Evaluation of lipid management following ACS

Low-density lipoprotein cholesterol control following acute coronary syndrome in non-Western countries: A real-world ACOSYM registry

Lipid management strategies are not completely adopted and optimized in real-world clinical practice in Asia-Pacific (APAC) and non-Western countries and are still not sufficiently efficacious in many patients for achieving low-density lipoprotein cholesterol (LDL-C) targets.

Key Takeaway

• Among post-acute coronary syndrome (ACS) patients from non-US, non-Western European countries:
  • A large proportion of patients did not achieve the LDL-C goal of <70 mg/dl, as recommended by most lipid management guidelines.
  • More than half (52.9%) of the primary objective population did not achieve this target; ~20% of this population had LDL-C >100 mg/dl.
  • 81.4% patients failed to reach the more aggressive European recommendation for high-risk patients (LDL-C <50 mg/dl).

Why This Matters

• Approximately half of the global burden of cardiovascular disease is concentrated in the APAC region.
• LDL-C target attainment in certain countries in Asia, Eastern Europe, and the Middle East is suboptimal.
• The Acute Coronary Syndrome Management (ACOSYM) registry aimed to describe LDL-C levels following ACS in patients from nine non-Western countries and to understand factors associated with LDL-C control post-ACS.

Study Design

• The ACOSYM is a multinational, multicenter, prospective observational registry evaluating LDL-C goal achievement and lipid-lowering therapy use in patients with recent ACS in nine countries: Colombia, Hong Kong, Indonesia, Malaysia, Russia, Saudi Arabia, Singapore, Taiwan, and Thailand.
• Inclusion criteria: Recent (≤12 weeks) hospitalization for ACS (unstable angina or myocardial infarction) and age ≥18 years
• Exclusion criteria: Unable or unwilling to provide informed consent, anticipated life expectancy <6 months, participation in any clinical trial at enrollment, or pregnancy
• Primary objective: Proportion of post-ACS patients reaching four LDLC targets (<130, <100, <70, and <50 mg/dl) within 6 months

Key Results

• Of 1,581 patients, 1,567 were eligible (mean age, 59.9 ± 11.6 years).
  • 992/1,567 (63.3%) patients had at least one LDL-C measured at >14 days following ACS admission (primary objective population).
  • Of these 992 patients, 47.1% achieved LDL-C <70 mg/dl and 52.9% had persistently elevated LDL-C (>70 mg/dl).
• In multivariable analysis, the likelihood of not achieving target LDL-C <70 mg/dl increased with increasing baseline LDL-C level.
• The likelihood of not achieving LDL-C targets was higher in patients receiving no or low/moderate statins at discharge than in those receiving high-intensity statins at discharge (<70 mg/dl target: odds ratio = 3.15; 95% confidence interval [CI]: 2.06–4.84).
• Primary objective population (n = 992): 32.1% vs 97.8% received statins before ACS admission vs at discharge (high-intensity statin: 39.3% vs 80%).
  • At discharge, 99.1% vs 98.9% patients achieving LDL-C goals of <70 vs <50 mg/dl were on statins.
  • Among the 776 patients on high-intensity statins at discharge, 81.8% (95% CI: 78.9–84.5) and 51.2% (95% CI: 47.6–54.7) achieved LDL-C goals of <100 and <70 mg/dl, respectively.
  • Among 194 patients on low/moderate-intensity statins at discharge, 74.2% (95% CI: 67.5–80.2) and 33.0% (95% CI: 26.4–40.1) achieved LDL-C goals of <100 and <70 mg/dl, respectively.
• Of those with a baseline and follow-up LDL-C (n = 733/992), 72.7%, 17.7%, and 9.6% reduced LDL-C level to a lower LDL-C category, remained in the same category, and had increased LDL-C level, respectively.

Limitations

• It was difficult to determine whether an increase or decrease in LDL-C over time was due to treatment profiles, patient adherence, or a combination of both.
• A large proportion of post-ACS patients from APAC and non-Western countries do not measure LDL-C levels post-ACS.
• A possible selection bias might exist as a large proportion of patients were on high-intensity statins.
• “Baseline” LDL-C value could have been assessed after up-titration/initiation of statin therapy owing to ACS events, underestimating true pre-ACS hospitalization LDL-C level.
• Lipid control may have been overestimated as the registry did not include patients who failed to see a physician at follow-up.
• Possible selection or reporting bias may suggest that nonachievement of LDL-C target post-ACS may underestimate the reality of LDL-C levels in this population.