A significant gap remains in LDL-C targets despite the high prescription rate of oral intensive lipid-lowering therapy in post-ACS: there is a need for more widespread usage of PCSK9 inhibitors

Background Patients suffering an acute coronary syndrome (ACS) are at very high risk for recurrent cardiovascular events. According to 2019 ESC/EAS Guidelines for the Management of Dyslipidaemias in-hopsital high-intensity statin (HIS) at the highest tolerated dose is given and ezetimibe (EZ) is added at 4-6 weeks after discarge if LDL-cholesterol (LDL-C) remains ≥55 mg/dL. If the combination of HIS+EZ fails to achieve the LDL-C target, then a proprotein convertase subtilisin/kexin type 9-inhibitor (PCSK9i) is recommended. Purpose To explore the lipid-lowering therapy (LLT) trends at discharge and 6 months later in patients suffering an ACS. Methods CALLINICUS-Hellas Registry is an ongoing prospective multicenter (18 hospitals of all geographical areas of Greece) observational study evaluating the adherence to LLT and the achievement of LDL-C targets at 6 and 24 months after the index event among ACS patients. Results A total of 1790 consecutive patients with ACS were recruited during the last 18 months. Prior admission 625 patients (34.9%) were on LLT. In particular, 140 (7.8%) were on HIS (monotherapy), 80 (4.5%) on HIS+EZ, 404 (22.6%) on moderate intensity statin (MIS)±EZ or EZ (monotherapy) and 1 (0.06%) on PCSK9i. At discharge HIS (monotherapy) were taking 698 patients (39%) and combination of HIS+EZ 924 (51.6%). On moderate intensity statin (MIS) were 74 (4.1%) patients, on combination of MIS+EZ 37 (2.1%), on monotherapy with EZ 4 (0.22%) and 18 (1%) patients did not receive any LLT. At 6 months after discharge follow-up was completed in 1340 patients. Sixty-five patients (4.9%) were not taking LLT while 75 (5.6%) had not performed lipid tests after discharge despite the instructions for this on the discharge letter. Among those on LLT (n=1275): 451 (35.4%) were on HIS, 657 (51.5%) on HIS+EZ, 70 (5.5%) on MIS, 56 (4.4%) on MIS+EZ, 18 (1.4%) of combination of fibrates+statins, 8 (0.63%) on PCSK9i and 4 (0.31%) on EZ only. The LDL-C target <55 mg/dL at 6 months had been achieved by 514 (40.8%) of the 1260 patients who had their lipids measured and were on LLT. The figure presents the proportion of ACS patients on HIS and HIS+EZ prior admission, at discharge and 6 months later. Conclusions Despite the significant improvement in the prescription of HIS and HIS+EZ in post-ACS patients both at discharge (~90%) and at 6 months later (~87%) only 40% achieve the optimal LDL-C target. This therapeutic gap is mainly due to the very low usage (<1%) of PCSK9i and highlights the need for health authorities to simplify their approval process.