Prognostic impact of achieving LDL cholesterol guidelines-recommended target in secondary prevention: a real-world study
Authors: Casula M , Taietti I , Galazzi M , Zeqaj I , Fortuni F , Cornara S , Somaschini A , Leonardi S , Camporotondo R , Totaro R , Ferlini M , Gnecchi M 
Published: October 2021

Abstract

Background
Lipid management plays a key role in secondary prevention after acute coronary syndrome. The 2019 European Society of Cardiology guidelines recommend a more ambitious target than the previous guidelines version (i.e., to achieve LDL cholesterol [LDL-C] &lt;55 mg/dL, and to reduce it ≥50% form baseline vs LDL-C&lt;70 mg/dl or reduced ≥50% form baseline). Currently, data on the reduction of cardiovascular events in patients achieving the 2019 goals in a real-world population are missing.

Purpose
The aim of this study was to determine the risk of major adverse cardiovascular events (MACE) during follow-up in post myocardial infarction (PMI) patients according to the achievement of the guidelines-recommended goals in terms of LDL-C reduction.

Methods
We conducted a retrospective analysis of a monocentric observational registry prospectively enrolling patients admitted to our hospital for ST segment elevation myocardial infarction and followed-up in our dedicated PMI ambulatory. The analysis considered the patients enrolled between January 2011 and February 2019. Demographical and clinical data were extracted from a dedicated digital database, and the clinical events occurred during follow-up were obtained by telephone interviews or clinical records. We considered a combined endpoint of MACE defined as all-cause death, non-fatal MI, non-fatal stroke and unplanned revascularization. LDL-C was collected at baseline and at 1, 6 and 12 months after the event. The lower value collected at follow-up was used to define the achievement of the target goals. We conducted a Kaplan-Meier analysis and log-rank test comparing patients who achieved LDL-C &lt;55 mg/dL and ≤50% from baseline (group 2019) vs those with LDL-C &lt;70 mg/dL or ≤50% from baseline (group 2016). Continue variable are presented as median (interquartile range).

Results
A total of 1201 patients (23% female) were included in our analysis. Median age was 63 (54–72) years, 56% had hypertension, 17% diabetes, and 38% were smoker. Baseline LDL-C was 123 (97–148) mg/dL, the median LDL-C at follow-up was 63 (52–78) mg/dL, significantly reduced from baseline (P&lt;0.0001). Between 6 and 12 months 83% of patients were treated with statin therapy alone (73% high intensity), and 17% with the addition of ezetimibe. The 2016 target was achieved in 828 patients (69%), while 270 patients (22.5%) obtained also the 2019 target. Median follow-up was 60 (40–77) months. The net incidence of MACE was 12.9% in group 2019 vs 23.7% in group 2016 (HR 0.61; 95% CI 0.42–0.88; P log-rank=0.0087; Number Needed to Treat=9; see Figure).

Conclusion
Our data from a real-world cohort of PMI patients emphasize the importance of achieving the guideline-recommended secondary prevention goals of LDL-C&lt;55 mg/dl and ≤50% from baseline in order to reduce MACE.

Funding Acknowledgement
Type of funding sources: None.