Clinician-level variation in lipid management for secondary prevention of atherosclerotic cardiovascular disease: Opportunities for practice improvement.

BackgroundCardiovascular disease remains the leading cause of morbidity and mortality worldwide, with dyslipidemia playing a key role in its progression. Despite advances in lipid-lowering therapy (LLT), LDL-C (Low-Density Lipoprotein Cholesterol) goal achievement remains suboptimal. This study evaluated LDL-C goal attainment in Colombian patients with very high cardiovascular risk (CVR) due to coronary artery disease (CAD) following ESC/EAS guidelines updates.MethodsEDHIPO MARCA (Evaluación De adherencia a la terapia HIPOlipemiante en pacientes de Muy Alto Riesgo CArdiovascular) is a retrospective, multicenter study assessing LDL-C goal achievement in patients with CAD. Data were collected from previous coronary angiogram reports and medical records across 11 Colombian healthcare institutions with certified interventional cardiology services. Patients with CAD who had at least one follow-up LDL-C measurement and an LLT prescription within 12 months post-angiogram were included. LDL-C goal attainment was assessed across three periods—2011–2012, 2016–2017, and 2021–2022—corresponding to the updates of ESC/EAS guidelines (2011, 2016, and 2019, respectively). The LDL-C goals were <70 mg/dL for the first two periods and <55 mg/dL for the most recent one. LDL-C was measured or estimated using the Friedewald equation. Descriptive analyses were performed.ResultsA total of 1,788 patients were included, with a median age of 66 years (IQR: 59–74), and 70.7% were male. Hypertension (67.5%) and overweight (40.8%) were the most common comorbidities. At discharge, statins were prescribed in 84.1% (95% CI: 82.4–85.8%) of patients, increasing to 99.1% (95% CI: 98.6–99.5%) at the end of follow-up (median 6.8 months); PCSK9 inhibitors were prescribed in 1.5%, exclusively in 2019. At the end of follow-up, 36.6% (95% CI: 34.3%, 38.8%) achieved LDL-C goals. By guideline period, goal attainment was 12.1% (95% CI: 5.4%, 18.8%) in 2011, 42.3% (95% CI: 37.9%, 46.8%) in 2016, and 36.2% (95% CI: 33.5%, 38.9%) in 2019. By number of follow-ups, LDL-C goal achievement increased from 32.9% (1 follow-up) to 44.0% (4 follow-ups).ConclusionsDespite widespread LLT use, LDL-C target achievement remains suboptimal. Frequent follow-up and greater use of combination therapy beyond statins may be essential to improve lipid control in very high CVR patients.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12944-025-02657-9.

AimThe aim of this study was to evaluate the relationship between renal function and low-density lipoprotein cholesterol (LDL-C) goal achievement and compare the strategy of lipid-lowering therapy (LLT) among the patients with coronary artery disease (CAD) with different renal functions.MethodsIn this study, we enrolled 933 Chinese patients with CAD from September 2020 to June 2021 admitted to the Cardiometabolic Center of Fuwai Hospital in Beijing consecutively. All individuals were divided into two groups based on their estimated glomerular filtration rate (eGFR). The multiple logistical regression analysis was performed to identify and compare the independent factors which impacted LDL-C goal achievement in the two groups after at least 3 months of treatment.ResultsThere were 808 subjects with eGFR ≥ 60 ml/min/1.73 m2 who were divided into Group 1 (G1). A total of 125 patients with eGFR <60 ml/min/1.73 m2 were divided into Group 2 (G2). The rate of LDL-C goal attainment (LDL-C <1.4 mmol/L) was significantly lower in G2 when compared with that in G1 (24.00% vs. 35.52%, P = 0.02), even though there was no significant difference in the aspect of LLT between the two groups (high-intensity LLT: 82.50% vs. 85.60% P = 0.40). Notably, in G1, the proportion of LDL-C goal achievement increased with the intensity of LLT (23.36% vs. 39.60% vs. 64.52% in the subgroup under low-/moderate-intensity LLT, or high-intensity LLT without proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (PCSK9i), or high-intensity LLT with PCSK9i, respectively, P < 0.005). In addition, in G2, there was a trend that the rate of LDL-C goal achievement was higher in the subgroup under high-intensity LLT (26.60% in the subgroup under high-intensity LLT without PCSK9i and 25.00% in the subgroup under high-intensity LLT with PCSK9i) than that under low-/moderate-intensity LLT (15.38%, P = 0.49). Importantly, after multiple regression analysis, we found that eGFR <60 ml/min/1.73 m2 [odds ratio (OR) 1.81; 95%CI, 1.15–2.87; P = 0.01] was an independent risk factor to impact LDL-C goal achievement. However, the combination strategy of LLT was a protective factor for LDL-C goal achievement independently (statin combined with ezetimibe: OR 0.42; 95%CI 0.30–0.60; P < 0.001; statin combined with PCSK9i: OR 0.15; 95%CI 0.07–0.32; P < 0.001, respectively).ConclusionImpaired renal function (eGFR <60 ml/min/1.73 m2) was an independent risk factor for LDL-C goal achievement in the patients with CAD. High-intensity LLT with PCSK9i could improve the rate of LDL-C goal achievement significantly. It should be suggested to increase the proportion of high-intensity LLT with PCSK9i for patients with CAD, especially those with impaired renal function.

We aimed to investigate trends in low-density lipoprotein cholesterol (LDL-C) goal achievement (LDL-C<1.8 mmol/L, equivalent to 70 mg/dL), initiation of lipid-lowering therapy (LLT) and changes in LLT intensity in individuals with atherosclerotic cardiovascular disease (ASCVD) at very high risk of recurrent cardiovascular disease. A cohort study design was used including individuals with incident ASCVD and LDL-C≥1.8 mmol/L in 2010-2015. Data were obtained from national, population-based registers (patient, prescription, income, and laboratory). We included 11,997 individuals. Acute myocardial infarction, ischemic stroke and stable angina pectoris accounted for 79.6% of the qualifying ASCVD events. At inclusion, 37.2% were in LLT. Mean LDL-C before or during ASCVD hospitalization was 3.1 mmol/L (120 mg/dL). LDL-C goal achievement increased within the first two years after inclusion from 40.5% to 50.6%. LLT initiation within the first 90 days increased from 48.6% to 56.0%. Initiation of intensive LLT increased from 9.6% to 32.8%. The largest change in LLT intensity was seen in the period 180 days before to 90 days after discharge with 2.2% in 2010 to 12.1% in 2015. LDL-C goal achievement within the first 2 years after inclusion increased from 40.5% in 2010 to 50.6% in 2015. LLT initiation within the first year after inclusion increased, especially for intensive LLT, although only one third initiated intensive LLT in 2015. Despite trends show improvements in LDL-C goal achievement, 49.4% of individuals at very high risk of a CV event did not achieve the LDL-C goal within 2 years after ASCVD hospitalization.

Changes in lipoprotein(a) and their association with LDL-C in patients withACS treated with triple oral lipid-lowering therapy.

Trends and predictors of high-intensity statin therapy and LDL-C goal achievement among Thai patients with acute coronary syndrome

BackgroundAdherence to lipid-lowering therapy (LLT) guidelines is suboptimal, leading to poor achievement of low-density lipoprotein cholesterol (LDL-C) goals and elevated risk for atherosclerotic cardiovascular disease (ASCVD) events.ObjectivesThe purpose of this study was to determine whether an educational intervention targeting physicians improves optimization of LLT over 1 year for patients with ASCVD.MethodsGOULD (Getting to an Improved Understanding of Low-Density Lipoprotein Cholesterol and Dyslipidemia Management) EDU (Education) was a 1-year extension in a subset of sites in the GOULD prospective, observational registry of United States patients with ASCVD. In a cluster-randomized, stepped-wedge design, sites were randomized to 2 waves of an educational intervention that included 2 webinars and access to interactive data reports showing site-specific performance alongside full-study data over the course of the study. Chart reviews assessed LLTs and patient outcomes. Outcomes assessed over 1 year included change in prescribed LLT, frequency of measurement of LDL-C, LDL-C levels, LDL-C goal achievement, and responses on a structured physician questionnaire.ResultsThirty sites were randomized to Step 1 (n = 616) and 26 sites to Step 2 (n = 382). The mean (SD) age was 70.2 (9.6) years, 61.1% (610/998) were male, and 85.3% (851/998) were White. During the study, 83.6% (820/981) of patients had no change in LLT, and intensification occurred in only 7.0% (69/981); intensification did not differ by intervention step. The percentage of patients who met the goal of LDL-C <70 mg/dL was 39.0% (202/518) at baseline and 39.5% (252/638) at 1 year.ConclusionsAn educational intervention with physicians had little impact on LLT optimization or LDL-C goal achievement in patients with ASCVD over a 1-year period. Novel approaches are needed to improve LDL-C goal achievement. (Getting to an Improved Understanding of Low-Density Lipoprotein Cholesterol and Dyslipidemia Management [GOULD] a Registry of High Cardiovascular Risk Subjects in the United States; NCT02993120)

Effects of switching statins on achievement of lipid goals: measuring effective reductions in cholesterol using rosuvastatin therapy (MERCURY I) study

Background In the 2019 ESC/EAS guidelines, documented ASCVD is a criterion for patients being categorised as at very high cardiovascular (CV) risk, and stringent low-density lipoprotein cholesterol (LDL-C) reductions of ≥50% plus a goal of &amp;lt;1.4 mmol/L are recommended. Intensive lipid lowering therapy (LLT) is therefore key to reducing the risk of future CV events. Purpose To describe patient characteristics, approaches to lipid management and LDL-C goal attainment at baseline in the subgroup of secondary prevention patients with a history of ASCVD enrolled in the SANTORINI study. Methods SANTORINI is a multinational observational study (NCT-04271280) evaluating the real-world use of LLT in adult patients with high- and very-high CV risk enrolled from primary and secondary care sites across Europe between March 2020 and February 2021. The ASCVD status of patients was defined based on medical records as either coronary (myocardial infarction; unstable angina; angina pectoris; coronary artery bypass graft surgery; percutaneous transluminal coronary angioplasty; coronary artery disease [CAD]; CAD unequivocal on imaging), cerebral (stroke; transient ischaemic attack; cerebrovascular disease; cerebrovascular disease unequivocal on imaging; carotid artery disease), peripheral/other (peripheral arterial disease [PAD]; lower extremity artery disease; PAD unequivocal on imaging; retinal vascular disease; abdominal aortic aneurysm; renovascular disease) or polyvascular (≥1 ASCVD). Results Of the 9044 patients included in the analysis 6954 (76.9%) had a history of ASCVD. Baseline demographics and patient characteristics by type of ASCVD are shown in Table 1. The majority of patients were male (76.9%) and mean (SD) age was 66.1 (10.4) years. Mean (SD) LDL-C level was 2.29 (1.13) mmol/L and a total of 20.7% of patients achieved CV risk-based LDL-C goals. Fewer patients with cerebral ASCVD attained LDL-C goals (15.0%). Despite being at very-high CV risk, 21.4% of all patients had no documented LLT (up to 28.5% for the cerebral ASCVD group). The majority of patients (49.2%) received statin monotherapy, particularly moderate (21.8%) and high-intensity statins (24.9%). The peripheral/other ASCVD and cerebral ASCVD groups recorded the highest use of monotherapy across subgroups (≥57.8%), whereas any other LLT alone was consistently low, including ezetimibe (≤2.5%) and PCSK9i (≤2.0%). Overall, only 25.6% of patients received combination therapy (17.5% statin + ezetimibe; 4.7% PCSK9i + statin and/or ezetimibe; 3.4% other). Conclusion The SANTORINI baseline analysis shows that the majority of patients with ASCVD do not achieve their LDL-C goals. The underutilisation of combination therapy in this very high CV risk population highlights the need to move beyond high-intensity statin monotherapy and rather focus on combination therapies which achieve more intensive LDL-C reductions, thus improving LDL-C goal attainment. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH, Munich, Germany

IntroductionClinical trial evidence supports early low-density lipoprotein cholesterol (LDL-C) goal achievement in patients with atherosclerotic cardiovascular disease (ASCVD), but real-world evidence in Asia is lacking. We investigated the effects of early LDL-C goal achievement on recurrent major cardiovascular events (MACEs) among patients with very-high-risk ASCVD in South Korea.MethodsWe included adult patients hospitalized with ASCVD (acute coronary syndrome [ACS], stable angina, ischemic stroke, transient ischemic attack, peripheral arterial disease, or asymptomatic coronary artery disease) at a major Korean tertiary hospital from 2000 to 2020. Patients were categorized into early or non-early target LDL-C groups based on LDL-C measured 4–12 weeks post-discharge (< 55 vs. ≥ 55 mg/dl). The primary outcome was recurrent MACEs, including myocardial infarction, ischemic stroke, all-cause mortality, hospitalization for unstable angina, and coronary revascularization. The secondary outcome was health resource use (frequency/length of stay [LOS]).ResultsDuring follow-up (mean: 5 years), the early target LDL-C group (n = 5702) had a lower risk of recurrent MACEs compared with the non-early target LDL-C group (n = 11,232; adjusted hazard ratio [95% CI]: 0.89 [0.82–0.96]). The effect was most pronounced in patients with ACS (0.73 [0.63–0.85]), particularly for recurrent MACEs within 6 months (0.61 [0.44–0.87]). The early target LDL-C group had 19% lower frequency and 31% shorter LOS for cardiovascular-related hospitalizations than the non-early group.ConclusionsEarly LDL-C goal achievement was associated with lower recurrent MACEs in patients with very-high-risk ASCVD in South Korea, especially in patients with ACS. These findings underscore the importance of early LDL-C management in improving cardiovascular outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40119-025-00397-6.

Introduction: Low-density lipoprotein cholesterol (LDL-C) is associated with heightened risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in patients with peripheral artery disease (PAD). Strategies that lower LDL-C levels reduce this risk. Hypothesis: We hypothesized that real-world PAD patients are overall undertreated with lipid lowering therapies (LLT) but that LLT use and achieved LDL-C are improved in high risk patients with ischemic events. Methods: Patients with PAD in the MarketScan database linked to PROGNOS lab data from January 1, 2014 through December 31, 2018 were examined. Outcomes included use of LLT, defined as high intensity (HI) (high intensity statin, any statin plus ezetimibe, or any use of a PCSK9 inhibitor), low intensity (LI) (any other lipid regimen), or no therapy, and follow up LDL-C level. Goal LDL-C was defined as &lt;70 mg/dl. Results: Among 18,747 PAD patients, 25% were on HI LLT, 43% were on LI LLT, and 32% were on no therapy at baseline (Figure A). The median LDL-C was 91 mg/dl (IQR 70, 118), and 25% of patients were at goal (Figure B). After a median follow up of 18 months, use of HI LLT increased by 4%, the median LDL-C decreased by 5 mg/dl, and an additional 3% of patients were at goal LDL-C. Greater use of HI LLT was observed among patients with a MACE (55%) or MALE (41%) event during follow up compared with patients without an ischemic event (26%) during follow up (Figure C). Follow up LDL-C levels remained above goal for most patients (post-MACE: median LDL-C 77 mg/dl, 42% patients at goal; post-MALE: median LDL-C 80 mg/dl, 36% patients at goal). Conclusions: In PAD patients, use of LLT is suboptimal, and LDL-C levels remain elevated. After an ischemic event, LLT use is intensified, with greater use of HI LLT observed after MACE than MALE. Despite this, LLT remains underutilized, with &gt;50% of patients not at goal LDL-C. Strategies to better implement proven therapies to reduce risk in this high risk population are needed.

DA VINCI study: Change in approach to cholesterol management will be needed to reduce the implementation gap between guidelines and clinical practice in Europe

Introduction: While prior studies have documented suboptimal lipid therapeutic management and low rates of LDL-C goal achievement in patients with ASCVD, the degree of variability between cardiologists in lipid-lowering therapy (LLT) practice patterns is less well described. Hypothesis: Significant variability exists between cardiologists in their use of LLT and achievement of LDL-C goals in patients with ASCVD. Methods: We evaluated the use of LLTs and achievement of LDL-C &lt;70 mg/dL among adults with ASCVD (peripheral arterial disease, coronary artery disease, or ischemic cerebrovascular disease) followed by a cardiologist at a large academic medical center from 1/1/22-6/30/24. LLT utilization and LDL-C goal achievement were modeled using mixed-effects logistic regression with clustering at the cardiologist level, adjusting for patient age, insurance, ASCVD type, and diabetes. From this model, we quantified physician-level variability using the adjusted median odds ratios (aMOR). Results: Among 10,531 patients with ASCVD (mean age 68.5 years, 61.1% male, 69.8% White) seen across 55 cardiologists, 80.6% were on any statin, 51.5% were on a high-intensity statin, 14.9% were on ezetimibe, 5.6% were on bempedoic acid or a PCSK9 inhibitor, and 15.1% were not on any LLT. Of those with a lipid panel in the past year (n= 7,555), 45.9% achieved an LDL-C &lt; 70 mg/dL. Lipid management strategies varied substantially across cardiologists ( Figure ). In mixed-effects models adjusting for patient-level factors, significant physician-level variation was observed in high-intensity statin use (aMOR 1.33, 95% CI 1.25-1.45), ezetimibe use (aMOR 1.62, 95% CI 1.46-1.85), bempedoic acid or PCSK9 inhibitor use (aMOR 2.03, 95% CI 1.75-2.45), and attainment of LDL-C &lt; 70 mg/dL (aMOR 1.27, 95% CI 1.20-1.38). Conclusion: Even among cardiologists at the same academic medical center, practice patterns varied widely in the use of LLT and achievement of LDL-C goals for secondary prevention. Understanding the reasons for this variability and standardizing lipid management across the specialty may improve quality of care for patients with ASCVD.

India has the highest burden of cardiovascular disease (CVD) among developing nations. Data from international studies show significant underimplementation of recommended aggressive lipid-lowering strategies for achieving low-density lipoprotein cholesterol (LDL-C) goals, especially after percutaneous coronary intervention (PCI), a pattern also observed in India. Moreover, ethnic variation in response to statin therapy has prompted clinicians to adopt lower doses of statin therapy in Asians to achieve comparable LDL-C lowering. To document the dose of statin ± ezetimibe required to achieve the European Society of Cardiology (ESC) goals of LDL-C <55 mg/dL in Indian patients with established atherosclerotic cardiovascular disease (ASCVD). This retrospective single-center, cross-sectional, observational, all-comers study in Mumbai evaluated the dose of atorvastatin (A)/rosuvastatin (R) ± ezetimibe (E) treatment at which patients with established ASCVD (n = 542), irrespective of their baseline level, achieved LDL-C goals (<55 mg/dL). Those with LDL-C levels >55 mg/dL on current therapy were switched to R 40 mg ± E 10 mg daily. The final data set (n = 340) included those who achieved LDL-C goals at the initial visit and those at follow-up. The primary and secondary outcomes assessed the impact of R 40 mg ± E 10 mg (R40 ± E10) on LDL-C (<55 mg/dL) and non-high-density lipoprotein cholesterol [non-HDL-C (<85 mg/dL)] goal achievement, respectively. At the end of follow-up, LDL-C <55 mg/dL was observed in 42.16% of patients (n = 113) with R40 and in another 43.28% (n = 116) with R40 + E10. A few patients (n = 39; 14.6%) achieved this goal with other dosages. Similarly, non-HDL-C <85 mg/dL was observed in 39.3% of patients (n = 107) with R40 and in another 47.4% of patients (n = 129) with R40 + E10. Overall, around 20% of patients were unable to achieve their LDL-C and non-HDL-C goals despite being on high-intensity statin ± E therapy. In the first report of its kind in India, this study showed that suboptimal LDL-C goal achievement occurred in around 20% of high-risk ASCVD patients on dual therapy. This indicates that clinicians should consider the addition of other therapies [e.g., bempedoic acid, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, and inclisiran] to mitigate the residual risk. Several more trials are needed to determine the most suitable treatment regimen for this population.

&lt;p dir="ltr"&gt;Introduction&lt;/p&gt;&lt;p dir="ltr"&gt;Low-density lipoprotein cholesterol (LDL-C), and other lipid fractions containing apolipoprotein B, have been identified as key components in the process of atherogenesis and consequently the progression to cardiovascular disease (CVD). Lowering LDL-C with lipid-lowering therapy has been identified as an important aspect in the reduction of the incidence of atherosclerotic CVD (ASCVD) events. The European Society of Cardiology (ESC) have published guidelines on LDL-C and provided recommendations on the use of lipid-lowering therapy. This thesis aimed to evaluate the implementation and potential implications of these recommendations in a real-world setting.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods and results&lt;/p&gt;&lt;p dir="ltr"&gt;In study I, the attainment of the LDL-C goals of the 2011 (&lt;1.8 mmol/L or ≥50% reduction from baseline levels) and the 2016 (&lt;1.8 mmol/L and &gt;50% lowering from baseline levels) ESC guidelines were evaluated. Using nationwide registers, including the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART), we identified all adult patients &lt;75 years with MI registered in SWEDEHEART between 2013 and 2017. We included those with available lipid data at follow-up visits 6-10 weeks (n=25,466) and 12-14 months (n=17,117) after the index MI. At both follow-ups, 84% (6-10 weeks) and 69% (12-14 months) of the patients were receiving high-intensity stain monotherapy. The fulfillment of the LDL-C goals of the 2011 guidelines were 64% at both follow-up visits. The proportion of patients that fulfilled the goals of the 2016 guidelines was 32%, at both follow-ups. When the goal attainment at follow-up visits before vs. after the publication of the 2016 guidelines were compared, the goal attainment improved from 30% to 35% (6-10-week visit), and from 28% to 38% (12-14-month visit), after the release of the 2016 guidelines.&lt;/p&gt;&lt;p dir="ltr"&gt;In study II, the potential implications of implementing the 2019 ESC dyslipidemia guidelines and the eligibility of combination lipid-lowering therapy were evaluated. Using data from SWEDEHEART and other national registries, the application of the 2019 ESC guideline goals (&lt;1.4 mmol/L and &gt;50% baseline level reduction) and recommendations were assessed in a cohort of patients at 6-10 weeks after the index MI (n=25,466). Using a Monte Carlo simulation model, the effects of maximizing and escalating treatment with lipid-lowering therapies on the attainment of the 2019 LDL-C goals were estimated. Despite most patients (87%) receiving high-intensity statin therapy, 83% of the cohort were still eligible for escalation of their lipid-lowering therapy since they had not attained the 2019 LDL-C goals. Simulating the use of maximized high-intensity statin therapy, 20% of the cohort reached the goals, and adding therapy with ezetimibe an additional 29% percent reached the goals. Thus, 51% of the cohort were still eligible for additional therapy with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. After therapy with PCSK9 inhibitors were simulated, approximately 90% of all patients reached the LDL-C goals.&lt;/p&gt;&lt;p dir="ltr"&gt;In study III, in accordance with the 2021 ESC guidelines, the prevalence of CVD risk categories and the proportion potentially eligible for lipid-lowering therapy were assessed in apparently healthy individuals. Using the Swedish Cardiopulmonary Bioimage Study (SCAPIS), which randomly invited individuals in Sweden aged 50- 64 years, apparently healthy individuals were identified. Applying the Systemic Coronary Risk Estimation 2 (SCORE2) equation to these individuals (n=26,570), 32% and 4% were estimated as having high and very high 10-year risk of fatal and nonfatal CVD, respectively. Among these individuals, 99% had LDL-C levels above the guidelines' targets, resulting in 35% of the total cohort being eligible for lipid- lowering therapy as per the 2021 guidelines. In individuals eligible for lipid-lowering therapy, 38% had no evidence of atherosclerosis in their coronary arteries according to computed tomography. When the SCORE2 multicell chart was used, the proportion eligible for lipid-lowering therapy was 52%, in which 44% had no evidence of coronary atherosclerosis. The use of lipid-lowering therapy was reported in 7% of those with high and very high risk, and an additional 11% received lipid-lowering therapy within 6 months after participating in SCAPIS.&lt;/p&gt;&lt;p dir="ltr"&gt;In study IV, utilization and discontinuation rates of secondary preventive medications (statins, renin-angiotensin-aldosterone system (RAAS) inhibitors, beta-blockers, and low-dose aspirin) after an MI were evaluated. We identified all adult patients with a first-time MI that survived &gt;30 days and were registered in SWEDEHEART during 2006-2021. Information on filled prescriptions were collected from national registries, and each drug class was analyzed separately for initiation, discontinuation, reinitiation, and the proportion of patients with ongoing therapy within 1-12 years after the index MI. We identified 122,288 patients discharged with a first statin prescription, 79,968 with a RAAS inhibitor, 105,095 with a beta-blocker, and 127,463 with low-dose aspirin. After discharge from the index MI, the proportion of patients filling a first prescription ranged from 95%-97% across the drugs. Using a grace period of 90 days, 12%-14% of those who initiated therapy discontinued it at 1 year, 79%-82% at 5 years, and 74%-79% at 12 years after the index MI. Among the patients who discontinued therapy, the rates of reinitiation ranged from 28% to 46% at 1 year, 42% to 62% at 5 years, and 47% to 67% at 12 years. The proportions of patients who were alive and had ongoing treatment (regardless of previous discontinuation) were 91%-92% at 1 year, 79%-82% at 5 years, and 74%-79% at 12 years after the index MI.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions&lt;/p&gt;&lt;p dir="ltr"&gt;In a nationwide real-world setting in Sweden, the LDL-C goals of the 2011 and 2016 ESC dyslipidemia guidelines were not attained in many patients with a recent MI. When applying the 2019 ESC dyslipidemia guidelines on patients with an MI, despite maximizing the use of high-intensity statins and ezetimibe, eligibility for PCSK9 inhibitors was estimated to be present in approximately half of the patients. In apparently healthy middle-aged individuals, application of the 2021 ESC guidelines resulted in 35% being eligible for lipid-lowering therapy, with many having no signs of coronary atherosclerosis. After a first-time MI, many patients discontinue therapy with CVD preventive medications during a period of 1-12 years. However, many patients later reinitiate previously discontinued therapy, and among alive patients many have ongoing treatment at 1-12 years after the MI.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;This thesis is based on the following papers, which will be referred to by their corresponding Roman numerals:&lt;/p&gt;&lt;p dir="ltr"&gt;I. Ali Allahyari*, Tomas Jernberg, Dominik Lautsch, Pia Lundman, Emil Hagström, Jessica Schubert, Robert Boggs, Stina Salomonsson, Peter Ueda. Low-density lipoprotein-cholesterol target attainment according to the 2011 and 2016 ESC/EAS dyslipidaemia guidelines in patients with a recent myocardial infarction: nationwide cohort study, 2013-17. European Heart Journal - Quality of Care and Clinical Outcomes. Volume 7, Issue 1, January 2021, Pages 59-67. &lt;a href="https://doi.org/10.1093/ehjqcco/qcaa016" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/ehjqcco/qcaa016&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. Ali Allahyari*, Tomas Jernberg, Emil Hagström, Margret Leosdottir, Pia Lundman, Peter Ueda. Application of the 2019 ESC/EAS dyslipidaemia guidelines to nationwide data of patients with a recent myocardial infarction: a simulation study, European Heart Journal. Volume 41, Issue 40, 21 October 2020, Pages 3900-3909. &lt;a href="https://doi.org/10.1093/eurheartj/ehaa034" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/eurheartj/ehaa034&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Ali Yari&lt;/b&gt;, Peter Ueda, Pia Lundman, Joakim Alfredsson, Annica Ravn- Fischer, Stefan Söderberg, Troels Yndigegn, Emil Hagström, Tomas Jernberg. Eligibility for lipid-lowering therapy when applying systemic coronary risk estimation 2 according to guidelines on apparently healthy middle-aged individuals. European Journal of Preventive Cardiology. Volume 31, Issue 15, October 2024, Pages 1890-1897. &lt;a href="https://doi.org/10.1093/eurjpc/zwae190" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/eurjpc/zwae190&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. &lt;b&gt;Ali Yari&lt;/b&gt;, Carl-Emil Lim, Emil Hagstrom, Pia Lundman, Jessica Schubert, Tomas Jernberg, Peter Ueda. Utilization and discontinuation of secondary preventive medications after myocardial infarction: a nationwide cohort study. [Manuscript]&lt;/p&gt;&lt;p dir="ltr"&gt;*Former last name&lt;/p&gt;

&lt;p dir="ltr"&gt;Introduction&lt;/p&gt;&lt;p dir="ltr"&gt;Low-density lipoprotein cholesterol (LDL-C), and other lipid fractions containing apolipoprotein B, have been identified as key components in the process of atherogenesis and consequently the progression to cardiovascular disease (CVD). Lowering LDL-C with lipid-lowering therapy has been identified as an important aspect in the reduction of the incidence of atherosclerotic CVD (ASCVD) events. The European Society of Cardiology (ESC) have published guidelines on LDL-C and provided recommendations on the use of lipid-lowering therapy. This thesis aimed to evaluate the implementation and potential implications of these recommendations in a real-world setting.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods and results&lt;/p&gt;&lt;p dir="ltr"&gt;In study I, the attainment of the LDL-C goals of the 2011 (&lt;1.8 mmol/L or ≥50% reduction from baseline levels) and the 2016 (&lt;1.8 mmol/L and &gt;50% lowering from baseline levels) ESC guidelines were evaluated. Using nationwide registers, including the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART), we identified all adult patients &lt;75 years with MI registered in SWEDEHEART between 2013 and 2017. We included those with available lipid data at follow-up visits 6-10 weeks (n=25,466) and 12-14 months (n=17,117) after the index MI. At both follow-ups, 84% (6-10 weeks) and 69% (12-14 months) of the patients were receiving high-intensity stain monotherapy. The fulfillment of the LDL-C goals of the 2011 guidelines were 64% at both follow-up visits. The proportion of patients that fulfilled the goals of the 2016 guidelines was 32%, at both follow-ups. When the goal attainment at follow-up visits before vs. after the publication of the 2016 guidelines were compared, the goal attainment improved from 30% to 35% (6-10-week visit), and from 28% to 38% (12-14-month visit), after the release of the 2016 guidelines.&lt;/p&gt;&lt;p dir="ltr"&gt;In study II, the potential implications of implementing the 2019 ESC dyslipidemia guidelines and the eligibility of combination lipid-lowering therapy were evaluated. Using data from SWEDEHEART and other national registries, the application of the 2019 ESC guideline goals (&lt;1.4 mmol/L and &gt;50% baseline level reduction) and recommendations were assessed in a cohort of patients at 6-10 weeks after the index MI (n=25,466). Using a Monte Carlo simulation model, the effects of maximizing and escalating treatment with lipid-lowering therapies on the attainment of the 2019 LDL-C goals were estimated. Despite most patients (87%) receiving high-intensity statin therapy, 83% of the cohort were still eligible for escalation of their lipid-lowering therapy since they had not attained the 2019 LDL-C goals. Simulating the use of maximized high-intensity statin therapy, 20% of the cohort reached the goals, and adding therapy with ezetimibe an additional 29% percent reached the goals. Thus, 51% of the cohort were still eligible for additional therapy with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. After therapy with PCSK9 inhibitors were simulated, approximately 90% of all patients reached the LDL-C goals.&lt;/p&gt;&lt;p dir="ltr"&gt;In study III, in accordance with the 2021 ESC guidelines, the prevalence of CVD risk categories and the proportion potentially eligible for lipid-lowering therapy were assessed in apparently healthy individuals. Using the Swedish Cardiopulmonary Bioimage Study (SCAPIS), which randomly invited individuals in Sweden aged 50- 64 years, apparently healthy individuals were identified. Applying the Systemic Coronary Risk Estimation 2 (SCORE2) equation to these individuals (n=26,570), 32% and 4% were estimated as having high and very high 10-year risk of fatal and nonfatal CVD, respectively. Among these individuals, 99% had LDL-C levels above the guidelines' targets, resulting in 35% of the total cohort being eligible for lipid- lowering therapy as per the 2021 guidelines. In individuals eligible for lipid-lowering therapy, 38% had no evidence of atherosclerosis in their coronary arteries according to computed tomography. When the SCORE2 multicell chart was used, the proportion eligible for lipid-lowering therapy was 52%, in which 44% had no evidence of coronary atherosclerosis. The use of lipid-lowering therapy was reported in 7% of those with high and very high risk, and an additional 11% received lipid-lowering therapy within 6 months after participating in SCAPIS.&lt;/p&gt;&lt;p dir="ltr"&gt;In study IV, utilization and discontinuation rates of secondary preventive medications (statins, renin-angiotensin-aldosterone system (RAAS) inhibitors, beta-blockers, and low-dose aspirin) after an MI were evaluated. We identified all adult patients with a first-time MI that survived &gt;30 days and were registered in SWEDEHEART during 2006-2021. Information on filled prescriptions were collected from national registries, and each drug class was analyzed separately for initiation, discontinuation, reinitiation, and the proportion of patients with ongoing therapy within 1-12 years after the index MI. We identified 122,288 patients discharged with a first statin prescription, 79,968 with a RAAS inhibitor, 105,095 with a beta-blocker, and 127,463 with low-dose aspirin. After discharge from the index MI, the proportion of patients filling a first prescription ranged from 95%-97% across the drugs. Using a grace period of 90 days, 12%-14% of those who initiated therapy discontinued it at 1 year, 79%-82% at 5 years, and 74%-79% at 12 years after the index MI. Among the patients who discontinued therapy, the rates of reinitiation ranged from 28% to 46% at 1 year, 42% to 62% at 5 years, and 47% to 67% at 12 years. The proportions of patients who were alive and had ongoing treatment (regardless of previous discontinuation) were 91%-92% at 1 year, 79%-82% at 5 years, and 74%-79% at 12 years after the index MI.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions&lt;/p&gt;&lt;p dir="ltr"&gt;In a nationwide real-world setting in Sweden, the LDL-C goals of the 2011 and 2016 ESC dyslipidemia guidelines were not attained in many patients with a recent MI. When applying the 2019 ESC dyslipidemia guidelines on patients with an MI, despite maximizing the use of high-intensity statins and ezetimibe, eligibility for PCSK9 inhibitors was estimated to be present in approximately half of the patients. In apparently healthy middle-aged individuals, application of the 2021 ESC guidelines resulted in 35% being eligible for lipid-lowering therapy, with many having no signs of coronary atherosclerosis. After a first-time MI, many patients discontinue therapy with CVD preventive medications during a period of 1-12 years. However, many patients later reinitiate previously discontinued therapy, and among alive patients many have ongoing treatment at 1-12 years after the MI.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;This thesis is based on the following papers, which will be referred to by their corresponding Roman numerals:&lt;/p&gt;&lt;p dir="ltr"&gt;I. Ali Allahyari*, Tomas Jernberg, Dominik Lautsch, Pia Lundman, Emil Hagström, Jessica Schubert, Robert Boggs, Stina Salomonsson, Peter Ueda. Low-density lipoprotein-cholesterol target attainment according to the 2011 and 2016 ESC/EAS dyslipidaemia guidelines in patients with a recent myocardial infarction: nationwide cohort study, 2013-17. European Heart Journal - Quality of Care and Clinical Outcomes. Volume 7, Issue 1, January 2021, Pages 59-67. &lt;a href="https://doi.org/10.1093/ehjqcco/qcaa016" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/ehjqcco/qcaa016&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. Ali Allahyari*, Tomas Jernberg, Emil Hagström, Margret Leosdottir, Pia Lundman, Peter Ueda. Application of the 2019 ESC/EAS dyslipidaemia guidelines to nationwide data of patients with a recent myocardial infarction: a simulation study, European Heart Journal. Volume 41, Issue 40, 21 October 2020, Pages 3900-3909. &lt;a href="https://doi.org/10.1093/eurheartj/ehaa034" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/eurheartj/ehaa034&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Ali Yari&lt;/b&gt;, Peter Ueda, Pia Lundman, Joakim Alfredsson, Annica Ravn- Fischer, Stefan Söderberg, Troels Yndigegn, Emil Hagström, Tomas Jernberg. Eligibility for lipid-lowering therapy when applying systemic coronary risk estimation 2 according to guidelines on apparently healthy middle-aged individuals. European Journal of Preventive Cardiology. Volume 31, Issue 15, October 2024, Pages 1890-1897. &lt;a href="https://doi.org/10.1093/eurjpc/zwae190" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/eurjpc/zwae190&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. &lt;b&gt;Ali Yari&lt;/b&gt;, Carl-Emil Lim, Emil Hagstrom, Pia Lundman, Jessica Schubert, Tomas Jernberg, Peter Ueda. Utilization and discontinuation of secondary preventive medications after myocardial infarction: a nationwide cohort study. [Manuscript]&lt;/p&gt;&lt;p dir="ltr"&gt;*Former last name&lt;/p&gt;