Temporal Trends and Racial/Ethnic- and Sex-Differences in LDL Cholesterol Control Among US Adults with Self-Reported Atherosclerotic Cardiovascular Disease

Objective Current guidelines for secondary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend a low-density lipoprotein cholesterol (LDL-C) of <70 mg/dL. However, temporal trends and racial/ethnic- and sex-differences in achievement of LDL-C targets are not well described. We assessed trends and racial/ethnic- and sex-differences in achievement of LDL-C <70 mg/dL using data from the National Health and Nutrition Examination Survey (NHANES) from 2005-2008 to 2017-March 2020. Methods We combined NHANES cycles into 4 periods: 2005-2008, 2009-2012, 2013-2016, and 2017-March 2020 and included participants ≥40 years with self-reported ASCVD. We estimated LDL-C <70 mg/dL prevalence over time and further stratified by sex and race/ethnicity. We used multivariable logistic regression adjusted for social determinants of health and clinical covariates to model LDL-C target attainment. Results Among NHANES participants representing US adults with self-reported ASCVD ( ≥65 years, male, White), LDL-C target attainment increased from (95% CI, ) in 2005-2008 to (95% CI, ) in 2017-March 2020 (P= for trend). Achievement of LDL-C <70 mg/dL significantly rose among men from (95% CI, ) to (95% CI, ) (P= for trend) without significant change in women (from 18.3% [95% CI, 13.6%-24.2%] to 22.5% [95% CI, 13.0%-35.9%]; P=0.241 for trend). Improvement in LDL-C target attainment was similar among White, Black, and Hispanic individuals (∼5-7% increase) and greatest among individuals of other (non-White, Hispanic, or Black) race/ethnicity (23.1% increase). In our multivariable analysis, comorbid diabetes and ages 65-75 and >75 years were associated with LDL-C target attainment. Conclusion LDL-C control modestly improved between 2005-2008 and 2017-March 2020; however, only ∼1/4 of individuals met guideline-directed LDL-C treatment targets by 2017-March 2020. Women had lower LDL-C control and lesser magnitude of improvement in LDL-C control than men, highlighting a need for targeted interventions to improve lipid-lowering therapy utilization in this population.