Were LDL-C targets achieved before acute coronary syndrome? A SCORE2-based primary prevention study

Introduction

Cardiovascular risk stratification tools such as SCORE2 and SCORE2-OP provide guidance for LDL-C targets in primary prevention. However, real-world adherence to these targets prior to acute events remains uncertain. Understanding whether patients admitted for acute coronary syndrome (ACS) had previously achieved guideline-recommended LDL-C levels may inform earlier intervention strategies.

Purpose

To evaluate whether patients admitted for ACS were at their recommended LDL-C targets according to cardiovascular risk category as defined by SCORE2 or SCORE2-OP.

Methods

This single-center retrospective study included patients hospitalized with ACS and enrolled in the Portuguese Registry of Acute Coronary Syndromes between October 2010 and July 2025. For each patient, SCORE2 or SCORE2-OP was calculated based on age, sex, smoking status, systolic blood pressure, and lipid profile at admission. Patients were then categorized into low, moderate, high, or very high cardiovascular risk according to 2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias (SCORE2/SCORE2-OP 2%, 2 and 10%, 10 and 20%, and 20%, respectively). LDL-C levels at index event were compared against the recommended targets for each risk category according to ESC guidelines. Patients with previous established cardiovascular disease, diabetes mellitus, chronic kidney disease, or familiar hypercholesterolaemia were excluded.

Results

A total of 751 patients were included (74% male, mean age of 63.7 13.6 years, 57.5% admitted for STEMI). Cardiovascular risk factors were frequent: 48.3% had arterial hypertension, 33.0% were smokers, 49.4% had dyslipidaemia, 6.3% family history of coronary disease and 18.9% were obese. Mean systolic blood pressure was 140.9 29.0 mmHg, total cholesterol was 189.2 46 mg/dL, and HDL-C 47.0 12.6 mg/dL.

Overall, 256 (34.1%) were classified as high risk and 126 (16.8%) as very high risk. Among very high-risk patients, only 4 (3.2%) had LDL-C <55 mg/dL and 16 (12.7%) had LDL-C <70 mg/dL, while 24 (9.3%) of high-risk patients achieved LDL-C <70 mg/dL and 89 (34.7%) achieved LDL-C <100 mg/dL. Prior statin use was documented in 33.3% of very high- and 25.8% of high-risk patients, among whom only 20.6% had LDL-C <70 mg/dL.

Conclusions

Most patients admitted for ACS had not achieved LDL-C targets appropriate for their cardiovascular risk level. These findings reveal a substantial gap in primary prevention and highlight the need for improved risk stratification and more aggressive lipid-lowering therapy in high-risk individuals.