Closing the gap in LDL-cholesterol goal attainment after myocardial infarction: progress and persistent challenges

Introduction

The European Society of Cardiology Guidelines recommend an LDL cholesterol (LDL-C) <55 mg/dL for patients with established atherosclerotic cardiovascular disease, but real-word data show that many patients fail to reach this target.

This study assessed temporal trends in LDL-C goal attainment and lipid-lowering therapy use over a three-year period in patients with prior myocardial infarction (MI).

Methods

This single-center cross-sectional study included 800 post-MI patients followed by 20 cardiologists in a tertiary hospital. A random sample of 20 patients per cardiologist was selected from consultations that took place in 2022 (2022 cohort, n=400) and 2025 (2025 cohort, n=400). Patients were eligible if they had a type 1 MI ≥6 months before the appointment, and stable lipid-lowering therapy for ≥6 weeks before a fasting lipid profile.

Results

The overall population had a mean age of 68 ± 12 years, with 78% male. There were no significant differences between the 2022 and 2025 cohorts regarding age, sex, cardiovascular risk factors, subtype of MI (STEMI vs. NSTEMI), or the proportion of patients with recent MI (<1 year).

The median LDL-C under therapy decreased from 70 mg/dL (IQR 58–86) in 2022 to 61 mg/dL (IQR 49–76) in 2025 (p < 0.001). Accordingly, the proportion of patients reaching LDL-C <55 mg/dL increased from 22% in 2022 to 36% in 2025 (p<0.001). There were significant increases in the use of high intensity statins, ezetimibe, PCSK9 inhibitors, and overall combination therapy (Figure). Despite these improvements, in the 2025 cohort, 69% of patients (n=178) who failed to reach LDL-C target did not have their therapy intensified, 47% of whom (n=84) with LDL-C values ≥70mg/dL. There was also a significant increase in the proportion of patients who were openly non-compliant or refused lipid therapy (2.5% vs. 5.0%, p=0.003).

Conclusion

LDL-C levels and target attainment improved over the three-year period, yet fewer than four in ten post-MI patients achieve the ESC-recommended goal. At the current rate of progress, many years will be required to reach acceptable LDL-C control in this very-high-risk population. Persistent therapeutic inertia and a rising number of patients refusing or discontinuing therapy further emphasize the need for more effective implementation of guideline-directed lipid management.For image description, please refer to the figure legend and surrounding text.