Longitudinal Control of Lipid Levels in Patients With Premature Coronary Artery Disease

Diana N Vikulova; Danielle Pinheiro-Muller; Carlos Rojas-Fernandez; Francois Leblond; Simon N Pimstone; Liam R Brunham

doi:10.1016/j.jacadv.2023.100696

Longitudinal Control of Lipid Levels in Patients With Premature Coronary Artery Disease

JACC Adv. 2023 Nov 14;2(10):100696. doi: 10.1016/j.jacadv.2023.100696. eCollection 2023 Dec.

Authors

Diana N Vikulova^{1

2}, Danielle Pinheiro-Muller¹, Carlos Rojas-Fernandez³, Francois Leblond³, Simon N Pimstone^{2

4}, Liam R Brunham^{1

2

5}

Affiliations

¹ Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada.
² Department of Medicine, University of British Columbia, Vancouver, Canada.
³ Novartis Pharmaceuticals Canada, Dorval, Quebec, Canada.
⁴ Division of Cardiology, University of British Columbia, Vancouver, Canada.
⁵ Department of Medical Genetics, University of British Columbia, Vancouver, Canada.

Abstract

Background: Lipid-lowering therapy (LLT) is a central aspect of the treatment of patients with coronary artery disease (CAD), and the benefits of LLT accrue over time. However, there are limited real-world data on longitudinal lipid control in patients with premature CAD.

Objectives: The purpose of this study was to assess longitudinal attainment of guideline-recommended lipid goals and outcomes in a contemporary cohort of patients with premature CAD.

Methods: We enrolled males younger than 50 years and females younger than 55 years with coronary stenosis of >50% and examined achievement of lipid goals, LLT characteristics, and cardiovascular outcomes (major adverse cardiovascular event [MACE]).

Results: Of 476 patients who presented with acute coronary syndrome (ST-elevation myocardial infarction, non-ST-segment elevation myocardial infarction, unstable angina) (68%), stable angina (28%), or other symptoms, 73.2% achieved low-density lipoprotein cholesterol (LDL-C) <1.8 mmol/L on at least 1 occasion, but only 27.3% consistently stayed in the target range for 3 years after diagnosis. Although 73.9% of patients received high-intensity LLT at the time of diagnosis, only 43.5% had good adherence over the following 3 years. In multivariable analysis, 1 mmol/L increase in time-weighted average exposure to LDL-C, but not the lowest achieved LDL-C, was associated with a higher risk of MACE, hazard ratio 2.02 (95% CI: 1.48-2.76), when adjusted for sex, age, hypertension, diabetes, and smoking.

Conclusions: We found low rates of longitudinal lipid target achievement in patients with premature CAD. Cumulative LDL-C exposure, but not lowest achieved LDL-C, was associated with risk of MACE. This highlights the critical importance of longitudinal control of lipids levels and identifies opportunities to improve LLT and maximize the time-dependent benefits of lipid-lowering.

Keywords: cardiovascular outcomes; longitudinal lipid control; premature coronary artery disease; time-weighted average exposure to LDL-C.