Uncontrolled hyperlidaemia is common in ACS patients according to new Australian research showing almost half of those hospitalised for the condition are not meeting lipid targets in the year after discharge.
Research published in the Medical Journal of Australia showed that 45% of patients hospitalised due to ACS did not meet the recommended targets of LDL-C (≤ 1.8 mmol/L) or total cholesterol (≤ 4 mmol/L) at 12 months.
The CONCORDANCE registry study provided data for 2,671 people discharged from hospital after ACS diagnosis, of whom 1,194 had not achieved lipid targets at their most recent follow‐up, including 876 (73%) who had been prescribed intensive lipid‐lowering therapy at discharge.
Factors associated with not meeting lipid goals included being over 65 and female gender, the study showed.
The study investigators said sex differences in the protective effect of HDL‐Cholesterol might lead some clinicians to underestimate cardiovascular risk in women. A secondary analysis showed that women were also more likely to not achieve the specific target of LDL-C levels.
“As LDL‐C levels are independent of those of HDL‐C, we concluded that higher HDL‐C levels did not appreciably influence whether women achieved lipid targets,” the authors said.
People who were already using lipid‐lowering therapy on admission or with higher cholesterol levels on admission, were also less likely to reach lipid level targets. This might be due to prior intolerance or ‘therapeutic inertia’, the researchers suggested.
Other factors linked to not achieving lipid targets included patients being prescribed fewer than four evidence‐based therapies or not prescribed intensive lipid‐lowering therapy on discharge.
The study showed 16% of people who had not achieved target levels were using moderate or low dose statin therapy, while 37% of people were using high‐intensity statin therapy without ezetimibe.
These results likely reflected the Australian ‘treat to target’ approach of titrating therapy to manage lipid levels in contrast to the US-style ‘fire and forget’ strategy of prescribing the highest dose tolerated by the patient.
“Optimising lipid levels in people at high risk of recurrent [ACS] could be achieved by dose escalation, combination therapies, and the adoption of newer lipid-lowering agents,” the study authors recommended, noting that PCSK9 inhibitors are now becoming accessible in Australia for patients at greatest risk of recurrent events.
Professor David Brieger, Head of Cardiology at Concord Repatriation General Hospital and a Professor of Medicine at the University of Sydney, said the study suggested clinicians needed to continue to be vigilant to lipid treatment in the months and years after ACS.
“Discharge prescription check lists would help but are rarely implemented in Australian hospitals in my experience,” he said. “Our data also suggests a de-escalation of hospital treatments in the months following discharge, which may not be in the patients’ best interests when we are trying to prevent recurrent events.”
Professor Brieger noted the indications for novel medications including PCSK9 inhibitors remained quite restrictive, with some challenges to their use.
“There is still some administrative work required to prescribe them which is a disincentive, and some patients do baulk at the injections,” he said.