Application of the 2019 ESC/EAS dyslipidaemia guidelines to nationwide data of patients with a recent myocardial infarction: a simulation study

Abstract

Aims: To estimate the proportion of patients with a recent myocardial infarction (MI) who would be eligible for additional lipid-lowering therapy according to the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidaemias, and to simulate the effects of expanded lipid-lowering therapy on attainment of the low-density lipoprotein cholesterol (LDL-C) target as recommended by the guidelines.

Methods and results: Using the nationwide SWEDEHEART register, we included 25 466 patients who had attended a follow-up visit 6-10 weeks after an MI event, 2013-17. While most patients (86.6%) were receiving high-intensity statins, 82.9% of the patients would be eligible for expanded lipid-lowering therapy, as they had not attained the target of an LDL-C level of <1.4 mmol and a ≥50% LDL-C level reduction. When maximized use of high-intensity statins followed by add-on therapy with ezetimibe was simulated using a Monte Carlo model, the LDL-C target was reached in 19.9% using high-intensity statin monotherapy and in another 28.5% with high-intensity statins and ezetimibe, while 50.7% would still be eligible for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. When use of alirocumab or evolocumab was simulated in those who were eligible for PCSK9 inhibitors, around 90% of all patients attained the LDL-C target.

Conclusion: Our study suggests that, even with maximized use of high-intensity statins and ezetimibe, around half of patients with MI would be eligible for treatment with PCSK9 inhibitors according to the 2019 ESC/EAS guidelines. Considering the current cost of PCSK9 inhibitors, the financial implications of the new guidelines may be substantial.

Keywords: ESC/EAS guidelines; Ezetimibe; LDL cholesterol target; PCSK9 inhibitors; Statins; Treatment goals.

Figure 1

Logic of scenarios for lipid-lowering treatment intensification and percentage of patients flowing through the treatment intensification logic in the simulation. High-intensity statin was defined as atorvastatin ≥40 mg, rosuvastatin ≥20 mg, or simvastatin 80 mg; patients who initiated high-intensity statin therapy in the simulation were set to receive atorvastatin 80 mg. ^aAlirocumab 75 mg biweekly. ^bEvolocumab 140 mg biweekly/420 mg monthly.

Figure 2

A flowchart for study population.

Figure 3

Observed and simulated proportions of the population by lipid-lowering therapy and low-density lipoprotein cholesterol target achievement. HIS, high-intensity statins; LMIS, low/moderate-intensity statins. ^aBiweekly and ^bmonthly.

Figure 4

Observed and simulated distribution of low-density lipoprotein cholesterol levels. The distribution of low-density lipoprotein cholesterol levels for proprotein convertase subtilisin/kexin type 9 inhibitors is shown for alirocumab 75 mg. The low-density lipoprotein cholesterol level distribution for evolocumab is shown in Supplementary material online, Figure S1.

Take home figure

Observed and simulated levels of low-density lipoprotein cholesterol, lipid-lowering therapy, and low-density lipoprotein cholesterol target attainment according to the 2019 ESC/EAS dyslipidaemia guidelines.