Registry Data Reveal Gaps in the Primary Prevention of Myocardial Infarction

Patients presenting to the hospital with a first acute myocardial infarction often have poorly controlled low-density lipoprotein cholesterol (LDL-C) levels due to the underutilization of lipid-lowering therapies, according to data from the Chest Pain-MI Registry presented at the 75th Annual Scientific Session of the American College of Cardiology, in New Orleans. 

“Lipid-lowering therapies continue to be the cornerstone of primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD),” said lead author Mohammed Essa, MD, a physician at Beth Israel Deaconess Medical Center in Boston, who presented the analysis in a moderated poster session. While providers should apply the principle “the lower, the better” when it comes to managing LDL-C levels, real-world data collected from patients sustaining a fist acute myocardial infarction seem to suggest that this threshold is seldom met, the speaker noted.  

Essa and colleagues collected information pertaining to more than 316,000 patients included in the Chest Pain-MI Registry between 2019 and 2023, who did not have a known history of ASCVD and were admitted with a first myocardial infarction. A vast majority of the patients were men, with a mean age of 63 years. LDL-C levels within 6 months of the acute myocardial infarction were analyzed for all patients. The researchers also looked at the use of lipid-lowering therapies at home before the heart attack and the rates of prescription of lipid-lowering therapies at discharge from the hospital. Less than one-third of patients (28.8%) were taking statins at home, and utilization of non-statin therapies was very low, both at admission and at discharge. Statins were prescribed at discharge in 95% of cases. However, combination therapy was seldom utilized, with only 0.5% of patients using it at admission and 3.8% receiving combination therapies at discharge. Rates of combination therapy utilization ranged from 0% to 7% across community and academic hospitals. 

The analysis showed that patients who were on home statins before a myocardial infarction had significantly lower LDL-C levels than the rest of the cohort, with higher proportions achieving LDL-C targets. However, lipid control remained suboptimal overall, as only 8% of the patients achieved LDL-C targets below 55 mg/dL. Use of statins at home, proportions of LDL-C at target, and use of combination lipid-lowering therapies at discharge remained largely unchanged over time, pointing to a persistently low use of preventive therapies and suboptimal LDL-C control before cardiac events. 

“Among patients presenting with their first acute myocardial infarction, the [rate of] lipid-lowering therapy use before hospitalization was low and, although we did a good job prescribing statins, the [utilization of] non-statin therapies, especially combination lipid-lowering therapies, remained very low,” Essa said. “These patterns did not change over time. Although we have proven multiple times in the literature that the lower the cholesterol [level] the better, we still have a long way to go.” 

The author noted that the observed patterns signal missed opportunities for earlier and more intensive lipid lowering. One strategy for overcoming implementation gaps is to add combination therapy as a preventive measure or at discharge after a cardiac event. “The combination lipid-lowering therapy upfront actually has a probability of [achieving] lower LDL cholesterol [levels] and better outcomes,” Essa added. “Maybe we could use metrics, or something as simple as adding a prompt into the electronic health record [to remind clinicians about combination therapy].”