A ‘First-Time-Right’ strategy in secondary prevention of coronary artery disease: Rationale and design of the prospective, temporally controlled observational GOLDEN study

Introduction After an acute coronary syndrome (ACS) or coronary revascularisation, the risk of recurrent vascular events remain substantial. Despite clear guideline recommendations, secondary prevention and long-term adherence to preventive treatment is often suboptimal. Current secondary prevention strategies typically involve initiating a limited number of pharmacologic therapies during hospitalisation, followed by sequential intensification after discharge to achieve individualized guideline-recommended targets. However, this strategy is prone to therapeutic inertia and negatively affects patient motivation and long-term adherence. We hypothesise that a 'first-time-right' strategy, where individualised, guideline-based pharmacological treatment is proactively initiated during hospitalisation, can improve risk factor control and adherence compared to current practice, and thereby reduce major cardiovascular events. Methods and analysis GOLDEN (Guided Optimisation for Long-term Disease rEduction in secoNdary Prevention of cardiovascular disease) is a prospective, temporally controlled observational cohort study aiming to include 5,586 patients hospitalised for ACS or coronary revascularisation. A guidelines-based ‘first-time-right’ pharmacological optimisation strategy will be compared to current practice on the 3-year incidence of cardiovascular death, myocardial infarction, stroke, or ischemia-driven revascularisation (4-point MACE). This strategy targets both patients and healthcare professionals and aims to utilise the teachable moment during hospitalisation to optimise pharmacological strategies, apply key behavioural principles to improve adherence, and reframe follow-up from reactive up-titration to proactive de-escalation. A pocket card and online tool will be provided to check applicable guidelines during hospitalisation and formulate follow-up recommendations. An on-site training visit and communication aids are intended to support implementation and promote adherence. Summary This study will evaluate the effects of a ‘first-time-right’ strategy - focused on early in-hospital initiation and optimisation of guideline-based pharmacotherapy after acute coronary syndrome or coronary revascularisation - on the risk of recurrent MACE compared to current practice.