A Crisis in Care: Why Millions of High-Risk Patients Fail to Control High Cholesterol

FERNANDINA BEACH, FL – December 03, 2025 – A startling new study reveals a profound and dangerous gap in American healthcare: despite the availability of effective treatments, the vast majority of patients with established heart disease are not achieving recommended cholesterol levels, leaving them vulnerable to preventable heart attacks and strokes. Research published in the American Journal of Preventive Cardiology by the Family Heart Foundation found that a staggering 87% of adults with atherosclerotic cardiovascular disease (ASCVD) failed to achieve comprehensive management of their low-density lipoprotein-cholesterol (LDL-C), often called “bad” cholesterol.

The study, which analyzed real-world data from 3.6 million individuals, paints a grim picture of the state of secondary prevention. It evaluated patients on three critical components of care: receiving guideline-recommended therapy, consistently taking that therapy, and reaching the target LDL-C level of less than 70 mg/dL. The finding that only 13% of this high-risk population met all three benchmarks signals a systemic breakdown that extends far beyond individual patient behavior.

“LDL-Cholesterol is a critical modifiable risk factor for cardiovascular disease. Timely, consistent, and appropriate management of LDL-Cholesterol reduces the incidence of an additional heart attack, stroke, or the need for an invasive cardiovascular procedure,” said Katherine Wilemon, founder and chief executive officer of the Family Heart Foundation, in a statement accompanying the release. “However, LDL-Cholesterol management in the U.S. is subpar and life-threatening.”

The Chasm Between Guidelines and Reality

The disconnect between established medical guidelines and actual clinical practice is at the heart of this crisis. Leading organizations like the American College of Cardiology (ACC) and American Heart Association (AHA) have long advocated for aggressive LDL-C reduction in patients who have already had a cardiovascular event. The guidelines are clear: for secondary prevention, the target is an LDL-C below 70 mg/dL, with some recommendations pushing for an even lower target of 55 mg/dL for very high-risk individuals. The science is unequivocal: lower is better.

Yet, the Family Heart Foundation’s data shows a starkly different reality:

• Only 41% of patients ever reached the sub-70 mg/dL LDL-C target.
• A mere 41% received guideline-directed, high-intensity therapy, while a shocking 28% received no treatment at all.
• Medication adherence was equally poor, with only 35% of patients being dispensed their LDL-C lowering therapy for at least 20 of the 24 months studied.

This isn't a failure of science, but of implementation. The therapeutic arsenal to combat high cholesterol is more robust than ever. High-intensity statins are the cornerstone of therapy, proven to reduce LDL-C by 50% or more. For patients who cannot reach their goal on a maximally tolerated statin, guidelines recommend adding non-statin agents. Ezetimibe is a common second-line therapy, followed by powerful PCSK9 inhibitors for those who still fall short. The existence of this clear, stepped-care approach makes the study's findings all the more concerning.

Systemic Inertia and Deep-Rooted Disparities

The report suggests that the problem is deeply embedded in the healthcare system itself. One of the primary drivers is “clinical inertia,” a phenomenon where healthcare providers fail to initiate or intensify therapy even when it is clearly indicated. This can stem from time-strapped clinical environments, a lack of familiarity with newer, more complex therapies, or an underestimation of a patient's residual risk.

Furthermore, market dynamics and access issues create significant hurdles. While statins are widely available and affordable, newer and more potent non-statin therapies like PCSK9 inhibitors often face significant barriers from insurers, including stringent prior authorization requirements and high patient co-pays. This creates a frustrating scenario where effective, guideline-recommended treatments are kept out of reach for the very patients who need them most. The study explicitly notes that low usage of these non-statin therapies is a major contributor to the management gap.

Compounding these systemic issues are glaring disparities in care. The research found that women, Black individuals, and patients younger than 50 with established heart disease were all less likely to receive optimal management. This isn't a new problem, but the data provides fresh evidence of its persistence.

Women’s cardiovascular risk is often underestimated, their symptoms can be atypical, and they are historically less likely to receive the same aggressive treatments as men. For Black individuals, the disparities are rooted in generations of systemic inequities and racial bias within healthcare, which manifest as less aggressive treatment and poorer health outcomes. The fact that younger patients are also undertreated is particularly alarming, as it represents a missed opportunity to halt disease progression early and prevent decades of cumulative damage.

Innovating a Path Forward

Addressing this multifaceted crisis requires more than simply reminding doctors to follow guidelines. The study’s authors and independent experts point toward a combination of clinical, technological, and health-system interventions. A crucial step is improving the uptake of combination therapy. Relying on statin monotherapy is no longer sufficient for a large portion of the high-risk population.

Pharmacological innovation offers part of the solution. Newer agents like inclisiran, a small interfering RNA (siRNA) therapy, can lower LDL-C with just two injections per year after an initial loading dose. Such infrequent dosing regimens could dramatically improve medication adherence, a key barrier identified in the study. Fixed-dose combination pills, which combine a statin and ezetimibe into a single tablet, also help by reducing a patient's daily pill burden.

Beyond new drugs, health systems must re-engineer their care delivery models. The implementation of team-based care—involving primary care physicians, cardiologists, pharmacists, and nurses—can provide the comprehensive education and follow-up that patients need. Integrating clinical decision support tools into electronic health records (EHRs) can flag at-risk patients and prompt clinicians to intensify therapy, directly combating clinical inertia. Finally, tying quality metrics and reimbursement to LDL-C control could provide the system-level incentive needed to prioritize this critical aspect of preventive care.

Ultimately, the Family Heart Foundation's findings are a call to action for the entire healthcare ecosystem—from policymakers and payers to providers and patients. The tools to prevent a significant number of secondary heart attacks and strokes already exist, but they are being catastrophically underutilized. Without a concerted effort to dismantle these clinical and systemic barriers, millions of high-risk individuals will remain unprotected from preventable cardiovascular events.