Early and low for LDL cholesterol management post-MI
Patients with the earliest and largest LDL cholesterol reductions after myocardial infarction (MI) gain the most cardiovascular benefit, according to real-world data from a Swedish registry (1).
Although clinical trials clearly show the cardiovascular benefits of targeting lower LDL cholesterol levels in acute coronary syndrome patients (2), whether this is still the case in a real-world setting is less evident. This question was the focus of a report from a Swedish registry of post-MI patients.
Overall, 40,607 post-MI patients were included in the registry and followed for mortality and major cardiovascular events. Changes in LDL cholesterol between the MI and a 6- to 10-week follow-up visit were analysed.
Compared with patients with a smaller reduction (0.36 mmol/L or 14 mg/dL, equating to the 25th percentile), those with an LDL cholesterol reduction of 1.85 mmol/L or 72 mg/dL (equating to the 75th percentile) had a 23% lower risk of cardiovascular outcomes (a composite of cardiovascular mortality, MI, and ischaemic stroke), 32% lower cardiovascular mortality and 29% lower risk of all-cause death (Table 1). Importantly, the 10,995 (27%) patients prescribed a high intensity statin at discharge who achieved ≥50% reduction in LDL cholesterol levels had a lower incidence of all outcomes compared with those on a lower intensity statin.
Table 1. Comparison of benefit with larger versus smaller LDL cholesterol reduction*
|Endpoint||Hazard ratio (95% confidence interval)|
|Composite cardiovascular endpoint||0.77 (0.70-0.84)|
|Cardiovascular mortality||0.68 (0.57-0.81)|
|Ischaemic stroke||0.76 (0.62-0.93)|
|Heart failure hospitalization||0.73 (0.63-0.85)|
|Coronary artery revascularization||86 (0.79-0.94)|
|All-cause death||0.71 (0.63-0.80)|
* Comparing patients in the 75th versus 25th percentile for LDL cholesterol reduction
In conclusion, these findings strengthen support for early, aggressive LDL cholesterol lowering in the post-MI patient. Early use of high-intensity statin treatment is clearly beneficial. The issue for many patients, however, is being able to achieve LDL cholesterol goal on high intensity statin alone (3). While focusing on adherence and persistence to high-intensity statin therapy is clearly important, the report also vindicates a role for combination with non-statin therapy, ezetimibe or a PCSK9 inhibitor, to optimise benefit (4).
- Schubert J, Lindahl B, Melhus H, et al. Low-density lipoprotein cholesterol reduction and statin intensity in myocardial infarction patients and major adverse outcomes: a Swedish nationwide cohort study. Eur Heart J 2021;42:243-252. PUBMED https://pubmed.ncbi.nlm.nih.gov/33367526/
- Schwartz GG, Steg PG, Szarek M, et al. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome. N Engl J Med 2018;379:2097-2107. PUBMED https://pubmed.ncbi.nlm.nih.gov/30403574/
- De Backer G, Jankowski P, Kotseva K, et al. Management of dyslipidaemia in patients with coronary heart disease: Results from the ESC-EORP EUROASPIRE V survey in 27 countries. Atherosclerosis 2019;285:135-146. PUBMED https://pubmed.ncbi.nlm.nih.gov/31054483/
- Masana L, Ibarretxe D, Plana N. Reasons Why Combination Therapy Should Be the New Standard of Care to Achieve the LDL-Cholesterol Targets : Lipid-lowering combination therapy. Curr Cardiol Rep 2020;22(8):66. PUBMED https://pubmed.ncbi.nlm.nih.gov/32562015/