Impact of ESC Guidelines implementation on lipid lowering strategy in a tertiary hospital cohort of STEMI patients: Can we aspire to do better than the EUROASPIRE V registry?
Authors: Ferrer M , Gonzalez C , Santalo M , Taroncher C , Gual M , Duran A , Barros A J , Bragagnini W , Garcia-Moll X , Lopez L , Rodriguez L , Vila M , Sionis A 
Published: November 2023

Abstract

Background
Treatment with LDL-C-lowering-drug therapy (LLT) is essential in the management of patients who have suffered an acute coronary syndrome. The latest 2019 ESC/EAS Guidelines for the management of dyslipidaemias recommend an LDL-C target of &lt;55mg/dL and 50% reduction in these very high risk patients. However, the impact of these recommendations on contemporary LLT prescription is uncertain.

Purpose
To analyse the impact of the publication of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias on the prescription of LLT in our centre in patients who have suffered a ST elevation myocardial infarct (STEMI) and its impact on the achievement of treatment objectives and major adverse cardiovascular events (MACEs) in the first year of treatment.

Methods
All patients who suffered a STEMI at our centre in 2018 and 2021 were retrospectively registered. We compared baseline characteristics, ESC Guidelines objectives achievement at first follow-up visit and MACE in the first 1 year of treatment in both groups. The 2016 ESC Guidelines objective was defined as an LDL-C &lt;70mg/dL and the 2019 ESC Guidelines objective was defined as an LDL-C &lt;55 mg/dL. MACEs were defined as a combination of mortality, acute coronary syndrome, stroke, peripheral ischemia and need for revascularization. Those patients whose follow-up time until LDL-C after discharge was greater than 1 year were excluded from the final analysis.

Results
Of a total 726 STEMI patients, 520 patients were included in the final analysis. 239 in 2018 and 281 in 2021. No significant differences were found in baseline characteristics. LDL-C at admission was 115.7±39.3 mg/dL in 2018 and 110.6±38.6 mg/dL in 2021 (p 0.11). The prescription of ezetimibe in association with a high potency statin at discharge was significantly higher in 2021 (125 patients; 33.6%) compared to 2018 (17 patients; 5.07%) (p&lt;0.001) and it was independently associated with the presence of prior lipid-lowering treatment (p &lt; 0.011) and higher LDL-C at admission (p &lt; 0.001). In 2018 there were 105 patients (50.24%) with LDL-C &lt;70mg/dL and 52 patients (24.88%) with LDL-C &lt;55mg/dL. This was significantly lower than in 2021, with 178 patients (66.67%) with LDL-C &lt;70mg/dL and 112 patients (41.95%) with LDL-C &lt;55mg/dL (p&lt;0.001). MACEs after 1 year of treatment occurred in 27 patients (8.88%) in 2018 and in 31 patients (9.06%) in 2021 (p 0.935).

Conclusions
The adoption of the 2019 ESC/EAS Dyslipidaemia Guidelines recommendations has fostered a change in the LLT strategy in our centre leading to a greater number of patients reaching the LDL-C goal. Unfortunately, nearly 60% of them still have an LDL-C &gt;55 mg/dL. This should prompt us to seek structured clinical pathways in order to improve our results.Figure 1