Underuse of statins and antiplatelet therapy in high-risk cardiovascular patients: sex-based differences

Abstract Introduction Statins and antiplatelet agents are cornerstone therapies for reducing ischemic events and mortality in patients with atherosclerotic cardiovascular disease. However, real-world adherence to these therapies in patients at high or very high cardiovascular risk remains suboptimal. Emerging evidence suggests that sex-based disparities may contribute to undertreatment. Purpose To evaluate adherence to statins and antiplatelet therapy among adults at high or very high cardiovascular risk and to assess sex-based differences in the use of these preventive treatments. Methods We conducted a prospective, multicenter registry across 30 cardiology centers in Argentina between April 2023 and October 2024. We included patients hospitalized for cardiovascular diseases, either as emergencies or for scheduled admissions. Patients were classified as high or very high risk if they had diabetes, chronic kidney disease (estimated creatinine clearance <60 ml/min/m²), or a history of cardiovascular events. High-intensity statin therapy was defined as atorvastatin ≥40 mg or rosuvastatin ≥20 mg daily. The study was approved by the Ethics Committee of the Faculty of Medicine, University of Rosario. Results A total of 1,800 patients were included, of whom 29.7% were women, with a mean age of 70.0 ±10.9 years. Table 1 summarizes baseline characteristics. Overall, 76.5% of patients received either antiplatelet or anticoagulant therapy, while 67.3% were on statins, 6.3% on ezetimibe, and 4.1% on fibrates. Among those with prior cardiovascular interventions, statin use was slightly higher (77.6%). Despite clinical indications, only 39.7% of patients were on high-intensity statins. Women were significantly less likely to receive antiplatelet therapy (p=0.018), statins (p=0.010), and high-intensity statins (p<0.001) compared to men (Table 2). When asked about the purpose of statins, 41.4% of patients did not know what they were used for, 48.4% believed their primary role was cholesterol reduction, and only 10.2% recognized their impact on cardiovascular events and mortality. Patients who perceived statins as highly beneficial (rating ≥8 on a 0–10 scale) were more likely to use them (85.5% vs. 57.2%; p<0.001) and to be on high-intensity therapy (50.7% vs. 33.6%; p<0.001). No significant sex differences were observed in the perception of statin efficacy (37.1% of women vs. 35.2% of men rated them as highly beneficial; p=0.435). Conclusion Our data suggest that a significant proportion of high-risk patients remain undertreated with statins and antiplatelet therapy, particularly women. The observed sex-based differences suggest that women may receive less aggressive preventive strategies, highlighting the need for targeted interventions. Additionally, patient awareness of statin benefits appears to influence adherence, underscoring the importance of education in optimizing long-term cardiovascular prevention.Table 1 Table 2