GUIDELINE-DIRECTED LIPID GOAL ATTAINMENT IN PATIENTS WITH DIABETES AT HIGH AND VERY HIGH CARDIOVASCULAR RISK: REAL-WORLD EVIDENCE OF A PROFOUND TREATMENT GAP

Abstract

Objective: To evaluate lipid-lowering therapy patterns and the attainment of guideline-directed low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) goals among high and very high-risk patients with diabetes mellitus in a real-world clinical setting. 
Material and Methods: This retrospective observational study included 202 patients (197 with type 2 and 5 with type 1 diabetes mellitus). Patients were stratified into high-risk (HR, n=132) and very high-risk (VHR, n=70) categories according to cardiovascular risk criteria. Statin utilization, combination therapy rates, and target attainment frequencies (LDL-C <70 mg/dL for HR; <55 mg/dL for VHR) were analyzed based on current European guidelines. 
Results: Only 51.0% of the total cohort received statin therapy (50.0% in HR and 52.9% in VHR groups). Combination therapy was exceptionally rare (0 .5%, n= 1). LD L-C target attainment was ala rmingly low; merely 18.2% of HR patients a nd 1 0.0% o f V HR patients achieved th eir sp ecific goa ls. Amo ng patients actively treated with statins, attainment rates remained highly inadequate (19.7% in HR and 10.8% in VHR). Non-HDL-C goals were successfully reached by only 16.7% of HR and 11.4% of VHR patients. 
Conclusion:  Guideline-directed lipid goal attainment i s critically suboptimal amo ng hig h and very high-risk diabetic patients. This profound treatment gap, likely driven by a complex interplay of physician-level therapeutic inertia and patient-level non-adherence or reluctance, highlights an urgent need for proactive, patient-centered, and protocol-driven lipid management.

Keywords

• Diabetes Mellitus
• Dyslipidemias
• Cholesterol
• LDL
• Treatment Outcome
• Guideline Adherence

Supporting Institution

Funding: The author received no financial support for the research, authorship, and/or publication of this article.

Ethical Statement

The study protocol was reviewed and approved by the Non-Invasive Clinical Research Ethics Committee of Yozgat Bozok University (decision date: 18.02.2026 number: 2026-GOKAEK-264_2026.02.18_27). The study was conducted in accordance with the principles of the Declaration of Helsinki. Informed Consent: Due to the retrospective nature of the study, the requirement for informed consent was waived by the ethics committee

Yüksek ve Çok Yüksek Kardiyovasküler Risk Taşıyan Diyabet Hastalarında Kılavuzların Önerdiği Lipid Hedeflerine Ulaşma: Ciddi Bir Tedavi Açığına Dair Gerçek Hayattan Kanıtlar

Abstract

Amaç: Yüksek ve çok yüksek kardiyovasküler riskli diyabet hastalarında lipit düşürücü tedavi kullanım kalıplarını ve kılavuzların önerdiği düşük yoğunluklu lipoprotein kolesterol (LDL-K) ile non-yüksek dansiteli lipoprotein kolesterol (non-HDL-K) hedeflerine ulaşma oranlarını gerçek yaşam verileriyle değerlendirmektir. 
Gereç ve Yöntemler: Bu retrospektif gözlemsel çalışmaya 202 diyabet hastası dahil edilmiştir. Hastalar kardiyovasküler risk kriterlerine göre yüksek riskli (YR, n=132) ve çok yüksek riskli (ÇYR, n=70) olarak iki kategoriye ayrılmıştır. Statin kullanımı, kombinasyon tedavi oranları ve güncel Avrupa kılavuzlarına dayalı hedeflere ulaşma sıklıkları ayrıntılı olarak analiz edilmiştir. 
Bulgular:  Tüm kohortun yalnızca %51,0'i statin tedavisi almaktaydı (YR %50,0, ÇYR %52,9). Kombinasyon tedavisi kullanımı istisnai derecede nadirdi (%0,5). Genel LDL-K hedefine ulaşma oranları endişe verici derecede düşüktü; YR hastalarının %18,2'si, ÇYR hastalarının ise sadece %10,0'u hedeflerine ulaştı. Statin tedavisi alan hastalar arasında dahi hedefe ulaşma oranları oldukça yetersiz kalmıştır (YR'de %19,7 ve ÇYR'de %10,8). Non-HDL-K hedeflerine ise YR hastalarının %16,7'si, ÇYR hastalarının %11,4'ü ulaşabilmiştir. Sonuç: Yüksek ve çok yüksek riskli diyabet hastalarında kılavuzların önerdiği lipit hedeflerine ulaşma oranları kritik derecede düşüktür. Muhtemelen hekim kaynaklı klinik atalet ile hasta uyumsuzluğu veya tedavi reddinin karmaşık etkileşiminden kaynaklanan bu derin tedavi boşluğu, proaktif, hasta odaklı ve protokole dayalı lipit yönetimine acil ihtiyaç duyulduğunu vurgulamaktadır.
 

Keywords

• Diabetes Mellitus
• Dislipidemiler
• Kolesterol
• LDL
• Tedavi Sonucu
• Kılavuza Uyum

Supporting Institution

Yazar, bu makalenin araştırılması, yazılması ve/veya yayınlanması için herhangi bir mali destek almamıştır.

Ethical Statement

The study protocol was reviewed and approved by the Non-Invasive Clinical Research Ethics Committee of Yozgat Bozok University (decision date: 18.02.2026 number: 2026-GOKAEK-264_2026.02.18_27). The study was conducted in accordance with the principles of the Declaration of Helsinki.

References

1. American Diabetes Association Professional Practice Committee for Diabetes. Standards of Care in Diabetes - 2026. Diabetes Care. 2026;49(Supplement 1):S1-371.
2. Gyberg V, Kotseva K, Dallongeville J, Backer GD, Mellbin L, Ryden L, et al. Does pharmacologic treatment in patients with established coronary artery disease and diabetes fulfil guideline recommended targets? A report from the EUROASPIRE III cross-sectional study. Eur J Prev Cardiol. 2015;22(6):753-61.
3. Averna M, Banach M, Bruckert E, Drexel H, Farnier M, Gaita D, et al. Practical guidance for combination lipid-modifying therapy in high- and very-high-risk patients: A statement from a European Atherosclerosis Society Task Force. Atherosclerosis. 2021;325:99-109.
4. Razavi AC, Sokolsky M, Belanger M, Blazoski C, Spitz JA, Sperling LS, et al. Progress in risk assessment and management: Forecasting updates across international cholesterol guidelines. Am J Prev Cardiol. 2026;26:101417.
5. Rottura M, Francesca Anna Drago S, Molonia A, Gianguzzo VM, Sacco FM, Pallio G, et al. Improving lipid-lowering treatment and cardiovascular risk management in primary care: findings from an audit and feedback project. Front Pharmacol. 2026;17:1787952.
6. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41(1):111-88.
7. Mach F, Koskinas KC, Roeters van Lennep JE, Tokgozoglu L, Badimon L, Baigent C, et al. 2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2025;46(42):4359-78.
8. Brandts J, Marx N. Combination Lipid-Lowering Therapy After ACS: Should this be the New Standard of Care? Curr Cardiol Rep. 2026;28(1):19.

9. Parhofer KG, Aguiar C, Banach M, Drexel H, Gouni-Berthold I, Perez de Isla L, et al. Expert opinion on the integration of combination therapy into the treatment algorithm for the management of dyslipidaemia: the integration of ezetimibe and bempedoic acid may enhance goal attainment. Eur Heart J Cardiovasc Pharmacother. 2025;11(4):367-79.
10. Ray KK, Molemans B, Schoonen WM, Giovas P, Bray S, Kiru G, et al. EU-Wi de Cross-Section al Obser v at ion al Study of Lipid-Modifying Therapy Use in Secondary and Primary Care: the DA VINCI study. Eur J Prev Cardiol. 2021;28(11):1279-89.
11. Ray KK, Haq I, Bilitou A, Manu MC, Burden A, Aguiar C, et al. Treatment gaps in the implementation of LDL cholesterol control among high-and very high-risk patients in Europe between 2020 and 2021: the multinational observational SANTORINI study. Lancet Reg Health Eur. 2023;29:100624.
12. De Backer G, Jankowski P, Kotseva K, Mirrakhimov E, Reiner Ž, Ryden L, et al. Management of dyslipidaemia in patients with coronary heart disease: results from the ESC-EORP EUROASPIRE V survey in 27 countries. Atherosclerosis. 2019;285:135-46.
13. Brandts J, Tittel SR, Bramlage P, Danne T, Brix JM, Zimny S, et al. Low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol in type 1 diabetes and type 2 diabetes: Lipid goal attainment in a large German-Austrian diabetes registry. Diabetes Obes Metab. 2023;25(12):3700-8.
14. Sabovic M, Pejkov H, Caraus A, Gruev I, Vintila VD, Csanadi Z, et al. Suboptimal management of hypercholesterolemia in countries with high or very high cardiovascular risk: findings from the international DISCOVERY study. Front Cardiovasc Med. 2025;12:1665059.
15. Bruckert E, Parhofer KG, Gonzalez-Juanatey JR, Nordestgaard B, Arca M, Giovas P, et al. Proportion of High-Risk/Very High-Risk Patients in Europe with Low-Density Lipoprotein Cholesterol at Target According to European Guidelines: A Systematic Review. Adv Ther. 2020;37(5):1724-36.
16. Yun SJ, Jeong IK, Cha JH, Lee J, Cho HC, Choi SH, et al. Current Status of Low-Density Lipoprotein Cholesterol Target Achievement in Patients with Type 2 Diabetes Mellitus in Korea Compared with Recent Guidelines. Diabetes Metab J. 2021;46(3):464-75.
17. Mert KU, Basaran O, Mert GO, Dogan V, Rencuzogullari I, Ozlek B, et al. Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real-life evidence of Under-treatment from the EPHESUS registry. Eur J Clin Invest. 2021;51(7):e13528.
18. Sen T, Dinc Asarcikli L, Guven S, Kocabas U, Ozgeyik M, Demir M, et al. Adherence to Current Dyslipidemia Guideline in Patients Utilizing Statins According to Risk Groups and Gender Differences: The AIZANOI Study. Anatol J Cardiol. 2024;28(6):273-82.
19. Chandalia HB, Jain JD, Chandalia SH. Achievement of ABC Goals in Type 2 Diabetes in Real-life. J Assoc Physicians India. 2024;72(11):39-44.
20. Garcia-Ulloa AC, Lechuga-Fonseca C, Del Razo-Olvera FM, Aguilar-Salinas CA, Galaviz KI, Narayan KMV, et al. Clinician prescription of lipid-lowering drugs and achievement of treatment goals in patients with newly diagnosed type 2 diabetes mellitus. BMJ Open Diabetes Res Care. 2021;9(1): e001891.
21. Yan X, Li Y, Dong Y, Wu Y, Li J, Bian R, et al. Blood pressure and low-density lipoprotein cholesterol control status in Chinese hypertensive dyslipidemia patients during lipid-lowering therapy. Lipids Health Dis. 2019;18(1):32.
22. Zhang YQ, Li Y, Dong YG, Wu YH, Bian R, Li JH, et al. A nationwide assessment of blood pressure control and the associated factors in Chinese type 2 diabetes mellitus patients. J Clin Hypertens (Greenwich). 2019;21(11):1654-63.
23. Sakamoto M, Edo N, Takahashi S, Okamura E, Uno K, Morita K, et al. Association between Prescription and Control Status of Dyslipidemia and Hypertension among Japanese Patients with Diabetes. J Atheroscler Thromb. 2019;26(9):805-20.
24. Yudin ZM, Yaacob LH, Hassan NB, Ismail SB, Draman N, Yusoff SSM. Achievement of LDL Cholesterol Goal and Adherence to Statin by Diabetes Patients in Kelantan. Malays J Med Sci. 2017;24(3):44-50.
25. Selim S, Alam MS, Talukder SK, Kabir ML, Gaffar AJ, Kabir MA, et al. Status of lipid control in Bangladeshi subjects with type 2 diabetes mellitus on lipid-lowering drugs: a multicenter, facility-based, cross-sectional study. BMC Endocr Disord. 2023;23(1):268.
26. Shafiee G, Gharibzadeh S, Panahi N, Razi F, Arzaghi SM, Haghpanah V, et al. Management goal achievements of diabetes care in Iran: study profile and main findings of DiaCare survey. J Diabetes Metab Disord. 2023;22(1):355-66.
27. Janghorbani M, Papi B, Amini M. Current status of glucose, blood pressure and lipid management in type 2 diabetes clinic attendees in Isfahan, Iran. J Diabetes Investig. 2015;6(6):716-25.
28. Lan NSR, Hiew J, Ferreira I, Ritter JC, Manning L, Fegan PG, et al. Achievement of low-density lipoprotein cholesterol goals in patients with diabetes-related foot ulceration. J Diabetes Complications. 2025;39(8):109069.
29. Banach M, Reiner Z, Surma S, Bajraktari G, Bielecka-Dabrowa A, Bunc M, et al. 2024 Recommendations on the Optimal Use of Lipid-Lowering Therapy in Established Atherosclerotic Cardiovascular Disease and Following Acute Coronary Syndromes: A Position Paper of the International Lipid Expert Panel (ILEP). Drugs. 2024;84(12):1541-77.
30. Barrios V, Pinto X, Escobar C, Varona JF, Gamez JM. Real-World Attainment of Low-Density Lipoprotein Cholesterol Goals in Patients at High Risk of Cardiovascular Disease Treated with High-Intensity Statins: The TERESA Study. J Clin Med. 2023;12(9):3187.
31. Mesquita-Lousada A, Barbosa A, Silva JB, D'Oria M, Santos Silva D, Andrade JP, et al. Knowledge, Use, and Barriers in Dyslipidemia Management: A Cross-Sectional Survey of Clinicians. J Clin Med. 2026;15(7):2745.
32. Kennedy AG, MacLean CD, Littenberg B, Ades PA, Pinckney RG. The challenge of achieving national cholesterol goals in patients with diabetes. Diabetes Care. 2005;28(5):1029-34.