25 years of lipid-lowering therapy: secular trends in therapy of coronary patients

Guidelines on dyslipidemia and lipid-lowering therapy (LLT) over the years recommend lower low-density lipoprotein cholesterol (LDL-C) goals by more intense therapy. Nevertheless, LDL‑C has increased in the general population. Real-world trends of LLT medication as well as of LDL‑C levels in cardiovascular high-risk patients are unclear.

From 2158 patients who were referred for elective coronary angiography, lipid medication was analyzed at admission in three cardiovascular observational studies (OS) over the last 25 years: OS1: 1999-2000, OS2: 2005-2008 and OS3: 2022-2023. The three studies were performed at the same cardiology unit of a tertiary care hospital in Austria.

The proportion of patients without LLT significantly decreased from OS1 through OS2 to OS3 (49.4%, 45.6%, and 18.5%, respectively, p_trend < 0.001). Moreover, the percentage of patients under high-intensity statin treatment significantly increased from 0% to 5.1%, and 56.5% (p_trend < 0.001). Significantly more patients became treated by more than one compound (OS1: 1.8%, OS2: 1.6%, OS3: 31.2%; p_trend < 0.001). In the latest OS3, a trend to fixed-dose combination of statins with ezetimibe was observed. Mean LDL‑C levels decreased from 129 mg/dL over 127 mg/dL to 83 mg/dL, respectively (p_trend < 0.001). Of the patients on high-intensity therapy 34% met the recent ESC/EAS goals (LDL-C < 55 mg/dL), but only 3% on non-intense therapy.

We conclude that during the observational period of a quarter of a century, treatment intensity increased and LDL‑C levels improved considerably. Guidelines apparently matter in this high-risk population and are considered by primary care physicians.