Achievement of LDL-C targets after acute myocardial infarction in a public healthcare center in Brazil

Abstract Background Cardiovascular diseases account for nearly one-third of deaths in Brazil. According to the 2021 Global Burden of Disease estimates, the age-standardized mortality rate for coronary artery disease in Brazil was 67.1 per 100,000 inhabitants. Plasma levels of low-density lipoprotein cholesterol (LDL-C) are associated with an increased cardiovascular risk and acute coronary syndromes, and guidelines on dyslipidemia have recommended more intensive LDL-C control. However, data on LDL-C target achievement in patients with previous cardiovascular events remain scarce in Brazil. Purpose To evaluate the achievement of LDL-C targets in patients with a history of acute myocardial infarction (AMI) followed at a tertiary cardiology hospital within Brazil’s universal healthcare system. Methods This was a retrospective cohort study that utilized electronic health record data from patients followed at a tertiary cardiology hospital from 2010 to 2023. We included patients with confirmed diagnosis and documented date of AMI. Data on age at the time of the event, associated comorbidities, revascularization strategy, baseline and follow-up LDL-C levels, and lipid-lowering therapy were analyzed. At the study center, within the framework of the Brazilian Unified Health System (SUS), only simvastatin and atorvastatin were available for prescription. Other lipid-lowering agents, such as ezetimibe and rosuvastatin, were not provided by SUS and could only be obtained if the patient opted to purchase them independently. Results From 55,646 patients we included 11,720 patients with a confirmed diagnosis and documented date of AMI. Among the study population, 67.6% were male. Regarding ethnicity, 87.2% were identified as white, 6.2% as mixed-race, and 4.8% as black (by the reception operator). Hypertension was present in 43.6% of patients, while 29.4% had a diagnosis of diabetes. The mean glycated hemoglobin at baseline was 6.6% (SD ± 1.6%). The mean baseline and lowest LDL-C levels were 111 mg/dl (SD ± 44) and 93 mg/dl (SD ± 38). Regarding lipid-lowering therapy, 78.7% were on high-intensity statin therapy, 20.1% on moderate-intensity, 0.5% on low-intensity, and 0.6% had no statin prescription. Ezetimibe was prescribed for 18.1% of patients. The distribution of initial and lowest achieved LDL-C according to specific ranges is represented below. Only 7.5% (877) achieved the LDL-C target 50 mg/dl and 7.7% (907) remained with LDL-C ≥ 50 mg/dl but had at least 50% reduction of LDL-C levels. Conclusions At this public tertiary center in Brazil, most patients with a history of AMI received high-intensity statin therapy. Despite an increased number of patients achieving either the 50 mg/dl goal or at least 50% reduction, most patients remained off the ideal target and under increased risk of recurrent events. Poor adherence and low accessibility to novel and potent lipid-lowering therapies are probably important players in this scenario.Figure 1 Figure 2