "We need to examine why people aren't taking these medications, whether they had a conversation with their primary care physician and then declined, or were offered another treatment or lifestyle management, or didn't have a conversation at all."

Allan, who wasn't involved with this study, coauthored the most recent simplified lipid guidelines for the prevention and management of CVD in primary care, which were published in the October 2023 issue of Canadian Family Physician. He and his colleagues noted the importance of understanding a patient's risk and having an informed conversation about the benefits and risks of starting a particular treatment.

"Many patients will decline treatment based on feeling that they're not high risk enough or they don't want to take a pill for a small decrease in CVD risk," he said. "There's a difference between someone who is well informed but doesn't want to take it and someone who was never offered the opportunity for treatment. There are 1000 reasons why a patient may not be treated, and we need to explore those more."

The authors did not report financial support for the research. Singer disclosed that he works as a knowledge translation consultant with the Canadian Cardiovascular Society. Allan reported no relevant disclosures.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.