The difference between guideline based lipid optimisation and real-world practice in a very high risk population
Authors: Ghazanfar A , Campbell R , Randall R , Child N 
Published: October 2024

Abstract

Background
Elevated low-density lipoprotein cholesterol (LDL-C) is an important risk factor for the progression of cardiovascular disease and early optimisation of lipid lowering therapy following an acute coronary syndrome (ACS) or stroke is associated with improved outcomes. Recent guidelines have advocated the use of combination lipid-lowering therapy and achieving very low LDL-C concentrations.Purpose
To identify if optimal lipid management in high risk patients has occurred.

Methods
A retrospective analysis of high-risk patients with a prior history of ACS or stroke presenting with a further subsequent ACS/stroke from January 2022 to December 2022 in a UK District General Hospital was performed. Lipid lowering therapy in primary care in the 18 months leading up admission, inpatient admission and subsequent 12 month post admission (delivered through the cardiac rehabilitation service post ACS and via primary care post stroke) was compared to our regional secondary prevention lipid lowering pathway. This patient group, with recurrent events, was selected as represents the "very high risk group" and had been through various clinicians multiple times increasing the opportunity to treat to guidance.

Results
102 very high risk patients were admitted within the 12 month period. Only 79/102 patients had lipid profile in preceding 18 months and only 19% were compliant with the standard secondary prevention guidelines (20/102 patients high intensity statins), mainly due to reduced intensity statin doses (60%) and no lipid lowering medications (15%). A significant proportion of patients did not have any lipid blood tests during their index admission (no lipid profile 21% in stroke group vs 77% in ACS group) and whilst there was a significant inpatient escalation in lipid therapy this was mainly confined to high dose statins, and seen more clearly in the ACS group (ACS 65% vs stroke 21%). During the 12 months following admission a significant number of patients had no further lipid profiles (21% ACS vs 57% stroke) and minimal further optimisation of lipid management. Further escalation following high intensity statins were rare with only 5 / 102 patients receiving high intensity statin plus ezetimibe, 1 patient receiving statin/ ezetimibe/ PCSK9 inhibitor. Only 45% of patients achieved the guideline target of LDL &lt; 1.8 mmol/L and only 18% achieved the ESC target of LDL &lt;1.4 during 1 year follow up.

Conclusion
Although lipid guidelines have changed in recent year’s clinical real-world practice locally has not reflected these important developments, even in a very high-risk group patients are not benefiting from established evidence-based interventions. A majority of our ACS patients did not have a lipid profile blood test during their admission highlighting the fact that whilst guidelines have progressed significantly over the last few years the clinical importance of lipid optimisation in practice has not been appreciated by many of the cliniciansResults