Less intensive lipid-lowering therapy after ST-elevation myocardial infarction is associated with cardiovascular events: 2-year follow-up of "Jena auf Ziel"

Abstract

Background: "Jena auf Ziel" ("JaZ") is a prospective cohort study in patients with ST-elevation myocardial infarction (STEMI). Early combination of a statin and ezetimibe was initiated on the day of admission and lipid-lowering therapy (LLT) was escalated during follow-up with bempedoic acid (BA) and PCSK9 inhibitors (PCSK9-I) to reach guideline-recommended LDL-cholesterol (LDL-C) levels. During the initial follow-up period of 12 months, all patients reached the recommended ESC/EAS LDL-C target for very high-risk patients of < 55 mg/dL.

Methods: Twelve months after the index event, patients enrolled in "JaZ" had the option of either continuing with regular follow-ups in the outpatient lipid clinic of the university hospital Jena or transitioning to standard care by their general practitioners (GPs). Fifty-three patients (62%) stayed with the outpatient lipid clinic and 32 (38%) preferred treatment by their local GP. After 24 months, we analyzed differences in prescribed lipid-lowering drugs, LDL-C target attainment, LDL-C time on target, and major adverse cardiac events (MACEs = nonfatal ischemic cardiovascular events, admission for heart failure, nonfatal stroke) between groups.

Results: All 85 patients enrolled in the initial study were followed up for 24 months. The average LDL-C after 24 months was 1.47 ± 0.71 mmol/L in the total study population. Fifty-one patients (60%) of the entire cohort were still on LDL-C target of 1.4 mmol/L or below (outpatient lipid clinic group: 72.5% vs. GP group: 27.5%; p = 0.037). The average LDL-C in patients followed up in the outpatient lipid clinic was significantly lower compared to patients who were treated by GPs (1.2 ± 0.7 mmol/L vs. 2.1 ± 1.04 mmol/L; p < 0.01). Moreover, patients in the outpatient lipid clinic had a longer time on LDL-C targets compared to patients treated by GPs (82.4 ± 29.5% vs. 62.4 ± 36.6%; p < 0.01). The main cause of missed LDL-C targets was deprescribing of LLT by local GPs, surpassing non-adherence (2.1 ± 1.04 mmol/L vs. LDL-C: 1.52 ± 0.53 mmol/L; p < 0.01). Patients with MACE during follow-up were characterized by a shorter time on LDL-C targets compared to patients without MACE (58.1 ± 29.9% vs. 79.1 ± 28.1%; p = 0.048) and higher LDL-C levels at 24 months (2.04 ± 1.26 mmol/L vs. 1.27 ± 0.72 mmol/L; p < 0.01).

Conclusion: In this cohort of STEMI patients, a less intensive lipid-lowering strategy during a 2-year follow-up was associated with higher LDL-C levels and a higher incidence of MACE. Therefore, a regular follow-up in a specialized lipid outpatient clinic was superior to standard care treatment by general practitioners.

Keywords: Jena auf Ziel; LDL-C; Lipid clinic; Lipid-lowering therapy; STEMI.