Impact of a personalized, strike early and strong approach on non-HDL-cholesterol levels and outcome in patients with acute myocardial infarction

Aims: We retrospectively evaluated the impact on non-HDL-cholesterol (non-HDL-C) levels of the systematic introduction in our institution of an individualized, pre-defined, strike early and strong (SES) strategy for lipid-lowering therapy (LLT) in patients with acute myocardial infarction (MI). Methods: We analyzed data from 500 consecutive patients admitted across three periods: Period A (N = 198, January-June 2019), when the non-HDL-C goal was <100 mg/dL and a stepwise LLT approach was indicated; Period B (N = 180, January-June 2021), when the non-HDL-C goal was <85 mg/dL and a stepwise approach was recommended; Period C (N = 122, January-June 2023), when the SES protocol was introduced. Primary endpoints were the percentage of patients reaching the non- HDL-C goal during follow-up and the incidence of major adverse cardiovascular events (MACE) at one year. Results: Compared to the other periods, the prevalence of prescription at discharge of potent statins, alone or in combination with ezetimibe, and PCSK9 inhibitors was greater in Period C. The achievement of the non-HDL-C goal in Period C was higher (87 % vs 67 % and 58 % in Periods A and B, respectively; p < 0.001). This achievement was associated with a lower occurrence of MACE (7 % vs. 13 % in patients not at target; log-rank p = 0.027). MACE incidence was the lowest in patients with early and sustained non-HDL-C < 85 mg/dL during follow-up. Conclusion: The systematic introduction of an individualized, SES approach for LLT in patients with acute MI led to higher achievement of the non-HDL-C goal and this translated into a lower risk of MACE.