As a result, cardiovascular disease (CVD) is the most common cause of morbidity and mortality over the globe, recognized as a major public health problem in rich and developing countries alike [1]. As per the World Health Organization (WHO), nearly one-third of people die each year from cardiovascular diseases, of which approximately 20 million are deaths [2]. Fatalities from these diseases are very premature, however, and within low- and moderate-income areas, access to more preventive treatment and long-term management techniques is isolated [3]. The epidemiological transition with urbanization, low physical activity, dietary patterns, and increased life expectancy has further increased the burden of CVD worldwide.

CVD has appeared as the most significant health problem in the country in the past two decades [4]. India is estimated to account for a considerable proportion of the global CVD burden, largely characterized by coronary artery disease, ischemic heart disease and stroke [5]. Prior studies have shown that Indians appear to have CVD a decade earlier than Western populations, often with more pronounced clinical presentations. The increase of classical risk factors, including diabetes mellitus (DM), hypertension, obesity, tobacco use, and dyslipidemia, has likely contributed significantly to this trend [6,7]. Additionally, there are regional differences in disease awareness, access to treatment, and control of risk factors over the long term, particularly in settings with limited resources.

The basis of most cardiovascular events is atherosclerosis, whose pathogenesis is known to be driven by dyslipidemia [8]. High levels of LDL-C, low levels of high-density lipoprotein cholesterol (HDL-C), and high triglycerides have all been found to cause endothelial functional impairment, plaque development, and ultimately6 lead to narrowing of the arteries [9]. Lipid-laden extracellular matrix plaques build up in the arterial wall, leading to an inflammatory response and destabilization of plaque, leading to acute coronary syndromes and cerebrovascular disease [10]. Through decades of clinical evidence, there is a strong, dose-dependent association between LDL-C and risk of cardiovascular disease, which has led to aggressive lipid control in primary and secondary prevention.

LLT, especially statins, constitutes the mainstay of secondary prevention in patients with CVD. Statins lower circulating LDL-C by inhibition of hepatic cholesterol synthesis and upregulation of hepatic LDL receptors [11]. It has been consistently proven in multiple large randomized controlled trials that statin therapy decreases the risk of myocardial infarction, stroke, and cardiovascular mortality. Besides statins, the development of newer agents such as ezetimibe and Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors has broadened the treatment modalities, particularly in high-risk patients not meeting targets after statin treatment [12]. Thus, optimization of LLT is of greatest importance in order to better long-term cardiovascular outcomes.

Rationale of the study

While evidence is well established regarding the use of LLT, patterns of real-world prescribing frequently deviate from those suggested by clinical trials, driven not only by physician preferences but also by patient, socioeconomic, and institutional factors. A few meta-observations have reported lipid management practices in large organized studies based in metropolitan cities, but information from Eastern India, especially from tertiary care institutions serving to diversified populations, is particularly available. In these situations, it is important to understand prescribing behaviors and treatment outcomes to streamline understanding of gaps in care and areas for improvement.

International guidelines from organizations like the American College of Cardiology and the European Society of Cardiology provide unequivocal recommendations on statin intensity, LDL-C targets, and combination therapy among high-risk patients. However, adherence to these guidelines in everyday practice is still suboptimal. Assessment of patients with established cardiovascular disease for the receipt of guideline-directed therapy and achievement of recommended lipid targets is critical for the optimization of secondary prevention efforts. Therefore, conducted this retrospective study to evaluate patterns of lipid-lowering therapy prescription and outcomes for cardiovascular disease in a tertiary center in Bihar, adding regional and local data to the existing body of evidence.

Objectives

• To assess the patterns of lipid-lowering with therapy in patients with CVD.

• To evaluate LDL-C with the reduction of over time
• To measure attainment of the target lipid levels
• To evaluate adverse drug reactions and analyse the therapy modification patterns

Study Design They performed a retrospective observational analysis to evaluate LLT prescription mechanisms and clinical outcomes among patients with a history of established CVD. A retrospective design was selected for evaluation of real-world clinical practise through existing medical records, ensuring no intervention on either physician prescribing patterns or patient management. Patients were treated in the context of routine care, which is reflective of current treatment practice and outcomes in a tertiary care environment. Study Setting The study was conducted at Patna Medical College and Hospital (PMCH), which is an important government tertiary care teaching hospital of Bihar. The institution serves a broad and diverse patient population from the urban and rural regions of the state, receiving outpatient cardiology services, inpatient care, and outpatient follow-up management for cardiovascular disorders. Study Duration Data for six months were collected from March 2025 to November 2025. Eligible patients were identified by reviewing medical records from cardiology outpatient departments or admissions to cardiology units during this period. Outcome assessment included follow-up lipid parameters available within this study period. Sample Size The study included all 118 patients satisfying the definition of eligibility (predefined between cohort identification and study conduct). To ensure sufficient statistical processing of the data and reliability of the findings, only cases with complete documentation were included in the analysis, reviewing all eligible records observed during the specified duration. Inclusion Criteria Patients were 18 years of age or older, with diagnosed CVD including the Coronary Artery Disease (CAD), Myocardial Infarction (MI), or ischemic stroke. Patients were included if they had been prescribed at least one LLT during the study period and had complete medical and laboratory records. Exclusion Criteria Patients were excluded if their medical records lacked baseline and follow-up lipid profiles. Those with documented advanced hepatic dysfunction were excluded owing to possible contraindications to statin therapy. Pregnant patients were also excluded from analysis to prevent confounding clinical implications of pregnancy. Data Collection A structured data extraction is used to collect data from the hospital medical records, and the demographic variables are age and gender. Data on clinical risk factors like DM, hypertension, smoking, and other comorbidities were documented. Information on the type of cardiovascular disease was recorded. Baseline lipid profile parameters were recorded as Total Cholesterol (TC), LDL-C, HDL-C and triglycerides (TG). They retrieved details on the LLT prescribed type of drug, including statin, ezetimibe, PCSK9 inhibitor, dose, and intensity. Lipid levels following treatment during the study period were recorded to evaluate treatment response. It also includes serious drug reactions, therapy changes, and mentions of drug compliance. Classification of Therapy Intensity and regimen of LLT were classified. Statin therapy was defined as high-intensity or moderate-intensity based on standard dosing. Combination therapy included statins along with other lipid-lowering agents (ezetimibe or PCSK9 inhibitors). Outcome Measures The primary outcome was the prescription pattern of lipid-lowering drugs in patients with CVD. Mean change of LDL-C from baseline to follow-up, proportion of patients achieving LDL-C targets (<70 mg/dL for very high-risk patients), occurrence of adverse drug reactions and therapy escalation or switching in the secondary outcomes. Statistical Analysis Data was analysed using SPSS software. Means ± standard deviation for continuous variables and frequencies with percentages for categorical variables were used to summarize demographic and clinical variables with descriptive statistics. Paired t-test applied to the comparison of baseline and follow-up values of LDL-C. Associations between categorical variables were analyzed with the chi-square test. Statistical significance was defined as p < 0.05. Ethical Considerations Data collection was only conducted after the Institutional Ethics Committee of the hospital approved the study protocol. This study was a retrospective record-based study, which did not involve directly contacting any patients. Identifying information extracted, stored and analysed was anonymous to maintain strict patient confidentiality.

Baseline Characteristics

The average age of the study population was 58.6 ± 10.8 years, and the majority of patients belonged to the 51–70-year age group. The study cohort had a higher proportion of males. Hypertension and DM were the most prevalent comorbidities.

Table 1 Baseline Demographic Characteristics (n = 118)

Gender Distribution:

• Male: 76 (64.4%)
• Female: 42 (35.6%)

Table 2 Comorbidities Among Study Population

CAD is the most common diagnosis, which is followed by previous myocardial infarction as well as ischemic stroke.

Prescribing Patterns

68 (57.6%) patients were on high-intensity and 38 (32.2%) were on moderate-intensity statins. Combination therapy was managed in 12 (10.2%) patients.

Table 3 Lipid-Lowering Therapy Prescribing Pattern

At the drug level, atorvastatin was the most prevalent statin (62%), followed by rosuvastatin (28%). Out of all add-on agents used, ezetimibe was the most commonly prescribed in combination therapy.

Lipid Profile Outcomes

Baseline LDL-C was 142.4 ± 28.6 mg/dL and there was a significant reduction over time to 86.7 ± 22.4 mg/dL at follow-up (p < 0.001). There was a mean reduction of 55.7 mg/dL (39.1%) from baseline LDL; HDL-C levels 38.5 ± 6.4 – 42.1 ± 7.2 mg/dL. There was a reduction in the triglyceride levels from a baseline mean of 186.3 ± 4.8 mg/dL to 154.2 ± 39.6 mg/dL.

Table 4 Comparison of Lipid Parameters (Baseline vs Follow-up)

Out of the 118 patients, 72 patients (61.0%) reached the target LDL-C <70 mg/dL, by definition of very high-risk.

Therapy Modifications

In 20 patients (16.9%), they had to increase the dose because the reduction in LDL was insufficient. 8 patients (6.8%) switched drugs owing mainly to intolerance or inadequate response. During the follow-up period, 12 patients (10.2%) needed add-on therapy (mostly using ezetimibe) to reach the lipid goals.

Adverse Effects

Adverse drug reactions were reported in 18 patients (15.3%). The most frequent adverse effect was myalgia, observed in 12 patients (10.2%). 6 patients (5.1%) had elevated liver enzymes. 4 patients (3.4%) had drug discontinuation because of adverse effects. LLT was associated with a marked change in lipid parameters in most patients and an acceptable safety profile was demonstrated.

Current retrospective analysis examines the LLT prescription patterns and clinical outcomes over duration in patients with established CVD at a tertiary care center in Bihar. The results show that the most frequently prescribed agents were high-intensity statins, resulting in a marked decrement of LDL-C during follow-up. Over half of the patients achieved guideline-recommended LDL targets, demonstrating an overall positive therapeutic response.

The results are similar to other Indian hospital-based studies showing a high use of statins in secondary prevention, particularly atorvastatin as first-line therapy. Similar prescribing patterns have been noted internationally where statins are the mainstay of dyslipidemia therapy. But, the other studies from urban centers in India and Western countries frequently find slightly higher rates of LDL target achievement due to better organized follow-up systems and more use of combination therapy. This conjunction with the lower-than-guidelines-recommended use of combination regimens observed suggests that adjunctive agents such as ezetimibe may be underutilised for those patients failing to achieve their desired treatment goal.

In this cohort, atorvastatin was the most selected statin, followed by rosuvastatin. This pattern aligns with national prescribing trends, potentially due to availability, clinician familiarity, cost-effectiveness, and hospital formulary policies [13]. More than half of the patients received high-intensity statin therapy, which reflects increasing recognition by clinicians of aggressive lipid control in very high-risk people.

Overall guideline adherence appeared moderate, even though the percentage of patients started on appropriate statin therapy was high, the frequency of reaching LDL-C levels lower than 70 mg/dl indicates that optimization strategies such as dose titration and combination therapy might still be improved.

Clinical Implications

These results strengthen the argument for intensive lipid control in patients with pre-existing cardiovascular disease. Low LDL-C is consistently associated with a lower risk of cardiovascular events; the evidence is robust. Consequently, appropriate statin intensity and timely therapy escalation are the key to optimization of secondary prevention.

It highlighted the need for a proper follow-up mechanism. Lipid monitoring, advice to the patient and early recognition of lack of response will strongly improve therapeutic results. And finally, physician prescribing has a crucial role in effective lipid management. The care that was delivered may become increasingly effective and uniform with the help of continuous medical education and institutional protocols with evidence-based guidelines.

Comparison with Guidelines

Present guidelines from the American College of Cardiology and the European Society of Cardiology recommend maximal statin treatment with a goal of <70 mg/dL of LDL-C in patients with established atherosclerotic CVD and lower limits in some very high-risk populations [14,15]. Most patients in this study were prescribed high-intensity statins, which indicates the partial alignment with these recommendations. However, the percentage of patients reaching target LDL-C levels suggests space for improvement and combination therapy should be used more often in patients who do not reach their LDL-C goal with statin treatment only.

Hence, though evidence from PMCH depicts good awareness of recent recommendations among prescribers, there is still room for medication optimization through better dose titration, organized monitoring, and adjuvant therapy use in order to achieve better adherence with international benchmark guidelines.

Strengths

The design of this study is an important strength, as it reflects typical clinical practice in the conditions of a controlled trial. It is valuable and important data from Eastern India of which limited published evidence exists on lipid management patterns. Both prescribing trends and biochemical outcomes are included in the analysis, which adds to its comprehensiveness.

Limitations

This study has certain limitations. This retrospective design limits causal inference and relies on recorded data to be accurate. The sample size was relatively small (118 patients), limiting generalizability. Any long-term cardiovascular outcomes or patterns in sustained adherence beyond 6-months post randomization may not be fully appraised. In addition, this was a single-center study and may not reflect practices at other institutions or in other regions.

This study shows that the majority of patients with CVD are being prescribed high-intensity statins at PMCH with a significant change in the lipid parameters. While better than half of the patients reached the optimized LDL targets, overall adherence to international guideline recommendations is suboptimal. Structured lipid monitoring, timely escalation of therapy, and increased use of combination therapy. More multicenter prospective studies with long-term follow-up in diverse populations are necessary to assess prescribing trends and eventual cardiovascular benefit over time.

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