Low density lipoprotein cholesterol dynamics after successful revascularization and relation with prognosis

Aim Despite significant progress in the identification of high-risk individuals and their treatment, there are few real-world data focusing on the dynamics of LDL cholesterol levels and the subsequent major coronary events after successful coronary revascularization. Methods The study provides real-world data for patients with a history of coronary revascularization from 20 heart centers in Bulgaria, selected through the period of 01.04.2021 - 31.03.2022, and followed for mortality and major cardiovascular events from 01.04.2020 to 31.03.2023. Dynamics in LDL-C between the first and subsequent revascularization were analyzed. Results A total of 8272 patients with coronary revascularizations were included in Real World Evidence of Arterial Hypertension and Lipids Evaluation Dynamics (REVEALED) observational study. During three – year follow-up there were 2451 (29.6%) repeated revascularizations (n=2 in 1898 and n>2 in 553 patients with a mean number of 2.3 revascularizations per patient). Overall LDL-C levels decrease from 3.2 mmol/l (IQR 2.2-4.06) to 2.3 mmol/l (1.6-2.8) during the second and 2.2 mmol/l (1.5-2.6) during the last revascularization. The results were mainly driven by the reduction of LDL-C in the group of patients with baseline LDL-C>2.6 mmol/l (65.3%, delta of LDL-C – 37.5%) and to a lesser degree in the group of baseline LDL-C 1.8-2.6 mmol/l (19.9%, delta of LDL-C – 5.8%). In contrast, in the groups with baseline LDL-C < 1.4 mmol/l (6.26%) and 1.4-1.8 mmol/l (8.6%), an increase of subsequent LDL-C was noticed (delta of LDL-C 32.5% and 10.3% respectively) mainly related with therapy discontinuation or de-escalation. Within a different time window from 0 to 332 days, 286 patients (11.7%) reached LDL-C levels below 1.4 mmol (mean 1.1 mmol/l, median 1.14 mmol/l). Only 33 patients (11.5%) of those presenting with LDL-C < 1.4 mmol/l at first revascularization maintain the levels within the entire three-year follow-up. In this group of patients the lowest mortality rate and future revascularizations were noticed - 1.8% and 0.9 revascularizations per patient versus 4.2% and 1.7 in a group with an increase of LDL-C levels during follow-up (p<0,001). Conclusions The speed of achievement of LDL-C targets and the success of their sustained long-term maintenance had an impact on prognosis, which reaffirm the current guidelines recommendations. Our results highlight the serious difficulties in both goals in real practice. The main problems arise from the lack of sufficient emphasis on therapy maintenance and adherence monitoring in patients with near-target levels, as well as insufficient intensification in the remaining patients.