Temporal Trends, Underuse, and Multilevel Factors Associated With Maximum-Dose Statin Therapy in Acute and Chronic Coronary Syndromes ― A Nationwide JROAD-DPC Study ―

Background High-intensity or maximally tolerated statin therapy has robust evidence for secondary prevention in patients with acute coronary syndrome (ACS) and chronic coronary syndrome (CCS), and is strongly recommended in international guidelines. However, comprehensive real-world data on its use and associated factors remain limited. Methods and results Using data from the JROAD-DPC database (2017-2022), we analyzed ACS and CCS patients who underwent revascularization and were discharged alive. We assessed temporal trends in lipid-lowering therapy and examined associated factors, including patient demographics, comorbidities, treatment strategies, and hospital structural characteristics, using multivariable mixed-effects logistic regression models. Among 358,570 patients with ACS and 392,821 with CCS, the use of maximum-dose statins increased from 8.6% in 2017 to 34.1% in 2022 in ACS and from 7.8% to 19.1% in CCS, but remained suboptimal. After multivariable adjustment, older age, underweight status, and coronary artery bypass grafting were associated with lower use of maximum-dose statins in ACS. In CCS, older age, underweight status, and higher comorbidity burden were associated with lower use of maximum-dose statins. Hospital structural factors, including a higher number of cardiologists, were also associated with a greater use of maximum-dose statins. Conclusions Maximum-dose statin use among ACS and CCS patients remains suboptimal in Japan. Multilevel factors contribute to this evidence-practice gap, underscoring the need for comprehensive interventions at multiple levels to reduce disparities in care delivery.