Therapeutic inertia in achieving targeted levels of LDL after myocardial infarction

    Authors

    Keywords

    acute coronary syndrome, dyslipidemia, therapeutic inertia, treatment goals

    DOI

    https://doi.org/10.15836/ccar2024.368

    Full Text

    **Introduction**: There are many trials who have demonstrated that lower low-density lipoprotein-cholesterol (LDL-C) levels after acute coronary syndrome (ACS) are associated with lower cardiovascular event rates (1). The current guidelines for secondary prevention recommend lowering LDL-C to 2) | 28.9±4.9 | 29.1±4.4 | 29.0±4.6 | | Medical history Hypertension, n (%) Diabetes, n (%) Coronary artery disease, n (%) Peripheral artery disease, n (%) | 512 (75.6%) 167 (25.7%) 111 (16.4%) 60 (8.9%) | 991 (74.2%) 310 (23.2%) 196 (14.7%) 185 (13.9%) | 1503 (74.7%) 477 (23.7%) 307 (15.3%) 245 (12.2%) | | ACS type STEMI NSTEMI UAP | 384 (56.7%) 288 (42.5%) 5 (0.7%) | 724 (54.2%) 596 (44.6%) 15 (1.1%) | 1108 (55.1%) 884 (43.9%) 20 (1.5%) | [†] ACS = acute coronary syndrome; STEMI = acute ST-elevation myocardial infarction; NSTEMI = non-ST-elevation myocardial infarction; UAP = unstable angina pectoris **Conclusion**: Our analysis shows that lipid-lowering treatment is suboptimal and needs significant improvement. Earlier control visits with therapeutic interventions should be performed. Also, earlier high intensity statin combination therapy should be encouraged.

    Literature

    1. Ference BA, Ginsberg HN, Graham I, Ray KK, Packard CJ, Bruckert E, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2017 August 21;38(32):2459–72. https://doi.org/10.1093/eurheartj/ehx144
    2. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 October 12;44(38):3720–826. https://doi.org/10.1093/eurheartj/ehad191
    Cardiologia Croatica
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    Therapeutic inertia in achieving targeted levels of LDL after myocardial infarction

    Extended Abstract
    Issue11-12
    Published
    Pages368
    PDF via DOIhttps://doi.org/10.15836/ccar2024.368
    acute coronary syndrome
    dyslipidemia
    therapeutic inertia
    treatment goals

    Authors

    Tomislav Čikara*ORCIDDubrava University Hospital, Zagreb, Croatia
    Irzal HadžibegovićORCIDDubrava University Hospital, Zagreb, Croatia
    Miroslav RagužORCIDDubrava University Hospital, Zagreb, Croatia
    Marin PavlovORCIDDubrava University Hospital, Zagreb, Croatia
    Nikola PavlovićORCIDDubrava University Hospital, Zagreb, Croatia
    Petra VitlovORCIDDubrava University Hospital, Zagreb, Croatia
    Petar LišnjićORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Šime ManolaORCIDDubrava University Hospital, Zagreb, Croatia
    Ivana JurinORCIDDubrava University Hospital, Zagreb, Croatia

    *Correspondence email: t.cikara@gmail.com

    Full Text

    Introduction: There are many trials who have demonstrated that lower low-density lipoprotein-cholesterol (LDL-C) levels after acute coronary syndrome (ACS) are associated with lower cardiovascular event rates (1). The current guidelines for secondary prevention recommend lowering LDL-C to <1.4 mmol/L or ≥50% LDL-C reduction from baseline values (2). Therapeutic inertia, defined as the failure to initiate or intensify therapy in a timely manner according to evidence-based clinical guidelines, is a key reason for not achieving those treatment goals. We conducted a study to find out how successful we are in achieving current recommended treatment goals for LDL-C levels in secondary prevention.

    Patients and Methods: We conducted a single-center registry-based study including patients who were hospitalized between January 2017 and September 2023 with ACS. LDL-C levels were measured and compared at the time of hospitalization and at 12-month follow-up.

    Results: This single-center registry-based study included 2012 patients admitted with ACS. Baseline characteristics of the study groups are given in Table 1. At discharge, statins were prescribed in 99.1% of patients. Alone in 96.5% of patients (96.2% of which at high doses), in 2.6% of cases in combination with ezetimibe and in one case in combination with proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9). Mean LDL-C level at admission was 3.46±1.16 mmol/L. There was a significant reduction in LDL-C levels on control visit, 3.46±1.16 vs 1.94±0.80, p<0.0001. After a 12 month follow up 678 (33.7%) of patients achieved a target LDL-C <1.4 mmol/L or ≥50% LDL-C reduction from baseline values. In that period only 110 (5.5%) patients had therapy intervention by cardiologist or general practitioner. 49 patients (47.1%) of the patients that had therapy intervention achieved a target LDL-C. 27 patients (50.9%) who started statin in combination with ezetimibe at hospitalization reached therapy goals. In comparison, 650 patients (33.2%) reached therapy goals on statins only (including high dosage).

    TABLE 1: Baseline characteristics of the study population. Group A, patients who the achieved therapy goal of a target LDL-C <1.4 mmol/L or ≥50% LDL-C reduction from baseline values 12 months after acute coronary syndrome . Group B, patients who did not achieve the therapy goal.

    Demographics Age, median (IQR) (years) Age range (years)
    Group A (n=677)
    63 (56-72) 20-92
    Group B (n=1335)
    64 (55-71) 29-96
    Total (n= 2012)
    63 (55-72) 20-96
    Sex Male, n (%) Female, n (%)
    Group A (n=677)
    483 (71.3%) 194 (28.7%)
    Group B (n=1335)
    944 (70.7%) 391 (29.3%)
    Total (n= 2012)
    1427 (70.9%) 585 (29.1%)
    Body mass index, mean±SD (kg/m2)
    Group A (n=677)
    28.9±4.9
    Group B (n=1335)
    29.1±4.4
    Total (n= 2012)
    29.0±4.6
    Medical history Hypertension, n (%) Diabetes, n (%) Coronary artery disease, n (%) Peripheral artery disease, n (%)
    Group A (n=677)
    512 (75.6%) 167 (25.7%) 111 (16.4%) 60 (8.9%)
    Group B (n=1335)
    991 (74.2%) 310 (23.2%) 196 (14.7%) 185 (13.9%)
    Total (n= 2012)
    1503 (74.7%) 477 (23.7%) 307 (15.3%) 245 (12.2%)
    ACS type STEMI NSTEMI UAP
    Group A (n=677)
    384 (56.7%) 288 (42.5%) 5 (0.7%)
    Group B (n=1335)
    724 (54.2%) 596 (44.6%) 15 (1.1%)
    Total (n= 2012)
    1108 (55.1%) 884 (43.9%) 20 (1.5%)

    ACS = acute coronary syndrome; STEMI = acute ST-elevation myocardial infarction; NSTEMI = non-ST-elevation myocardial infarction; UAP = unstable angina pectoris

    Conclusion: Our analysis shows that lipid-lowering treatment is suboptimal and needs significant improvement. Earlier control visits with therapeutic interventions should be performed. Also, earlier high intensity statin combination therapy should be encouraged.

    Literature

    1. 1.
      Ference BA, Ginsberg HN, Graham I, Ray KK, Packard CJ, Bruckert E, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2017 August 21;38(32):2459–72.DOI
    2. 2.
      Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 October 12;44(38):3720–826.DOI