Insufficient long-term LDL-cholesterol management in patients with familial hypercholesterolemia 5 years after an acute coronary syndrome

Abstract

Abstract Background Long-term control of cardiovascular risk factors after an acute coronary syndrome (ACS) is a cornerstone in preventing cardiovascular event recurrence. In patients with familial hypercholesterolemia (FH) and ACS, long-term management of LDL-cholesterol has been poorly studied. Purpose To investigate the extent of LDL-c and other cardiovascular risk factor management 5 years after ACS in patients with and without FH. Methods We collected data from 3,201 patients with an ACS from a Swiss multicenter cohort study and with 5-years follow-up data. At hospital admission for ACS, clinical FH was defined based on personal and familial history of premature cardiovascular disease as well as LDL-c levels, using the Dutch Lipid Clinic and the Simon Broome definitions. At the 5-years follow-up visit after ACS, we assessed LDL-c levels, lipid-lowering drugs, and control of cardiovascular risk factors comparing patients with FH and without FH. Results At the time of ACS, mean age of the 3,201 patients was 61.6 years old (SD 12.2), 643 (20.1%) were female, and 740 (23.1%) were diagnosed with clinical FH. At 5-years follow-up post-ACS, mean age was 56.6 years for FH patients and 69.6 years for patients without FH. 5 years after ACS, 15.4% and 33.5% patients with FH had an LDL-cholesterol ≤ 1.4 mmol/l, respectively ≤ 1.8 mmol/l, compared with 21.0% and 44.3% of those without FH (p=0.01, respectively <0.001) (see Figure and Table). Use of statins was similar between groups, but patients with FH were more frequently using high-dose statins compared to patients without FH (51.0% vs 42.9%, p<0.001). Use of lipid-lowering therapy in general such as statins, ezetimibe, fibrates, or niacin was more frequent in patients with FH than in those without FH (91.0% vs 87.0%, p=0.01). Beside LDL-c management, 5-year control of other cardiovascular risk factors tended to be superior in FH patients as compared to patients without FH: 78.5% vs 69.0% p<0.001 for systolic blood pressure (BP) < 140 mmHg; 46.2% vs 38.9% p=0.4 for reaching HbA1c < 7% in patients with diabetes; 46.9% vs 42.7% p=0.27 for smoking cessation, and 28.2% vs 21.0% p=0.1 for reduction of alcohol consumption <14 units/week . Conclusion Five years after an ACS, patients with FH had less optimal control of LDL-c levels despite being younger and more frequently using high dose statins compared to patients without FH. Combination of lipid-lowering therapy needs to be studied for optimal long-term management of patients with ACS and FH.Figure:CVRF 5 years post-ACS FH/non-FHTable:CVRF 5 years post-ACS FH/non-FH