Analysis of Residual Risk and Recurrent Event Trends Following Acute Coronary Syndrome: A Cohort Study
Authors: Shuey Timothy C. , Voyce Stephen J. , Jones Laney K. , Johns Alicia , deRichemond Caroline , LeMaire Scott A. , Lagerman Braxton , Agarwal Shikhar 
Published: September 2024

Background

A comprehensive real-world analysis of residual risk factors for recurrent major adverse cardiovascular events (MACE) following hospital admission for acute coronary syndrome (ACS) is lacking. The objectives of this study were: 1) to describe population trends for outcomes, risk factors, and medication prescribing patterns post-ACS and 2) to identify factors associated with recurrent MACE.

Methods

A retrospective cohort study of 4,884 post-ACS patients admitted at a large integrated healthcare system between 2015-2021 was performed to investigate the relationship between recurrent MACE (ACS, cerebrovascular events, all-cause mortality, and unplanned revascularization), modifiable risk factor trends, and medical therapy prescribing patterns. Patients were separated into 2 cohorts based upon whether they experienced recurrent MACE following the initial hospitalization. Data were obtained via programmatic extraction from the electronic health record. Descriptive statistics were performed. Generalized linear models were used to assess risk factor trends and pairwise comparisons were performed between time points.

Results

Median length of follow-up after ACS was 31.2 months. Recurrent MACE occurred in 28% of patients. Despite 95.9% of all patients receiving prescriptions for high-intensity statins, >40% did not achieve LDL-C goal of <70 mg/dL, and only 11.6% and 2.6% of all patients were prescribed ezetimibe or proprotein convertase subtilisin kexin type 9 inhibiting monoclonal antibodies, respectively. Although >30.0% of patients had triglycerides ≥150 mg/dL at all time points, ≤6% were prescribed any non-statin triglyceride lowering therapy and 0.6% were prescribed icosapent ethyl. Persistent hypertriglyceridemia (≥150 mg/dL) was associated with recurrent MACE at 6-, 12-, and 24-months post-ACS (p<0.05), and the relative risk ranged between 1.20-1.35 at those timepoints.

Conclusions

This study demonstrates the need for more comprehensive post-ACS care to address residual cardiometabolic risk factors and suboptimal prescribing patterns for indicated therapies. Targeted strategies are needed to address hypertriglyceridemia for cardiovascular risk reduction.

Clinical Perspective

1)

What is new?

This retrospective cohort study of post-acute coronary syndrome (ACS) patients addressed significant gaps in the literature by performing a comprehensive analysis of all major modifiable risk factors and medical therapy prescribing patterns to describe secular trends and identify factors associated with recurrent MACE.

Although all modifiable risk factors were suboptimally controlled, only hypertriglyceridemia (>150 mg/dL) was significantly associated with recurrent MACE.

Despite >95% of patients being on high-intensity statins, >40% of post-ACS patients did not achieve LDL-C goal of <70 mg/dL and there was suboptimal intensification of lipid-lowering therapies proven to reduce residual cardiovascular risk.

2)

What are the clinical implications?

Targeted strategies are needed to address elevated LDL-C and hypertriglyceridemia in the post-ACS population.

Implementation strategies to educate clinicians may help to improve medical therapy prescribing patterns for secondary prevention through treatment of cardiometabolic disease.