{
  "abstract": "Introduction Multimorbidity, defined as the presence of two or more chronic conditions, is increasingly common in primary care and complicates strategies for atherosclerotic cardiovascular disease (ASCVD) prevention. Multimorbid patients, particularly those with diabetes, hypertension, chronic kidney disease (CKD), and other comorbidities, are at significantly higher risk for developing ASCVD, which challenges the conventional understanding of primary prevention. 1 Current NICE guidelines recommend a 40% reduction in non-HDL cholesterol for primary prevention; however, the cumulative risk associated with multimorbidity may approach that of secondary prevention populations.2 This analysis assesses the effectiveness of bempedoic acid, a non-statin lipid-lowering therapy, in achieving NICE non-HDL cholesterol targets in multimorbid patients currently classified as primary prevention, and explores whether their elevated risk profile warrants reclassification to secondary prevention.3Methods A retrospective cohort study was conducted with 708 adults prescribed bempedoic acid-containing therapies in a rural UK general practice between 2021 and 2020. The cohort consisted of 336 males and 372 females, with a mean age of 69.2 years (SD 10.2); 608 patients had at least two chronic conditions known to elevate atherosclerotic cardiovascular disease (ASCVD) risk, including 460 patients with hypertension, 261 patients with CKD, 191 patients with diabetes, 149 patients with pre-diabetes, 85 patients with COPD, and 50 patients with heart failure. The most common chronic condition was hypertension, representing 65% of the cohort. Baseline LDL-C was 2.83 mmol/L (SD 1.08), and non-HDL cholesterol was 3.71 mmol/L (SD 1.16). The primary outcome was a 40% reduction in non-HDL cholesterol, as recommended by NICE.Results LDL-C and Non-HDL Cholesterol Reduction:At baseline, LDL-C was 2.83 mmol/L and decreased to 1.92 mmol/L, 1.80 mmol/L, and 1.71 mmol/L across sequential follow-up intervals. Non-HDL cholesterol showed a significant reduction from 3.71 mmol/L to 2.73 mmol/L, 2.60 mmol/L, 2.51 mmol/L, and 2.30 mmol/L over the follow-up periods. This represents a 40% reduction in non-HDL cholesterol in 58% of patients, meeting the NICE target for primary prevention.3Multimorbidity and Risk:The cohort’s high burden of multimorbidity raises the question of whether these patients should still be classified as primary prevention. 86% of patients had comorbidities such as diabetes, hypertension, and CKD, all of which are well-established ASCVD risk factors. In fact, patients with multiple chronic conditions may experience compounded risks, putting them at a higher risk for CVD events similar to those with established ASCVD. The NICE guidelines for secondary prevention typically apply more aggressive LDL-C targets (≤2.0 mmol/L for high-risk patients), which may be more appropriate for this cohort, suggesting that their CVD risk profile may warrant secondary prevention strategies rather than traditional primary prevention approaches. If reclassified as secondary prevention, 48% of patients would have achieved the secondary prevention NICE target of <2.0 mmol/L for LDL-C.Adherence and Persistence:Adherence to therapy was 90.7%, with 85% of patients continuing therapy. Discontinuation occurred in 15.8% of patients, primarily due to non-specific symptoms, with most patients transitioning to ezetimibe monotherapy, maintaining partial LDL-C control.Conclusion This analysis demonstrates that bempedoic acid is effective in achieving NICE targets in multimorbid patients currently classified as primary prevention, with 58% achieving a 40% reduction in non-HDL cholesterol. 1–3 However, the high prevalence of comorbid conditions in this cohort calls into question whether these patients should still be classified as primary prevention. The cumulative cardiovascular risk associated with multimorbidity may approach that of secondary prevention.1The significant reductions in LDL-C and non-HDL cholesterol observed support reconsideration of current prevention definitions for patients with multimorbidity. Given their elevated cardiovascular risk, these individuals may benefit from more intensive lipid-lowering strategies aligned with secondary prevention, including earlier use of combination therapy. In this context, bempedoic acid may play a key role in enabling patients to achieve both NICE primary and secondary prevention targets.2 3Overall, these findings highlight the need for a more personalised approach to lipid management that accounts for multimorbidity. Reclassification of high-risk primary prevention patients and adoption of more aggressive lipid-lowering strategies may be necessary to optimise long-term cardiovascular outcomes in this population.1–3",
  "authors": [
    {
      "affiliations": [
        "Marsh Medical Practice, Louth, United Kingdom"
      ],
      "name": "Meredith Donaldson"
    },
    {
      "affiliations": [
        "Marsh Medical Practice, Louth, United Kingdom"
      ],
      "name": "Carl Deaney"
    }
  ],
  "title": "291 Primary prevention in multimorbid patients: rethinking the classification of primary prevention and the role of bempedoic acid in achieving NICE targets in rural primary care",
  "uid": "fe4c5ace-d651-5f3f-9a6d-a4eb76d84076"
}