Effects of a stepwise, structured LDL-C lowering strategy in patients post-acute coronary syndrome

Aaram Omar Khader, Tinka van Trier, Sander van der Brug, An ho Liem, Bjorn E. Groenemeijer, Astrid Schut, Harald T. Jorstad, Fabrice M.A.C. Martens, Marco A.M.W. Alings

Research output: Contribution to journalArticleAcademicpeer-review

2 Citations (Scopus)

Abstract

Objective: Low-density lipoprotein cholesterol (LDL-C) lowering constitutes a cornerstone of secondary prevention of atherosclerotic cardiovascular disease (ASCVD), yet a considerable number of patients do not achieve guideline-recommended LDL‑C targets. The 2016 European guidelines recommended titration of LDL‑C lowering medication in a set number of steps, starting with oral medication. We aimed to investigate the effects of this stepwise approach in post-acute coronary syndrome (ACS) patients. Methods: In a multicentre, prospective, non-randomised trial, we evaluated a three-step strategy aiming to reduce LDL‑C to ≤ 1.8 mmol/l in post-ACS patients with prior ASCVD and/or diabetes mellitus. Steps, undertaken every 4–6 weeks, included: 1) start high-intensity statin (HIST); 2) addition of ezetimibe; 3) addition of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i). The primary outcome was the proportion of patients achieving LDL-C ≤ 1.8 mmol/l after Steps 1 and 2 (using oral medications alone). Secondary outcomes examined the prevalence of meeting the target throughout all steps (https://onderzoekmetmensen.nl/nl/trial/21157). Results: Out of 999 patients, 84% (95% confidence intervals (CI): 81–86) achieved the LDL‑C target using only statin and/or ezetimibe. In an intention-to-treat analysis, the percentages of patients meeting the LDL‑C target after each step were 69% (95% CI: 67–72), 84% (95% CI: 81–86), and 87% (95% CI: 85–89), respectively. There were protocol deviations for 23, 38 and 23 patients at each respective step. Conclusion: Through stepwise intensification of lipid-lowering therapy, 84% of very high-risk post-ACS patients achieved an LDL‑C target of ≤ 1.8 mmol/l with oral medications alone. Addition of PCSK9i further increased this rate to 87% (95% CI: 85–89).

Original languageEnglish
Pages (from-to)206-212
Number of pages7
JournalNetherlands heart journal
Volume32
Issue number5
Early online date26 Jan 2024
DOIs
Publication statusPublished - May 2024

Keywords

  • Cholesterol
  • Ezetimibe
  • Hydroxymethylglutaryl-CoA reductase inhibitors
  • Hyperlipidemia/drug therapy
  • LDL‑C
  • Proprotein convertase subtilisin/kexin type 9 inhibitors

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