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The benefits of measuring the size and number of lipoprotein particles for cardiovascular risk prediction: A systematic review and meta-analysis. CLÍNICA E INVESTIGACIÓN EN ARTERIOSCLEROSIS 2022:S0214-9168(22)00134-6. [PMID: 36522243 DOI: 10.1016/j.arteri.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Cardiovascular risk (CVR) is conventionally calculated by measuring the total cholesterol content of high-density lipoproteins (HDL) and low-density lipoproteins (LDL). The purpose of this systematic review was to assess the CVR associated with LDL and HDL particle size and number as determined by nuclear magnetic resonance (NMR) spectroscopy. MATERIAL AND METHODS A literature search was performed using the electronic databases MEDLINE and Scopus. All cohort and case-control studies published before January 1, 2019 that met the following inclusion criteria were included: HDL-P, LDL-P, HDL-Z and/or LDL-Z measured by NMR spectroscopy; cardiovascular event as an outcome variable; risk of cardiovascular events expressed as odds ratios or hazard ratios; only adult patients. A meta-analysis was performed for each exposure variable (4 for LDL and 5 for HDL) and for each exposure measure (highest versus lowest quartile and 1-standard deviation increment). RESULTS This review included 24 studies. Number of LDL particles was directly associated with CVR: risk increased by 28% with each standard deviation increment. LDL particle size was inversely and significantly associated with CVR: each standard deviation increment corresponded to an 8% risk reduction. CVR increased by 12% with each standard deviation increase in number of small LDL particles. HD, particle number and size were inversely associated with CVR. CONCLUSION Larger particle size provided greater protection, although this relationship was inconsistent between studies. Larger number of LDL particles and smaller LDL particle size are associated with increased CVR. Risk decreases with increasing number and size of HDL particles.
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Sarak B, Savu A, Kaul P, McAlister FA, Welsh RC, Yan AT, Goodman SG. Lipid Testing, Lipid-Modifying Therapy, and PCSK9 (Proprotein Convertase Subtilisin-Kexin Type 9) Inhibitor Eligibility in 27 979 Patients With Incident Acute Coronary Syndrome. Circ Cardiovasc Qual Outcomes 2021; 14:e006646. [PMID: 33813856 DOI: 10.1161/circoutcomes.120.006646] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While registry-based studies have shown that as many as 1 in 2 patients with stable atherosclerotic cardiovascular disease would be eligible for PCSK9i (proprotein convertase subtilisin-kexin type 9 inhibitor) therapy, this has not been studied in a large population-based postacute coronary syndrome (ACS) cohort. METHODS We examined lipid testing performed in hospital or within 90 days of discharge and lipid-lowering therapies dispensed within 90 days of discharge in patients surviving for at least 1 year after their first ACS between 2012 and 2018 in the province of Alberta, Canada. We estimated the proportion of patients eligible for PCSK9i and the expected benefits of treatment. RESULTS Of the 27 979 patients (median age 64.0 years, 29.3% female, 28.0% diabetic), 3750 (13.4%) did not have lipid testing in-hospital or within 90 days postdischarge. Untested patients were more likely to be older, female, from rural areas, to have more comorbidities, to already be on cardioprotective therapies, to present with unstable angina, and were less likely to have invasive interventions (all P<0.0001). Of the 24 229 tested, 18 767 (77.5%) had at least one lipid value above guideline-recommended threshold (LDL [low-density lipoprotein] ≥1.8 mmol/L [70 mg/dL] and non-HDL [high-density lipoprotein] ≥2.6 mmol/L [100 mg/dL]), of which 7284 (38.8%) did not have repeat testing within the year after discharge. Lipid testing in hospital was associated with higher rates of initiation or escalation of statin therapy within 90 days of their ACS (adjusted odds ratio, 2.13 [95% CI, 1.97-2.30). In total, 9592 patients (39.6% of the tested cohort) would be eligible for PCSK9i use, which could result in 184 fewer cardiovascular events over 3.4 years, including cardiovascular death, nonfatal ACS (myocardial infarction or unstable angina requiring hospitalization), and ischemic stroke. CONCLUSIONS Within 90 days of incident ACS, ≈80% of patients did not meet guideline-recommended lipid thresholds and more than one-third would potentially be eligible for PCSK9i.
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Affiliation(s)
- Bradley Sarak
- St Michael's Hospital, University of Toronto, Canada (B.S., A.T.Y., S.G.G.)
| | - Anamaria Savu
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (A.S., P.K., F.A.M., R.C.W., S.G.G.)
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (A.S., P.K., F.A.M., R.C.W., S.G.G.)
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (A.S., P.K., F.A.M., R.C.W., S.G.G.)
| | - Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (A.S., P.K., F.A.M., R.C.W., S.G.G.).,Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Canada (R.C.W.)
| | - Andrew T Yan
- St Michael's Hospital, University of Toronto, Canada (B.S., A.T.Y., S.G.G.)
| | - Shaun G Goodman
- St Michael's Hospital, University of Toronto, Canada (B.S., A.T.Y., S.G.G.).,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (A.S., P.K., F.A.M., R.C.W., S.G.G.)
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Gouda P, Welsh RC, Padarath M, Grégoire JC, Hegele RA, Gupta M. Landscape of Lipid Management Following an Acute Coronary Syndrome Event: Survey of Canadian Specialists. CJC Open 2020; 2:625-631. [PMID: 33305223 PMCID: PMC7710998 DOI: 10.1016/j.cjco.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022] Open
Abstract
Background Following the occurrence of an acute coronary syndrome (ACS), patients are at high risk for subsequent cardiovascular events. Therapies to lower the level of low-density lipoprotein (LDL) cholesterol remain a pillar in secondary prevention approaches following ACS. Significant variability remains in the application of therapies to lower cholesterol level in clinical practice. Methods A cross-sectional, online survey was conducted of 200 cardiovascular and lipid specialists across Canada who routinely care for patients following the occurrence of ACSs. The survey consisted of 50 multiple-choice questions with opportunities for free-text entry exploring knowledge of lipid guidelines and recent clinical trials, and in-hospital and outpatient management of lipids and familial hypercholesterolemia. Results A total of 67.5% (n = 135) of participants stated that a lipid panel would routinely be obtained during the first 24 hours of an admission for an ACS, and 68.5% (n = 137) stated that their hospitals had standing orders for statin initiation at ACS presentation. In high-risk patients, the majority (75.5%; n = 151) of participants indicated that they target an LDL cholesterol level of <1.8 mmol/L. However, a subset (22%; n = 44) would target lower LDL cholesterol levels ranging from 0.5 to 1.7 mmol/L. Only 32.0% (n = 64) of participants stated that >70% of their ACS patients were at or below guideline-recommended LDL cholesterol levels. Respondents generally underappreciated the prevalence of familial hypercholesterolemia in both the general population and ACS patients. Conclusions There is significant variation in practice patterns involving therapies to lower LDL cholesterol level in the post–ACS onset period. To improve management of lipids in this high-risk population, changes to institutional policies, shared responsibility of lipid management across multiple disciplines, and physician education are required.
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Affiliation(s)
- Pishoy Gouda
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Robert C Welsh
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Jean C Grégoire
- Division of Cardiology, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Robert A Hegele
- Department of Medicine, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Milan Gupta
- Canadian Collaborative Research Network, Brampton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Nakahashi T, Tada H, Sakata K, Yakuta Y, Tanaka Y, Nomura A, Gamou T, Terai H, Horita Y, Ikeda M, Namura M, Takamura M, Hayashi K, Yamagishi M, Kawashiri MA. Paradoxical impact of decreased low-density lipoprotein cholesterol level at baseline on the long-term prognosis in patients with acute coronary syndrome. Heart Vessels 2017; 33:695-705. [PMID: 29288404 DOI: 10.1007/s00380-017-1111-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 12/22/2017] [Indexed: 11/30/2022]
Abstract
Although statin therapy is beneficial in the setting of acute coronary syndrome (ACS), a substantial proportion of patients with ACS still do not receive the guideline-recommended lipid management in contemporary practice. We hypothesize that the low-density lipoprotein cholesterol (LDL-C) level at the time of admission might affect patient management and the subsequent outcome. Nine-hundred and forty-two consecutive patients with ACS who underwent percutaneous coronary intervention were analyzed retrospectively. The study patients were first divided into two groups based on the LDL-C level on admission: group A (n = 267), with LDL-C < 100 mg/dL; and group B (n = 675), with LDL-C ≥ 100 mg/dL. Each group was then further divided into those who were prescribed statins or not at the time of discharge from the hospital. The primary endpoint was all-cause death. In addition, we analyzed the serial changes of LDL-C within 1 year. Patients in group A were significantly older and more likely to have multiple comorbidities compared with group B. The proportion of patients who were prescribed statin at discharge was significantly smaller in group A compared with group B (57.7 vs. 77.3%, p < 0.001). During the median 4-year follow-up, there were 122 incidents of all-cause death. Multivariate Cox proportional hazard analysis revealed that LDL-C < 100 mg/dL on admission [hazard ratio (HR), 1.61; 95% confidence interval (CI), 1.09-2.39; p < 0.05] and prescription of statins at discharge (HR, 0.52; 95% CI, 0.36-0.76; p < 0.001) were associated significantly with all-cause death. Under these conditions, increasing LDL-C levels were documented during follow-up in those patients in group A when no statins were prescribed at discharge (79 ± 15-96 ± 29 mg/dL, p < 0.001), whereas these remained unchanged when statins were prescribed at discharge (79 ± 15-77 ± 22 mg/dL, p = 0.30). These results demonstrate that decreased LDL-C on admission in ACS led to less prescription for statins, which could result in increased death, probably due to underestimation of the baseline LDL-C.
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Affiliation(s)
- Takuya Nakahashi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hayato Tada
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Kenji Sakata
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yohei Yakuta
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Yoshihiro Tanaka
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Akihiro Nomura
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Tadatsugu Gamou
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hidenobu Terai
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Yuki Horita
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masatoshi Ikeda
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masanobu Namura
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masayuki Takamura
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Kenshi Hayashi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Masakazu Yamagishi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.
| | - Masa-Aki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
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Zhang L, Li J, Li X, Nasir K, Zhang H, Wu Y, Hu S, Wang Q, Downing NS, Desai NR, Masoudi FA, Spertus JA, Krumholz HM, Jiang L. National Assessment of Statin Therapy in Patients Hospitalized with Acute Myocardial Infarction: Insight from China PEACE-Retrospective AMI Study, 2001, 2006, 2011. PLoS One 2016; 11:e0150806. [PMID: 27058862 PMCID: PMC4825974 DOI: 10.1371/journal.pone.0150806] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 02/19/2016] [Indexed: 12/03/2022] Open
Abstract
Background Statin therapy is among the most effective treatments to improve short- and long-term mortality after acute myocardial infarction. The use of statin, and the intensity of their use, has not been described in acute myocardial infarction patients in China, a country with a rapidly growing burden of cardiovascular disease. Methods and Results Using a nationally representative sample of patients with acute myocardial infarction admitted to 162 Chinese hospitals in 2001, 2006 and 2011, we identified 14,958 patients eligible for statin therapy to determine rates of statin use and the intensity of statin therapy, defined as those statin regimens with expected low-density lipoprotein cholesterol lowering of at least 40%, to identify factors associated with the use of statin therapy. Statin use among hospitalized patients with acute myocardial infarction increased from 27.9% in 2001 to 72.5% in 2006, and 88.8% in 2011 (P<0.001 for trend). Regional variation in statin use correspondingly decreased over time. Among treated patients, those receiving intensive statin therapy increased from 1.0% in 2001 to 24.2% in 2006 to 57.2% in 2011(P<0.001 for trend). Patients without low-density lipoprotein cholesterol measured were less likely to be treated with statin or to receive intensive therapy. Conclusions The use of statin therapy has dramatically increased over the past decade in Chinese patients with acute myocardial infarction. However, half of patients still did not receive intensive statin therapy in 2011.Given that guidelines strongly endorse intensive statin therapy for acute myocardial infarction patients, initiatives promoting the use of statin therapy, with attention to treatment intensity, would support further improvements in practice.
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Affiliation(s)
- Lihua Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Khurram Nasir
- Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, Miami, Florida, United States of America.,Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, United States of America
| | - Haibo Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yongjian Wu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shuang Hu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qing Wang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Nicholas S Downing
- The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
| | - Nihar R Desai
- The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri Kansas City, Kansas City, Missouri, United States of America
| | - Harlan M Krumholz
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, United States of America.,Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, United States of America.,Department of Health Policy and Management, Yale School of Public Health, New Haven, United States of America
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Current practice on the management of acute coronary syndrome in China. Int J Cardiol 2013; 169:1-6. [DOI: 10.1016/j.ijcard.2013.08.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/29/2013] [Indexed: 11/18/2022]
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Spighi A, Tartagni E, D’Addato S, Dormi A, Borghi C. Lipid-lowering treatment in patients at high cardiovascular risk discharged from an Italian hospital. J Cardiovasc Med (Hagerstown) 2013; 14:270-5. [DOI: 10.2459/jcm.0b013e328355fae8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Giugliano RP, Braunwald E. The Year in Non–ST-Segment Elevation Acute Coronary Syndrome. J Am Coll Cardiol 2012; 60:2127-39. [DOI: 10.1016/j.jacc.2012.08.972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 08/06/2012] [Accepted: 08/13/2012] [Indexed: 10/27/2022]
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Kim MJ, Jeon DS, Gwon HC, Kim SJ, Chang K, Kim HS, Tahk SJ. Current statin usage for patients with acute coronary syndrome undergoing percutaneous coronary intervention: multicenter survey in Korea. Clin Cardiol 2012; 35:700-6. [PMID: 22825844 DOI: 10.1002/clc.22038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 06/09/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Although high-dose statin therapy has been reported to improve outcomes in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), patterns of statin usage for such patients have not been reported in real-world clinical practice. HYPOTHESIS Some clinical factors would affect the pattern of statin usage in patients with ACS. METHODS In the multicenter prospective registry, 3362 patients with ACS who underwent PCI were analyzed. High-dose statin treatment was defined as atorvastatin ≥40 mg or rosuvastatin ≥20 mg per day. The patterns of statin usage were investigated for 30 days after the index PCI. RESULTS High-dose statins were administered prior to PCI to 13.7% and 19.6% of patients with unstable angina/non-ST-elevated myocardial infarction (UA/NSTEMI) and ST-elevated myocardial infarction (STEMI), respectively (P < 0.001). After PCI, 476 (14.2%) patients were maintained on high-dose statins, and 550 (16.4%) patients received no statins. Independent factors associated with high-dose statin usage after PCI were STEMI (odds ratio [OR]: 1.704, 95% confidence interval [CI]: 1.321-2.197, P < 0.001), high total cholesterol level (OR: 1.445, 95% CI: 1.136-1.837, P = 0.003), and current smoker (OR: 1.556, 95% CI: 1.206-2.008, P < 0.011). The absence of hypercholesterolemia was an independent factor determining the nonuse of statins (OR: 0.229, 95% CI: 0.148-0.353, P < 0.001). CONCLUSIONS In real-world clinical practice, high-dose statin treatment is being underused despite extensive evidence for patients with ACS undergoing PCI, particularly in UA/NSTEMI. Efforts are needed to ensure that clinical practice complies with evidence-based guidelines.
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Affiliation(s)
- Mi-Jeong Kim
- Cardiovascular Center, Incheon St. Mary's Hospital, The Catholic University, Incheon, Republic of Korea
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