Lipid profile patterns and clinical outcomes in acute coronary syndrome: Findings from the Malaysian National Cardiovascular Disease Database (NCVD)-ACS registry 2022–2023

Background Dyslipidaemia is a key driver of atherosclerotic cardiovascular disease, yet the prognostic implications of different lipid phenotypes during acute coronary syndrome (ACS) remain incompletely understood. While Low-Density Lipoprotein (LDL) cholesterol has traditionally been the primary therapeutic target, the independent contributions of High-Density Lipoprotein (HDL) and triglycerides to short-term outcomes in real-world ACS populations are less clear. Objective This study aimed to evaluate dyslipidaemia patterns and associated clinical characteristics among patients presenting with ACS in a multi-centre registry. Methods This multi-centre registry analysis included consecutive ACS admissions stratified by lipid categories: LDL (<1.4 vs ≥1.4 mmol/L), total cholesterol (≥5.2 vs <5.2 mmol/L), HDL (<1.0 vs ≥1.0 mmol/L), and triglycerides (≥1.7 vs <1.7 mmol/L). Baseline characteristics, ACS subtype, left ventricular ejection fraction (LVEF), and outcomes were compared. Logistic regression identified independent predictors of lipid abnormalities and in-hospital mortality. Results Distinct clinical patterns were observed across lipid phenotypes. Patients with LDL ≥1.4 mmol/L were more likely to present with non-ST-segment Elevation Myocardial Infarction (NSTEMI) (adjusted OR 2.24, *p* = 0.001) and had higher prevalence of diabetes, hypertension, and dyslipidaemia. Total cholesterol ≥5.2 mmol/L was independently associated with increased in-hospital mortality (adjusted OR 1.33, *p* = 0.001). Low HDL (<1.0 mmol/L) was linked to adverse metabolic profiles and modestly higher mortality (5.1% vs 4.2%), while elevated triglycerides (≥1.7 mmol/L) independently predicted mortality risk (adjusted OR 1.22, *p* = 0.023). Conversely, preserved systolic function (LVEF >50%) was consistently protective across lipid categories. Notably, LDL level alone did not independently predict mortality, suggesting residual risk beyond traditional LDL-focused assessment. Conclusion Patients with known dyslipidaemia presented with better preserved ventricular function, lower clinical severity, and faster reperfusion, likely driven by earlier disease recognition and prior statin therapy. These findings underscore that proactive lipid management may attenuate ACS severity and improve survival. Early identification and aggressive lipid-lowering therapy may therefore translate directly into better real-world outcomes.