Lipid-lowering prescription patterns after a non-fatal acute coronary syndrome

Abstract Introduction After an acute atherosclerotic cardiovascular event, high-intensity lipid-lowering therapy (LLT) is needed to reduce the risk of recurrence. Moreover, despite 2016/2019 ESC/EAS guidance on lipid management according to risk, several studies indicate that most patients do not attain low-density lipoprotein-cholesterol (LDL-C) goals. The present study aims to describe LLT prescription patterns after a non-fatal acute coronary syndrome (ACS) and identify opportunities for improvement in secondary preventive measures, namely LDL-C control. Methods Retrospective cohort study featuring adults aged 40-80 residing in a Portuguese municipality Portugal, using Electronic Health Records between 2016 and 2022. Selected patients had ≥1 general practice appointment three years before the occurrence of an ACS, which was considered an index date. Sub-analysis was made based on patients’ age (under and high or equal to 65 years), gender, and whether their LDL-C levels were controlled according to gradual upper thresholds of 100 mg/dL in the period before the ACS event and 55 mg/dL at one-year post-ACS. Results Among the 544 selected patients, 270 were younger than 65 years. Females comprised 30% (164 patients) of the total cohort, 27% of the under-65 group, and nearly 38% of the 65 and older group. In younger patients, LDL-C levels were higher at presentation (132 mg/dL) and had a significantly greater decrease during the follow-up period compared to the older group. In the period before the ACS, 71.1% of men and 56.7% of women had no previous prescription of LLT, and younger patients had worse levels of LDL-C control (24.1%) compared to older patients (46.0%). One year post-ACS, the pattern of LLT revealed a substantial drop in patients without any LLT prescription from 66.7% to 13.6% and an increase in high-intensity LLT from 2.4% to 16.5%. Still, moderate-intensity LLT (66%) remained the most frequently used LLT. An increase in LLT potency was observed in the follow-up, although there was a decrease in patients achieving LDL-C control. Previous to the ACS event, 35.3% of men and 34.8% of women had initially controlled LDL-C levels according to defined thresholds, which significantly reduced to 11.3% and 8.5%, respectively, at one-year post-ACS. Conclusion Despite initiating or intensifying LLT after ACS, LDL-C goals were not achieved in approximately 9 out of 10 patients at 1-year follow-up, highlighting that the LLT adjustment was insufficient. Therefore, there is a need for better optimisation of LLT after ACS, unveiling an alarming gap in guideline implementation in clinical practice.