Singapore expert consensus on optimising lipid-lowering strategies in acute coronary syndrome: A modified Delphi study

Introduction: Acute coronary syndrome (ACS) carries a high early risk of recurrent events, yet time-to-target low-density lipoprotein cholesterol (LDL-C) is often prolonged, and goal attainment is suboptimal in real-world practice. The authors aimed to develop expert consensus recommendations for post-ACS lipid management in Singapore, focusing on LDL-C targets, pharmacotherapy, escalation strategies, and implementation tools to improve adherence and reduce therapeutic inertia. Method: A modified Delphi methodology was employed with a panel of 10 members. Evidence was synthesised from guidelines, randomised trials, metaanalyses, and observational studies. Thirty-two statements were drafted across 5 domains (LDL-C targets; timing/ monitoring; pharmacotherapy; special populations; implementation/adherence/health-system strategies) and rated anonymously on a 5-point Likert scale. Consensus thresholds were defined as high (≥75% concordant), moderate (55-74%), and low (<55%). Results: After the final round, 30 of 32 statements achieved high consensus, and 2 received low consensus. Key agreements included measuring lipids within 24 hours of admission and retesting at 4-6 weeks, early initiation of high-intensity statins, and upfront combination therapy with statin + ezetimibe when monotherapy is unlikely to achieve the goals. Consideration of a proprotein convertase subtilisin/kexin type 9 inhibitor at discharge was recommended if LDL-C remained >1.4 mmol/L. Special considerations included older adults, familial hypercholesterolaemia, lower statin adherence among women, and the role of lipoprotein(a). The panel recommended adopting objective metrics, integrating electronic health record prompts, and developing localised pathways to harmonise care transitions. Conclusion: The consensus recommendations provide a tailored approach for Singapore, emphasising early action, proactive escalation, and systems-level interventions to improve post-ACS outcomes.