J Clin Lipidol. 2026 Jun 13:S1933-2874(26)00396-X. doi: 10.1016/j.jacl.2026.06.008. Online ahead of print.
ABSTRACT
BACKGROUND: The European Society of Cardiology guideline recommends lowering low-density lipoprotein cholesterol (LDL-C) to <1.4 mmol/L for the prevention of atherosclerotic cardiovascular disease (ASCVD) in patients with very high-risk. However, despite favorable LDL-C control, atherosclerosis still continues to progress, which eventually causes cardiovascular events.
OBJECTIVE: To characterize the clinical demographics of patients with coronary artery disease (CAD) who experienced subsequent ASCVD despite achieving LDL-C <1.4 mmol/L.
METHODS: The current study retrospectively analyzed 780 patients with CAD who achieved LDL-C <1.4 mmol/L after percutaneous coronary intervention. Clinical characteristics were compared between patients with and without major adverse cardiovascular events (MACE) (=cardiac death, nonfatal MI, and clinically driven coronary revascularization at nonculprit segments).
RESULTS: During the observational period (median = 1632 days), MACE occurred in 6.2% (=48/780) of the study population. Patients experiencing MACE were more likely to exhibit polyvascular disease (PVD) (72.9% vs 17.3%, P < .001). Statins and high-intensity statins were frequently used in both groups (statin = 94.8%, P = .218; high-intensity statin = 73.3%, P = .198), whereas patients with MACE were less likely to receive ezetimibe (45.8% vs 63.2%, P = .023). Consequently, a lower proportion of on-treatment LDL-C <1.0 mmol/L was observed in those with MACE (16.7% vs 33.2%, P = .018). On multivariate analysis, PVD (hazard ratio [HR] = 10.74, 95% CI = 5.65-20.39, P < .001) and on-treatment LDL-C <1.0 mmol/L (HR = 0.37, 95% CI = 0.17-0.81, P = .010) were independently associated with MACE. In patients with PVD (n = 162), on-treatment LDL-C <1.0 mmol/L was associated with a lower frequency of MACE (HR = 0.36, 95% CI = 0.14-0.87, P = .024).
CONCLUSION: Ongoing cardiovascular risks existed despite achieving LDL-C <1.4 mmol/L. Given the association of on-treatment LDL-C <1.0 mmol/L with a reduced risk of MACE, a further lower LDL-C goal may be considered to prevent recurrence of ASCVD in patients with CAD.
PMID:42373416 | DOI:10.1016/j.jacl.2026.06.008