Elective coronary revascularisation represents an unutilised opportunity to optimise lipid management: results from a multicentre observational cohort

Background After a coronary event, patients are at markedly elevated risk of recurrent cardiovascular events, with low-density lipoprotein cholesterol (LDL-C) representing an important component of residual risk. However, guideline-recommended LDL-C targets are not achieved in a considerable number of patients. Furthermore, in patients with acute coronary syndrome (ACS), early initiation of intensive lipid-lowering therapy (LLT) during hospitalisation has been shown to result in greater LDL-C reduction compared with more gradual up-titration. However, it remains unclear whether hospitalisation for elective coronary revascularisation represents a similar ‘window of opportunity’ to optimise lipid management. Purpose To compare LDL-C management during hospitalisation for ACS versus elective coronary revascularisation. Methods We included consecutive patients hospitalised for ACS (ST- or non-ST segment elevation myocardial infarction [STEMI/NSTEMI], or unstable angina pectoris [uAP]) or elective coronary revascularisation (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) in 26 hospitals in the Netherlands between June 2024 and February 2026. Patient characteristics, laboratory data (collected during index hospitalisation or within 6 months prior) and discharge medication prescriptions were extracted from electronic health records. LDL-C targets of <1.8 mmol/L (Dutch guideline) and <1.4 mmol/L (2019 ESC/EAS guideline) were evaluated. Adequate LLT was defined as treatment with a potency equivalent to or greater than a high-intensity statin combined with ezetimibe (i.e. ~ 60% LDL-C reduction). To account for baseline differences, elective coronary revascularisation patients were matched to ACS patients on age, sex, LDL-C at admission, and cardiovascular history. Results In 1,985 patients (27% female; median age 68 years [IQR 60–76]); 76% had ACS and 24% underwent elective coronary revascularisation. LDL-C at admission was <1.8 mmol/L in 19% of ACS patients and 24% of elective coronary revascularisation patients (Table 1). At discharge, adequate LLT was prescribed in 27% of ACS patients compared to 16% of elective coronary revascularisation patients (p<0.001). After matching (n=330 per group, 99% of elective patients with complete data) this LLT disparity remained (27% vs. 15%, p<0.001) (Figure 1). Conclusion In a contemporary large multicentre cohort, lipid management during hospitalisation for a coronary event remains suboptimal, with particular potential for improvement in elective coronary revascularisation patients. Strategies to improve adequate LLT during hospitalisation regardless of ACS or elective coronary revascularisation are urgently needed to improve secondary prevention.