Lipid-lowering intensification post-ACS in very high-risk patients on high-intensity statins: Insights from a mayo clinic registry

Background/Synopsis

After experiencing acute coronary syndrome (ACS), particularly in very high-risk (VHR) patients, current guidelines recommend a 50% reduction in low-density lipoprotein (LDL) levels, aiming for an LDL target below 55 mg/dL. We hypothesize that a significant number of VHR patients who present with ACS and are already on high-intensity statins (HIS) do not have their lipid-lowering therapy (LLT) intensified. This leads to an underutilization of non-statin therapies that could help achieve these LDL goals.

Objective/Purpose

To quantify the practice gap in intensifying LLT for patients who present with acute coronary syndrome while already on high-intensity statins.

Methods

We reviewed all patients from January 2019 to August 2024 who underwent percutaneous coronary intervention (PCI) for ACS at Mayo Clinic Arizona and were already on HIS. Ninety-one patients met these criteria, and of these, 45 were followed at Mayo Clinic and had repeat lipid panels drawn between 2 and 12 months after the ACS event. A one-tailed, two-sample t-test was used to determine statistical significance.

Results

Out of the 91 patients presenting with ACS already on HIS, 59 (64.8%) maintained the same LLT. Among these patients, 65 (71.4%) met the American College of Cardiology (ACC) criteria for VHR, but 22 of these (66.2%) did not have their therapy intensified. Notably, 37 patients (45.7%) had already achieved their LDL target upon presentation, with a median LDL of 60 mg/dL (54 mg/dL for VHR). The mean change in LDL for the group that had their LLT increased was -15.1% (standard deviation = 33.3%), while the mean change for the unchanged therapy group was significantly higher at +14.6% (standard deviation = 65.4%) (p = 0.0455).

Conclusions

Our analysis highlights a significant gap between best practices and the actual intensification of LLT in VHR patients on HIS following ACS. Approximately 66% of these patients did not have their LLT adjusted. Additionally, 45% of patients on HIS had already achieved their LDL target upon presentation. Adjunctive therapies such as ezetimibe and PCSK9 inhibitors were underutilized in the acute care setting. There is a pressing need for further initiatives to improve LDL control in this high-risk population. We hope our study will encourage the initiation of non-statin therapies during hospitalization, promote the establishment of educational programs for physicians, and lead to the implementation of automated prompts in electronic medical records when appropriate.