Modifiable factors associated with failure to attain low-density lipoprotein cholesterol goal at 6 months after acute myocardial infarction

Abstract

Background: Although controversial, reducing low-density lipoprotein cholesterol (LDL-C) to target levels remains a common therapeutic goal after acute myocardial infarction (AMI). We sought to illuminate patient and provider characteristics associated with LDL-C goal nonattainment after AMI.

Methods: In an observational registry of 24 US hospitals, we included 366 patients with AMI who had baseline LDL-C levels ≥100 mg/dL and underwent 6-month fasting LDL-C reassessment. Our primary outcome was failure to reach the guideline-recommended LDL-C goal of <100 mg/dL at 6 months post-AMI.

Results: One in 3 patients with AMI with initially elevated LDL-C failed to attain LDL-C goal at 6 months. Compared with those who attained LDL-C goal, those who did not were more often discharged without a statin (21% vs 9%, P < .001), despite only 4% having documented contraindications. Patients not achieving LDL-C goal also more frequently discontinued statin use by 6 months (24% vs 6%, P < .001). Multivariable modeling (c index, 0.78) revealed the absence of a statin prescription at discharge and lack of persistence on statin therapy as the strongest independent factors associated with failure to reach LDL-C goal. Additional independent risk factors were patient report of not consistently adhering to prescribed medications, not participating in cardiac rehabilitation, nonwhite race, and lack of insurance.

Conclusions: One-third of patients with AMI with baseline hyperlipidemia do not attain the LDL-C goal of <100 mg/dL at 6 months. Our findings support targeted interventions in the transition of AMI care to promote affordable statin prescription at discharge, medication persistence and adherence, and cardiac rehabilitation participation.

Figure 1. Low-density lipoprotein cholesterol (LDL-C) levels at baseline and 6-months post-myocardial infarction in those who attained (-) and those who did not attain (- - -) LDL-C goal at 6 months

Numeric values are medians and whiskers indicate interquartile ranges.

Figure 2. Multivariable analysis of factors associated with failure to attain the low-density lipoprotein cholesterol (LDL-C) goal of <100 mg/dL at 6-months

All factors in the forest plot were included in the multivariable analysis. Relative risks (RR) and 95% confidence intervals (CI) are presented. MI = myocardial infarction.