Cardiovascular Outcomes in Response to Achieved LDL-C Levels After PCI in ACS and CCS

Acute coronary syndrome (ACS) exhibits greater risks of recurrent atherosclerotic cardiovascular disease compared to chronic coronary syndrome (CCS), suggesting the need for more intensified preventive management, including low-density lipoprotein cholesterol (LDL-C) control. However, current guidelines advocate the "same" LDL-C goals in both ACS and CCS.

The authors aimed to compare cardiovascular outcomes following attainment of guideline-recommended LDL-C control between ACS and CCS.

This multicenter retrospective observational study (ACTION-LDLC; jRCT 1050260064) analyzed 2,560 Japanese patients with coronary artery disease (ACS/CCS = 1,682/878). Risk of major adverse cardiovascular events (MACE; cardiac-caused death + nonfatal MI + coronary revascularization in nonculprit segments) was compared according to achieved LDL-C levels 8 weeks after percutaneous coronary intervention (<55, 55-69 and ≥70 mg/dL) in ACS and CCS, respectively.

LDL-C <55 mg/dL was achieved in 29.4% and 32.5% of patients with ACS and CCS, respectively (P = 0.124). During the 3.7- and 3.8-year observation, achieving lower LDL-C levels was associated with reduced MACE risks in ACS (P < 0.001) and CCS (P = 0.040). Notably, lower standardized 3-year MACE rates (ACS = 4.4%, CCS = 9.9%, P < 0.001) and greater absolute risk differences (from ≥70 to <55 mg/dL: ACS = -26.5%, CCS = -5.3%, P < 0.001; from 55-69 to <55 mg/dL: ACS = -11.5%, CCS = -1.1%, P < 0.001) following achieved LDL-C <55 mg/dL were observed in ACS compared to CCS. Furthermore, in patients with achieved LDL-C <55 mg/dL (n = 780), an even lower risk of standardized 3-year MACE existed in ACS patients achieving LDL-C <40 mg/dL (log-rank P = 0.017). In contrast, in those who did not achieve LDL-C <70 mg/dL, risks of standardized 3-year MACE substantially increased in ACS compared to CCS (30.9% vs 15.2%, P < 0.001).

Distinct cardiovascular risks with LDL-C control exist in ACS compared to CCS, suggesting the potential importance of achieving stricter LDL-C goals in ACS patients.