Novel preventive cardiology clinic associated with reduced risk of recurrent major adverse cardiovascular events for patients with prior acute coronary syndrome

Abstract Background Despite conventional treatment, up to a third of patients experience recurrent cardiovascular events within five years of an acute coronary syndrome (ACS).1 Clinical efforts often focus on treating the acute event, although aggressive use of new risk-reducing medications also offers a promising strategy to improve long-term outcomes. We set up a specialist secondary prevention clinic to maximise use of all risk-reducing treatments according to ESC and NICE guidelines. These included recent lipid-lowering medications (ezetimibe and/or PCSK9 inhibitors), diabetes treatments (SGLT2 inhibitors or GLP1 agonists) and long-term dual antithrombotic therapy (low-dose rivaroxaban or ticagrelor). Purpose This study compared cardiovascular outcomes of patients seen in the new specialist prevention clinic with those in standard post-ACS clinics. Methods In October 2020, a novel pilot secondary prevention cardiology clinic was established alongside standard clinics in two hospitals. All patients had prior ACS, and prevention clinic patients were compared to similar patients seen in standard clinics during the same period. We determined the percentage of patients who received recommended treatments when eligible according to guidelines. We assessed survival using Kaplan-Meier curves and multivariate Cox regression. The primary endpoint was major adverse cardiovascular events (MACE), defined as cardiovascular death, non-fatal MI and ischaemic stroke. Results Between October 2020 and June 2022, 353 patients were included. At baseline, the prevention clinic group had a higher prevalence of multivessel coronary artery disease (p=0.003), hypertension (p=0.002), hypercholesterolaemia (p=0.046), type 2 diabetes (p0.001) and glycated haemoglobin (p=0.013) compared to the standard clinic group. Use of ESC and NICE guideline-recommended treatments was significantly higher in eligible patients in the prevention clinic. This included SGLT2 inhibitors/GLP1 agonists (92% vs 17%; p0.001), PCSK9 inhibitors (100% vs 27%; p=0.03), ezetimibe (90% vs 24%; p0.001), long-term dual antithrombotic therapy (92% vs 4%; p0.001) and statins at an optimal dose (99% vs 80%; p0.001). Median follow-up time was 1232 (1087–1352) days. The primary outcome occurred in 14 of 116 patients (12%) in the prevention clinic and 49 of 237 (21%) in the standard clinic (Log-Rank p=0.04). Cerebrovascular disease, multivessel coronary artery disease and hypercholesterolaemia were independent predictors for MACE after adjusting for other predictors. Attending the prevention clinic was associated with reduced MACE (HR 0.53; p=0.04) after adjusting for other predictors. Conclusion There was improved use of new guideline-recommended treatments in the prevention clinic compared to standard clinics, including lipid-lowering medications, diabetes treatments and long-term dual antithrombotic therapy. This was associated with a 47% lower rate of cardiovascular events over a 3-year period.