PROMPT-Lipid Trial Shows EMR Tools Improve LDL Cholesterol Management

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At the annual Family Heart Global Summit on September 23, 2024, in Dallas, Texas, a presentation addressed the gap between scientific knowledge, such as guidelines for low-density lipoprotein (LDL) cholesterol management, and their implementation in clinical practice.¹

Presenter Nihar Desai, MD, MPH, from Yale School of Medicine, discussed the importance of implementing scientific discoveries and clinical guidelines into actual practice, specifically within cardiovascular care. He also shared the benefits of a pragmatic electronic health record (EMR)-based approach to improving lipid control as evaluated in the PROMPT-Lipid Trial (PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia).

The PROMPT-Lipid trial examined whether electronic health record alerts could enhance the intensification of lipid-lowering therapy within 90 days for patients with very high-risk atherosclerotic cardiovascular disease (ASCVD).² In this study, cardiovascular and internal medicine clinicians from Yale New Haven Health were cluster-randomized to receive an alert with individualized lipid-lowering therapy recommendations or no alert for outpatients with very high-risk ASCVD and LDL-C ≥ 70 mg/dL.

The primary outcome was the 90-day lipid-lowering intensification—in other words, the change to high-intensity statin and the addition of ezetimibe or PPCSK9i. Secondary outcomes included LDL-C levels, number of patients with LDL-C of < 70 or < 55 mg/dL, rate of major adverse cardiovascular events, emergency department visits, and 6-month mortality.

The alert group had 49 clinicians and 1130 patients with a mean age of 72 years, 47% female, and a medium LDL-C of 91 mg/dL. The non-alert group had 47 clinicians and 1370 patients with a mean age of 71 years, 50.1% female, and a medium LDL-C of 93 mg/dL.

In total, 14.1% of participants in the alert group had lipid-lowering intensification after 90 days, compared with 10.4% in the non-alert group. The study did not observe any differences in secondary outcomes at 6 months. Ultimately, the study showed among patients whose clinicians did not ignore the electronic health record alert recommendations, lipid-lowering therapy intensification was significantly greater (21.2% vs 10.4%; odds ratio [OR], 2.33; 95% confidence interval [CI], 1.48 – 3.66).

Desai explained that the trial aimed to understand why current guidelines are not leading to the expected treatment outcomes.¹ During the session, he posed the question, “How could the science tell us about the importance of LDL, explosion of new therapies, and yet so few patients are actually getting to the LDL levels that the science and the guidelines [tell us]?

Despite strong scientific evidence and therapies, Desai described implementation challenges, particularly clinical inertia—the hesitation or failure to act.

“Clinical inertia conspires against us, and is a very powerful force in PD projects... It’s too easy in the setting of a routine clinical interaction to not do something, to just leave things unchanged,” Desai noted.

He suggested that leveraging electronic health records and decision support tools can provide real-time, evidence-based care that aligns with guidelines, potentially improving outcomes for ASCVD patients. Desai advocated for integrating precision medicine with implementation science to bridge the gap between new medical insights and their application in patient care. He believes low-cost, EMR-based tools can standardize treatment and improve outcomes across various aspects of cardiovascular care.

“If we just [focus on new therapies and discovering implementation science], we'll continue to have the same results that we've had for too long,” Desai said.

References

1. ^{Desai, N. A Pragmatic EMR-Based Approach to Improving Lipid Control: the PROMPT-Lipid Trial. Session presented the annual Family Heart Global Summit in Dallas, Texas, on September 23, 2024.}
2. ^{Shah NN, Ghazi L, Yamamoto Y, et al. Pragmatic Trial of Messaging to Providers About Treatment of Hyperlipidemia (PROMPT-LIPID): A Randomized Clinical Trial. Circ Cardiovasc Qual Outcomes. 2024;17(5):e010335. doi:10.1161/CIRCOUTCOMES.123.010335}