. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inherited atherogenic dyslipidemias: are they correctly reported? Tiziana Sampietro 1 *, Srefania Pieroni 2 , Sabrina Molinaro 2 , Francesco Sbrana 1 , Beatrice Dal Pino 1 , Federico Bigazzi 1 , Massimiliano Ruscica 3 , Cesare R. Sirtori 3 , and Michela Franchini 2 1 Fondazione Gabriele Monasterio per la Ricerca e la Sanita ` Pubblica, Italy; 2 Institute of Clinical Physiology, National Research Council, Italy; and 3 Department of Pharmacological and Biomolecular Sciences, Universita ` degli Studi di Milano, Italy Online publish-ahead-of-print 12 June 2020 Inherited atherogenic dyslipidemias are pathological entities, included in the International Classification of Diseases (ICD), well described in medical textbooks and the object of extensive research and literature worldwide. They include familial hypercholesterolemia (FH; ICD-9: 272.0), familial combined hyperlipidemia (FCHL; ICD-9: 272.2), familial primary hypoalphalipoproteinemia (FHA; formerly ICD-9 272.4 and later ICD-10 E78.6). 1,2 Interest in these pathological entities is high, both because of extensive epidemiological monitoring and also because administrative databases constantly evaluate ongoing treatments. Classification of these inherited disorders allows us to provide reli- able data on the prevalence of the diagnoses. Expected prevalence in the general population is high 3 and very high (up to 75%) among cor- onary patients under 65 years of age. 4,5 Nonetheless, in current clin- ical practice inherited atherogenic dyslipidemias are seldom reported. Strategies to identify inherited atherogenic dyslipidemias in the general population are different among countries. In the US, inherited atherogenic dyslipidemia data are provided by the Getting to an imprOved Understanding of Low-Density Lipoprotein- Cholesterol and Dyslipidemia Management (GOULD) 6 and Patient and Provider Assessment of Lipid Management (PALM) 7 registries, both, however, mainly addressed to the evaluation of quality manage- ment. In Italy, the use of hospital administrative data, the digital docu- ments generated during each interaction between the patient and the healthcare infrastructure, allows us to provide a comprehensive pic- ture of the health state of patients and to evaluate the performance of the healthcare system. 8 In this analysis, the hospital discharge records (N = 61,217) of con- secutive cases, covering 4 years of admissions to hospitals in Pisa (Tuscany, Italy), were examined in order to evaluate the occurrence of inherited atherogenic dyslipidemia codes among the reported diagnoses (Table 1). Patients’ comorbidity profiles and the average individual costs for hospitalisation, outpatient visits and drugs have been also evaluated. Out of 61,217 patients studied, for only 3309 (5.4%) was an inherited atherogenic dyslipidemia code provided, mainly reported as a secondary diagnosis. Of the 31,380 patients admitted for atherosclerotic cardiovascular disease (ASCVD), an inherited atherogenic dyslipidemia code was present in only 2827 (9%) (Figure 1(a)). In the 13,221 subjects under 65 years of age (42% of this population), only 1218 were also diagnosed with an inherited atherogenic dyslipidemia code, accounting for 9.2% of this subpopula- tion (Figure 1(b)). Interestingly, the mean cost per patient in the case of inherited atherogenic dyslipidemia presenting with ASCVD was double that of inherited atherogenic dyslipidemia without ASCVD (e15,285 vs. e5699). Inherited atherogenic dyslipidemia diagnoses are thus reported in a far lower number of cases than reality. This low coding incidence may be partly attributable to the short duration of hospitalisation for acute coronary syndromes (ACS). This results in a high patient turn- over, limiting discharge indications to the prescription of high-inten- sity statins and other pharmacological treatments, as described in the quality indicators for ACS by Schiele et al. 9 This behaviour probably reflects a generalised approach, as depicted in FH, very frequently underdiagnosed 10 and for which new therapeutic agents agents are becoming available. 11 In the absence of a diagnosis of inherited atherogenic dyslipidemia and consequent follow-up, secondary prevention of cardiovascular complications by appropriate treatment and cascade screening for early diagnosis may still take place. It would, however, seem appropriate to include the diagnosis of inherited atherogenic dyslipidemia as an additional indicator of quality of care. 9 The inclusion of this indicator would be of value for an upcoming edition of this essential tool for both specialists and administrators. Inherited atherogenic dyslipidemias account for a large fraction of healthcare, in particular considering the social costs related to ASCVD complications, and this should be recognised. As millions of individuals currently worry about their high cholesterol levels, statins * Corresponding author. Tiziana Sampietro, Fondazione Gabriele Monasterio per la Ricerca e la Sanita ` Pubblica, Italy. Email: massimiliano.ruscica@unimi.it Published on behalf of the European Society of Cardiology. All rights reserved. V C The Author(s) 2020. For permissions, please email: journals.permissions@oup.com. European Journal of Preventive Cardiology (2021) 28, e1–e3 LETTER TO THE EDITOR doi:10.1177/2047487320930308 Downloaded from https://academic.oup.com/eurjpc/article/28/8/e1/6145755 by guest on 11 November 2022