[Potential cardiovascular benefit of optimized lipid-lowering and antiplatelet therapy in patients with acute coronary syndrome - a simulation analysis]

Introduction: Lipid lowering therapy – despite the accumulated clinical trial evidence behind it and its significant preventive role reflected in the guidelines – does not have its rightful place in the value system of patients or doctors, there is a great gap between practice and principles. Objective: In order to increase the prestige of lipid-lowering therapy, the potential benefit of lowering LDL cholesterol was compared with antiplatelet therapy, which is generally more accepted. Method: We processed the data of 531 patients of the Bekes County Central Hospital Pandy Kalman Branch in Gyula who underwent percutaneous coronary intervention for acute coronary syndrome for one year starting on April 1, 2020. A simulation study was conducted during which, based on the results of large clinical studies, the cardiovascular prevention effect of optimal lipid reduction and platelet aggregation inhibition for one year was estimated. Results: In all 531 patients treated for acute coronary syndrome, if LDL cholesterol levels had remained at the mean level of 3.37 mmol/L found at admission, 59 major cardiovascular events could have occurred within one year after the index event. If LDL-cholesterol levels were to be reduced to 1.4 mmol/L, which is the very high-risk target value in the lipid recommendations of the European Society of Cardiology, the number of events would be 13, and 16 if the theoretical, very low, non-target value of 0.5 mmol/L was reached. Lowering LDL cholesterol levels is therefore expected to avoid 13 and 16 major cardiovascular events, respectively. If aspirin alone was given for antiplatelet aggregation, 14 events could be prevented over a year, 17 events could be prevented using aspirin and clopidogrel combination, and 20 events with aspirin and prasugrel or aspirin and ticagrelor. Discussion: Based on the low rates of achieving LDL cholesterol targets, there is a considerable potential for optimizing lipid-lowering treatment worldwide. In patients with acute coronary syndrome, one of the most vulnerable patient groups in cardiology practice, the study results suggest that lipid reduction and platelet aggregation inhibition could achieve a similar reduction in the number of major cardiovascular events. Conclusion: The simulation study confirms the comparable cardiovascular benefit of the two interventions. Since the attainment rate of LDL cholesterol targets set in the guidelines is very poor – with physicians’ therapeutic inertia playing a major role –, we hope our findings will convince colleagues that more attention should be paid to more optimal lipid reduction. Orv Hetil. 2024; 165(44): 1746–1752.