Lipid management in patients with coronary artery disease at risk of a first major atherosclerotic cardiovascular event: findings from the VESALIUS-REAL global study

Background/Introduction Patients with established atherosclerotic cardiovascular disease (ASCVD) without prior myocardial infarction (MI) or stroke are at substantial risk of major adverse cardiovascular events (MACE).1 Guidelines recommend intensive lipid-lowering therapy (LLT) to mitigate this risk by achieving low levels of low-density lipoprotein cholesterol (LDL-C).2 However, real-world patterns of LLT use and attainment of guideline-recommended LDL-C goals in this high-risk population remain poorly characterised across diverse global healthcare settings. Purpose To describe lipid management patterns and LDL-C goal achievement in patients with coronary artery disease (CAD) and no prior MI or stroke who are at risk of their first MACE from 11 databases from North America, Europe, and Asia-Pacific. Methods Patients aged ≥ 50 years with either CAD, atherosclerotic cerebrovascular disease, peripheral artery disease (PAD), or high-risk diabetes mellitus (DM; defined as DM with microvascular complications or chronic insulin use), plus additional cardiovascular (CV) risk factors and elevated lipid levels, but no history of MI, stroke, or end-stage renal disease, were identified between 2017 and 2022 from the VESALIUS-REAL global study.3 Elevated lipids were defined as ≥ 1 measurement of either LDL-C ≥ 2.3 mmol/L, non–high-density lipoprotein cholesterol ≥ 3.1 mmol/L, or apolipoprotein B ≥ 0.8 g/L. The index date was the earliest date on which all eligibility criteria were met. A total of 1,126,756 patients were included in VESALIUS-REAL study. Demographics, comorbidities, LLT use, LLT intensification, LDL-C testing, and LDL-C goal achievement based on local guidelines of patients with documented CAD were summarised in the current study. Results Among 449,030 patients with CAD (48% female), 6% had atherosclerotic cerebrovascular disease, 3% had PAD, and 7% had high-risk DM (Table 1). At index, 42% of patients were on LLT and statin monotherapy was the predominant regimen (87%; Table 2). For patients not on LLT at index, only 29% initiated LLT within 1 year post-index; for those who had ongoing LLT, 12% intensified their LLT within 1 year post-index. Only 50% of patients underwent LDL-C testing within 1 year of follow-up (n = 167,439), and 24% met their local guideline-recommended LDL-C goal. Conclusions In this large, global, real-world study, most patients with CAD at risk of a first MACE were undertreated with LLT and did not achieve recommended LDL-C levels. These findings highlight substantial gaps between guideline recommendations and real-world practice, and underscore a missed opportunity for earlier optimisation of lipid management to prevent initial MACE in patients with established CAD.