Trends in lipid-lowering therapies in acute coronary syndromes after Chinese new insurance policy: a real-world analysis

BACKGROUND: The Chinese new insurance policy for proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), which made it more affordable to patients from January 1, 2022, may change lipid-lowering therapy (LLT) pattern for acute coronary syndromes (ACS), but real-world data is still lacking. This study assessed to evaluate the impact of the reimbursement policy on LLT trends and its implications. METHODS: This cohort study is based on a large, ongoing, and prospective Chinese Cardiovascular Association Database-Chest Pain Center. Between January 1, 2021, and June 30, 2022, 789,829 patients with ACS from 4441 centers aged 18-80 years were included. Patients discharged after and before the policy were observational and control group, respectively. Propensity score matching (PSM) was performed at discharge, 1 month, and 3 months. Temporal trends in LLT are grouped into the 7 most common strategies: (1) high-intensity statin (HIS) monotherapy, (2) moderate-intensity statin (MIS) monotherapy, (3) MIS plus ezetimibe, (4) MIS plus PCSK9i, (5) MIS plus ezetimibe and PCSK9i, (6) ezetimibe monotherapy, and (7) PCSK9i monotherapy. RESULTS: A total of 789,829 (age 64 ± 10.7 years; females 37.84%) patients were included (268,089 in observational group). Temporally, MIS plus PCSK9i, MIS plus ezetimibe and PCSK9i, and PCSK9i monotherapy increased, ezetimibe monotherapy decreased, and statins keep relatively constant after the new policy. After PSM in observational group, MIS monotherapy slightly decreased (81.61% vs 89.29%, P < 0.0001) at discharge but increased in 1 month (84.54% vs 80.11%, P < 0.0001) and 3 months (82.97% vs 80.09%, P = 0.0013). MIS plus PCSK9i kept growing (0.86% vs 0.33%, P < 0.0001; 1.99% vs 0.80%, P < 0.0001; and 2.57% vs 0.60%, P < 0.0001, respectively). MIS plus ezetimibe and PCSK9i (0.15% vs 0.06%, P < 0.0001), and PCSK9i monotherapy (0.09% vs 0.03%, P < 0.0001) just increased at discharge. Low-density lipoprotein cholesterol (LDL-C) goal attainment rate increased at 3 months (15.73% vs 14.02%, P = 0.0283, before PSM; 15.73% vs 13.97%, P = 0.0306, after PSM). MIS plus PCSK9i and MIS monotherapy was associated with a higher 3-month LDL-C goal attainment rate. CONCLUSIONS: The PCSK9i reimburse policy adjustment was associated with increased intensive LLT for ACS in China, especially more PCSK9i prescription, which modestly correlated to higher LDL-C goal attainment rate.