Attainment of LDL-cholesterol goals in patients with previous myocardial infarction: a real-world cross-sectional analysis

Abstract

Abstract Background ESC guidelines recommend an LDL-cholesterol (LDL-C) <55mg/dL for patients with established cardiovascular disease. While the Friedewald’s equation to estimate LDL-C is still widely used, the newer Martin-Hopkins’ formula has shown greater accuracy. The aims of this work were: 1) to assess the proportion of patients reaching their LDL-C goal and the therapies used, and 2) to assess the impact of using the Martin-Hopkins' method instead of Friedewald’s formula on the proportion of controlled patients. Methods Single-centre cross-sectional study including consecutive post-myocardial infarction patients followed by 20 different cardiologists in a tertiary hospital. Data were collected retrospectively from clinical appointments that took place after April 2022. Only those with an available ambulatory lipid profile were considered. For each patient, LDL-C levels and goal attainment were estimated by both Friedewald’s and Martin-Hopkins’ equations. Results A total of 400 patients were included (age 67±13 years, 77% male, 31% diabetics). The last myocardial infarction had occurred a median of 4,5 years before the appointment. Using Friedewald’s equation, median LDL-C under therapy was 64 mg/dL [IQR (50-81)]. Overall, 125 patients (31%) had LDL-C within target (Figure 1). High intensity statins were used in 256 patients (64%), 146 (37%) were under ezetimibe, and 2 (0.5%) were under PCSK9 inhibitors. Combination therapy of high intensity statin + ezetimibe was used in 102 patients (26%) (Figure 2). These patients had a median LDL-C of 61mg/dL [IQR (45-75)], with 35% attaining LDL-C levels <55 mg/dL, and 11% remaining above 100 mg/dL. Applying the Martin-Hopkins method would reclassify a total of 31 patients (7.8% of total). Among those deemed controlled by the Friedewald’s equation, 27 (21.6%) would have a Martin-Hopkins’ LDL-C above the target, while 4 (1.5%) of the uncontrolled patients would have a recalculated LDL-C <55mg/dL. The following medical appointment was scheduled a median of 8 months (IQR 6-11) later. Conclusion Less than one third of post-myocardial infarction patients followed in a tertiary hospital’s cardiology clinic had LDL-C values within the goal, with a prescription pattern suggesting a large underutilization of readily available therapies. Applying the Martin-Hopkins’ formula to calculate LDL-C would reclassify roughly one fifth of presumably controlled patients into the non-controlled group.Figure 1Figure 2