Lipid management after an acute coronary syndrome: reasons to hope, reasons to persist

This editorial refers to ‘The ACS EuroPath survey series: time trends in lipid management after an acute coronary syndrome’, by U. Laufs et al., https://doi.org/10.1093/eurjpc/zwaf399. Appropriate lipid management in patients with acute coronary syndromes (ACSs) is undoubtedly crucial for cardiologists. Over the past 15–20 years, numerous studies have documented that more potent lipid-lowering therapy was associated with improved outcomes and improved survival in these patients.1 In their interesting study of everyday practice in patients with ACSs, Laufs et al.3 found improvement regarding lipid management strategies in recent years, from 2018 (i.e. before the latest guidelines were published2) to 2024. The study involved 530 cardiologists in six European countries, with 2650 patients participating in each of three surveys (2018, 2022, and 2024). Of note, as only cardiologists having a large experience in treating ACS patients (>15–20 cases per month) were invited to participate in the survey, and as the results are based on only those of them willing to participate in the surveys, it is likely that the results observed are, to some extent, more optimistic than they would have been regarding the whole population of ACS patients. Temporal trends, however, are likely to be rather similar. Patient profiles did not markedly change from 2018 to 2024, with the exception of obesity (rising from 28 to 34%) and, strangely enough, family history of premature cardiovascular disease (increasing from 29 to 36%) despite a similar age of the three populations. Of note, although 200 centres) in metropolitan France during a 1-month period 5 years apart from 2005 to 2015; LDL-c was tested during the hospital stay in 65% of the patients in 2005, 72% in 2010, and 76% in 2015 (personal data). There was no improvement, however, from 2018 to 2024, with a percentage slightly decreasing in 2024 (86%), compared with the 2018 and 2022 surveys (90%). Many of the 10–15% remaining patients with no measurement are presumably in poor overall condition or with major complications, such as cardiogenic shock, where lipid management at the acute stage is likely to be a second-line preoccupation for cardiologists. Second, more potent lipid-lowering therapy is now prescribed at discharge. In 2024, 70% of the patients received either high-dose statins or a statin–ezetimibe combination. In the FAST-MI surveys, the percentage of patients with high-intensity lipid-lowering therapy was 14% in 2005 and rose to 45% in 2010 and 46% in 2015 (Central illustration). The 2024 data therefore represent a major improvement in the appropriate use of lipid-lowering therapy. In conjunction with the generalized measurement of LDL-c (or non-HDL-c), most cardiologists seem to be appropriately convinced that in patients with higher LDL-c levels, only potent medications or combination therapy gives a chance to reach the recommended LDL-c targets.5,6 In keeping with these findings, the mean LDL-c levels during follow-up decreased, and the proportion of patients achieving the recommended