Diabetes, Long-Term mortality, and LDL-C target attainment after an acute coronary syndrome: A population-based...

To quantify the excess acute coronary syndrome (ACS) burden and post-ACS mortality associated with diabetes and assess LDL-C target attainment, focusing on sex differences.

We conducted a retrospective cohort study including 5,361 patients with the first ACS admission identified during the study period (2016-2024) in a Spanish healthcare department. Hospitalization trends were analyzed using population-based regression models. Long-term mortality was assessed by Kaplan-Meier and multivariable Cox regression. LDL-C target attainment was evaluated according to ESC/EAS recommendations.

Diabetes was present in 36.9 % of patients. ACS hospitalization rates declined by 8.3 % annually (95 % CI 6.1-10.4), with no diabetes-by-time interaction (p = 0.17). In-hospital case fatality was 6.3 % and did not differ by diabetes status. During a median 4.9-year follow-up, diabetes was associated with higher all-cause mortality (adjusted HR 1.22, 95 % CI 1.11-1.33), with a stronger association in women than men (interaction p = 0.009). Only 28.9 % achieved LDL-C < 55 mg/dL, with no temporal improvement; female sex independently predicted poor LDL-C control (adjusted OR 1.65, 95 % CI 1.38-1.97).

Despite declining ACS hospitalizations, DM remained associated with increased long-term mortality, particularly in women. LDL-C target attainment remained suboptimal, highlighting persistent gaps in secondary prevention.