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Singapore expert consensus on optimising lipid-lowering strategies in acute coronary syndrome: A modified Delphi
Ru San Tan1,2, Jonathan Yap1,2, Colin Yeo3
1Department of Cardiology, National Heart Centre Singapore, Singapore.
Insights
Expert consensus in Singapore provides new lipid management guidelines for acute coronary syndrome (ACS) patients. These recommendations aim to improve low-density lipoprotein cholesterol (LDL-C) control and reduce recurrent events.
Area of Science:
- Cardiology
- Public Health
- Pharmacology
Background:
- Acute coronary syndrome (ACS) patients face high early risks of recurrent events.
- Current post-ACS lipid management often shows delayed time-to-target low-density lipoprotein cholesterol (LDL-C) and suboptimal goal attainment.
- Therapeutic inertia and poor adherence contribute to suboptimal outcomes in real-world practice.
Purpose of the Study:
- To develop expert consensus recommendations for post-ACS lipid management specifically for Singapore.
- To define optimal LDL-C targets, pharmacotherapy strategies, and escalation protocols.
- To identify implementation tools to enhance adherence and mitigate therapeutic inertia.
Main Methods:
- A modified Delphi methodology was used with a 10-member expert panel.
- Evidence synthesis included guidelines, randomized trials, meta-analyses, and observational studies.
- Thirty-two statements across five domains were anonymously rated using a 5-point Likert scale, with consensus defined by specific thresholds.
Main Results:
- High consensus (≥75%) was achieved for 30 out of 32 statements.
- Key agreements include early lipid measurement (within 24h admission, 4-6 weeks retest), early high-intensity statin initiation, and upfront statin + ezetimibe combination therapy.
- Proprotein convertase subtilisin/kexin type 9 inhibitor consideration at discharge for LDL-C >1.4 mmol/L was recommended, alongside special considerations for older adults, familial hypercholesterolaemia, women's adherence, and lipoprotein(a).
Conclusions:
- The consensus provides a tailored framework for post-ACS lipid management in Singapore.
- Emphasis is placed on early intervention, proactive treatment escalation, and system-level strategies.
- These recommendations aim to improve adherence, reduce therapeutic inertia, and ultimately enhance post-ACS patient outcomes.
Introduction:
Acute coronary syndrome (ACS) carries a high early risk of recurrent events, yet time-to-target low-density lipoprotein cholesterol (LDL-C) is often prolonged, and goal attainment is suboptimal in real-world practice. The authors aimed to develop expert consensus recommendations for post-ACS lipid management in Singapore, focusing on LDL-C targets, pharmacotherapy, escalation strategies, and implementation tools to improve adherence and reduce therapeutic inertia.
Method:
A modified Delphi methodology was employed with a panel of 10 members. Evidence was synthesised from guidelines, randomised trials, metaanalyses, and observational studies. Thirty-two statements were drafted across 5 domains (LDL-C targets; timing/ monitoring; pharmacotherapy; special populations; implementation/adherence/health-system strategies) and rated anonymously on a 5-point Likert scale. Consensus thresholds were defined as high (≥75% concordant), moderate (55-74%), and low (<55%).
Results:
After the final round, 30 of 32 statements achieved high consensus, and 2 received low consensus. Key agreements included measuring lipids within 24 hours of admission and retesting at 4-6 weeks, early initiation of high-intensity statins, and upfront combination therapy with statin + ezetimibe when monotherapy is unlikely to achieve the goals. Consideration of a proprotein convertase subtilisin/kexin type 9 inhibitor at discharge was recommended if LDL-C remained >1.4 mmol/L. Special considerations included older adults, familial hypercholesterolaemia, lower statin adherence among women, and the role of lipoprotein(a). The panel recommended adopting objective metrics, integrating electronic health record prompts, and developing localised pathways to harmonise care transitions.
Conclusion:
The consensus recommendations provide a tailored approach for Singapore, emphasising early action, proactive escalation, and systems-level interventions to improve post-ACS outcomes.
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