Patient factors affecting prescribing and outcomes in cardiovascular disease
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Date
2026-05-01
Authors
Elhiny, Rehab Hassan Ahmed
Journal Title
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Publisher
University College Cork
Published Version
Abstract
Background Cardiovascular diseases (CVDs) are the leading cause of death worldwide. Low density lipoprotein cholesterol (LDL-C) and high blood pressure (BP) are significant risk factors for developing CVDs. Evidence demonstrates a reduction in LDL-C levels and optimal BP control can significantly reduce the incidence of major adverse CV events. However, controlling these critical risk factors remains challenging in clinical practice.
Aims This thesis aims to assess the control of CVD risk factors, in particular dyslipidemia and hypertension control among people treated for primary prevention and people treated for secondary prevention of CVD. In addition, the thesis aims to identify the patient and medication factors that could influence the achievement of recommended LDL-C and BP guideline goals in clinical practice.
Methods In chapter 1, a systematic review and a meta-analysis was conducted to summarise the existing published evidence from Ireland regarding LDL-C and BP control, medication adherence among patients and guideline adherence among prescribers and to identify the gaps in the literature. Chapter 2 used data from the Mitchelstown Cohort Study rescreen dataset of primary care participants aged 51 - 77 years, collected in 2015. The proportion of participants who achieved LDL-C goals in accordance with treatment targets set out in both the 2011 and 2019 European Society of Cardiology (ESC)/ European Atherosclerosis Society (EAS) guidelines for management of dyslipidemia was examined and the prescribing pattern of lipid lowering therapies (LLTs) was assessed. A multivariable logistic regression analysis was conducted to identify the patients’ factors that could predict the prescribing of LLTs and LDL-C goal achievements. In chapter 3, using the same Mitchelstown Cohort Study rescreen dataset, multiple imputation by chained equation (MICE) was performed to assess the proportion of people with prescribed antihypertensive medications who achieved systolic BP and diastolic BP goals in accordance with the treatment targets set out in the 2013 and the 2024 ESC/ European Hypertension Society (EHS) guidelines for management of arterial hypertension, and the prescribing pattern of antihypertensive medications. Medication non-adherence was assessed using a validated self-reported 3-item measure. Multivariable logistic regression analysis was conducted to identify the patients’ factors that could predict goal achievements and medication non-adherence in this population. Chapter 4 used the Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM) dataset. OPERAM was a multicenter controlled trial which recruited hospitalised people aged 70 years and older with multimorbidity and polypharmacy. The proportion of people who achieved LDL-C goals in accordance with the treatment targets set out in the 2016 and 2019 ESC/EAS guidelines was assessed. In addition, the prescribing pattern of LLT and the self-reported medication adherence among people with prescribed LLTs was analyzed. A further comparison of LDL-C goal achievements and prescribing pattern of LLTs between clinical trial sites was conducted. In addition, multivariable logistic regression analysis was conducted to identify the patients’ factors that could predict LDL-C goal achievements and medication adherence in this population
Results Twenty-three studies were included in the systematic review and 10 studies were included in the proportional meta-analysis. The meta-analysis showed suboptimal control of LDL-C and BP in Ireland. The level of patient adherence to antihypertensive medications varied according to the assessment tools used and adherence to the prescribing guidelines was suboptimal. There was very limited data on adherence to LLTs and the factors associated with LDL-C goal achievement. In the Mitchelstown Cohort Study rescreen dataset, 48.5% of participants were prescribed LLT. However, less than 40% of those prescribed LLT achieved their LDL-C goals, when stratified by their CVD risk category. Diabetes diagnosis and hyper-polypharmacy were predictors of prescribing LLT, while male sex and age ≤59 years or 60–64 years were among the predictors of achieving LDL-C goals. In the same cohort, BP control was suboptimal, with 63.8% of participants on antihypertensive medications achieving the recommended 2013 BP goals, falling to 38.4% when applying the stricter 2024 goals. Female sex was a predictor of medication adherence. Being overweight or obese, being non-adherent or having polypharmacy or hyper-polypharmacy were associated with less likelihood of achieving 2024 goals only. In the OPERAM dataset, 66.5% of participants prescribed LLTs achieved LDL-C goals as recommended in the 2016 ESC/EAS guideline, with just 38.8% achieving LDL-C goal when applying the 2019 ESC/EAS guideline goals. Female sex was a predictor for not achieving LDL-C goals, while people who were treated for primary prevention were more likely to achieve their LDL-C goals than those treated for secondary cardiovascular prevention.
Conclusion The thesis demonstrates suboptimal control of CVD risk factors, in particular dyslipidemia and BP in clinical practice across a wide age range of adults in both Ireland and Europe. Findings demonstrate a significant proportion of people at risk of CVD are not achieving LDL-C and BP goals. Medication adherence is not consistently measured or reported, but where measured, it is suboptimal, potentially limiting goal achievements. Many people with an indication for LLT or antihypertensive medications are not prescribed these therapies when they should be, according to guidelines. Where people are prescribed these medications, they are often not prescribed at the intensity required to meet guideline goals. Some patients’ demographic factors including age, sex, body mass index (BMI), and being prescribed polypharmacy may influence LDL-C and BP goal achievements.
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Keywords
Dyslipidemias, LDL-C control , Hypertension , Blood pressure control , Medication adherence , Antihypertensive prescription , Cardiovascular diseases risk factors
Citation
Elhiny, R. H. A. 2026. Patient factors affecting prescribing and outcomes in cardiovascular disease. PhD Thesis, University College Cork.