Longitudinal trends in statin prescribing and LDL-C control prior to acute myocardial infarction (AMI) in France: we continue to “miss the mark”

Background Evidence supports LDL-C lowering therapy for reducing first and recurrent AMI. While guidelines have moved towards increasingly stringent LDL-C targets, substantial gaps in control persist in clinical practice. "Real-world" representative data on trends in statin use and LDL-C levels before AMI in France are limited. Purpose To examine trends and determinants of statin prescribing and LDL-C control prior to AMI in France over two decades, and their impact on in-hospital mortality. Methods Data were pooled from the FAST-MI nationwide periodic surveys (conducted every 5 years between 2005 and 2015) and the FRENCHIE longitudinal cohort (2019-2022). Both included patients with AMI admitted to 24/7 PCI-capable centres across France. Statin prescription and LDL-C levels were assessed on admission. Patients were stratified by prior history of atherosclerotic cardiovascular disease (ASCVD): coronary artery disease, peripheral arterial disease, or ischaemic stroke. Results Among 27,461 patients admitted for AMI, 19,696 (71.7%) had no prior ASCVD. In patients without prior ASCVD, statin prescription did not increase and in fact showed a slight decline (13.2% in 2005 vs 11.1% in 2022), with no improvement across age and sex strata. After adjustment, there was still no evidence of improvement over time (2022 vs 2005: aOR 0.99, 95% CI 0.80–1.21; p=0.891). Among very-high-risk primary prevention patients with both hypertension and diabetes, statin use remained low and unchanged (35.9% in 2022), despite 62.7% receiving RAAS inhibitors. Older age, ≥3 CV risk factors, chronic kidney disease, and male sex were independently associated with a higher likelihood of prior statin use. Admission LDL-C levels remained stable over time (123 mg/dL in 2005 vs 128 mg/dL in 2022). Prior statin use was independently associated with lower in-hospital mortality (aOR 0.68, 95% CI 0.47–0.98; p=0.037). In patients with prior ASCVD, statin prescribing increased modestly, from 48.9% in 2005 to 60.9% in 2022. Multivariable modeling confirmed a significant improvement over time (2022 vs 2005: aOR 1.42, 95% CI 1.15–1.75; p<0.001). After adjustment, statin use was more frequent in patients with diabetes (aOR 1.19, 95% CI 1.06–1.34; p<0.001), less frequent in women (aOR 0.79, 95% CI 0.70–0.91; p<0.01), and remained independently associated with lower in-hospital mortality (aOR 0.69, 95% CI 0.53–0.90; p=0.006). Conclusion Over two decades, despite universal coverage, statin use prior to AMI improved only modestly in patients with known ASCVD and has stagnated in those without prior ASCVD. Notably, 40% of secondary prevention patients and most high-risk primary prevention patients were not on statins at the time of AMI. Given that prior statin use is independently associated with improved in-hospital survival during the index event, in addition to its established long-term benefits, these findings highlight a major missed opportunity in CV prevention.