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Recurrence of cardiovascular events despite achieving LDL-C <1.4 mmol/L in patients with coronary artery disease
Yu Kataoka1, Stephen J Nicholls2, Satoshi Kitahara3
1Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center (Kataoka, Katasako-Yabumoto, Mitsui, Murai, Iwai, Sawada, Matama, Honda, Takagi, Fujino, Yoneda, Nakao, Asaumi, and Noguchi), Osaka, Japan.
Insights
Even with low-density lipoprotein cholesterol (LDL-C) below 1.4 mmol/L, patients with coronary artery disease (CAD) face ongoing risks. Achieving LDL-C below 1.0 mmol/L may further reduce major adverse cardiovascular events (MACE).
Area of Science:
- Cardiology
- Vascular Medicine
- Clinical Research
Background:
- European Society of Cardiology guidelines recommend LDL-C <1.4 mmol/L for very high-risk patients to prevent atherosclerotic cardiovascular disease (ASCVD).
- Despite achieving target LDL-C levels, atherosclerosis progression and subsequent cardiovascular events remain a concern.
- Coronary artery disease (CAD) patients require further risk stratification beyond LDL-C levels.
Purpose of the Study:
- To investigate the clinical characteristics of CAD patients experiencing ASCVD events despite achieving LDL-C <1.4 mmol/L.
- To identify predictors of major adverse cardiovascular events (MACE) in this patient cohort.
- To evaluate the impact of achieving lower on-treatment LDL-C levels (<1.0 mmol/L) on MACE.
Main Methods:
- Retrospective analysis of 780 CAD patients who achieved LDL-C <1.4 mmol/L post-percutaneous coronary intervention.
- Comparison of clinical demographics between patients with and without MACE (cardiac death, MI, revascularization).
- Multivariate analysis to identify independent predictors of MACE, including polyvascular disease (PVD) and on-treatment LDL-C levels.
Main Results:
- MACE occurred in 6.2% of patients during a median follow-up of 1632 days.
- Patients with MACE were significantly more likely to have PVD (72.9% vs 17.3%) and less likely to receive ezetimibe (45.8% vs 63.2%).
- Lower on-treatment LDL-C <1.0 mmol/L was associated with reduced MACE risk (HR=0.37), particularly in patients with PVD (HR=0.36).
Conclusions:
- Achieving LDL-C <1.4 mmol/L does not eliminate cardiovascular risk in CAD patients.
- Polyvascular disease is a significant predictor of MACE in this population.
- A more stringent LDL-C goal (<1.0 mmol/L) may be beneficial for preventing recurrent ASCVD events, especially in patients with PVD.
Background:
The European Society of Cardiology guideline recommends lowering low-density lipoprotein cholesterol (LDL-C) to <1.4 mmol/L for the prevention of atherosclerotic cardiovascular disease (ASCVD) in patients with very high-risk. However, despite favorable LDL-C control, atherosclerosis still continues to progress, which eventually causes cardiovascular events.
Objective:
To characterize the clinical demographics of patients with coronary artery disease (CAD) who experienced subsequent ASCVD despite achieving LDL-C <1.4 mmol/L.
Methods:
The current study retrospectively analyzed 780 patients with CAD who achieved LDL-C <1.4 mmol/L after percutaneous coronary intervention. Clinical characteristics were compared between patients with and without major adverse cardiovascular events (MACE) (=cardiac death, nonfatal MI, and clinically driven coronary revascularization at nonculprit segments).
Results:
During the observational period (median = 1632 days), MACE occurred in 6.2% (=48/780) of the study population. Patients experiencing MACE were more likely to exhibit polyvascular disease (PVD) (72.9% vs 17.3%, P < 0.001). Statins and high-intensity statins were frequently used in both groups (statin = 94.8%, P = 0.218; high-intensity statin = 73.3%, P = 0.198), whereas patients with MACE were less likely to receive ezetimibe (45.8% vs 63.2%, P = 0.023). Consequently, a lower proportion of on-treatment LDL-C <1.0 mmol/L was observed in those with MACE (16.7% vs 33.2%, P = 0.018). On multivariate analysis, PVD (hazard ratio [HR] = 10.74, 95% CI = 5.65-20.39, P < 0.001) and on-treatment LDL-C <1.0 mmol/L (HR = 0.37, 95% CI = 0.17-0.81, P = 0.010) were independently associated with MACE. In patients with PVD (n = 162), on-treatment LDL-C <1.0 mmol/L was associated with a lower frequency of MACE (HR = 0.36, 95% CI = 0.14-0.87, P = 0.024).
Conclusion:
Ongoing cardiovascular risks existed despite achieving LDL-C <1.4 mmol/L. Given the association of on-treatment LDL-C <1.0 mmol/L with a reduced risk of MACE, a further lower LDL-C goal may be considered to prevent recurrence of ASCVD in patients with CAD.
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