Analysis of Residual Risk and Recurrent Event Trends Following Acute Coronary Syndrome: A Cohort Study

Background: A comprehensive real-world analysis of residual risk factors for recurrent major adverse cardiovascular events (MACE) following hospital admission for acute coronary syndrome (ACS) is lacking. The objectives of this study were: 1) to describe population trends for outcomes, risk factors, and medication prescribing patterns post-ACS and 2) to identify factors associated with recurrent MACE. Methods: A retrospective cohort study of 4,884 post-ACS patients admitted at a large integrated healthcare system between 2015-2021 was performed to investigate the relationship between recurrent MACE (ACS, cerebrovascular events, all-cause mortality, and unplanned revascularization), modifiable risk factor trends, and medical therapy prescribing patterns. Patients were separated into 2 cohorts based upon whether they experienced recurrent MACE following the initial hospitalization. Data were obtained via programmatic extraction from the electronic health record. Descriptive statistics were performed. Generalized linear models were used to assess risk factor trends and pairwise comparisons were performed between time points. Results: Median length of follow-up after ACS was 31.2 months. Recurrent MACE occurred in 28% of patients. Despite 95.9% of all patients receiving prescriptions for high-intensity statins, >40% did not achieve LDL-C goal of <70 mg/dL, and only 11.6% and 2.6% of all patients were prescribed ezetimibe or proprotein convertase subtilisin kexin type 9 inhibiting monoclonal antibodies, respectively. Although >30.0% of patients had triglycerides ≥150 mg/dL at all time points, ≤6% were prescribed any non-statin triglyceride lowering therapy and 0.6% were prescribed icosapent ethyl. Persistent hypertriglyceridemia (≥150 mg/dL) was associated with recurrent MACE at 6-, 12-, and 24-months post-ACS (p<0.05), and the relative risk ranged between 1.20-1.35 at those timepoints. Conclusions: This study demonstrates the need for more comprehensive post-ACS care to address residual cardiometabolic risk factors and suboptimal prescribing patterns for indicated therapies. Targeted strategies are needed to address hypertriglyceridemia for cardiovascular risk reduction.