The current state of secondary prevention in high-risk patients

The current state of secondary prevention in high-risk patients
Hello, I'm Tom Lüscher. I'm a cardiologist at the Royal Brompton and Harefield Hospitals and, currently, president of the European Society of Cardiology.
The ESC is very concerned about guideline implementation, and in fact, we have organized cardiovascular roundtables together with industry, EMA and device industry.
In this particular study that I would like to share with you, which is work from my fellows, Majid Akhtar, Florian Wenzl, Francesco Bruno, and Allan Davies, is a study on a registry in North West London of Imperial College called the Discover Registry.
Here, we have 76-odd thousand patients after PCI with ischemic heart disease. We looked at the secondary prevention after this intervention to see what, and there's a focus on lipids of course, statin use, LDL measurements, and the like, would do on outcomes. Now, the key success factor of registries in the United Kingdom is that it provides full documentation of mortality of every single patient as well as MACE. This is unique. Many have looked at lipid control, looking at LDL levels. We are looking at hard endpoints. That's the novelty.
Here, you see if you measure LDL in a patient, it reflects the quality of care. Here, you see that the frequency of lipid measurement and outcomes is very, very important. On top of the curve, you see those guys that never measured their LDL, they have the highest mortality. If you measure it once, it's much lower. If you measure it several times, it's the lowest mortality. That means if you know about your LDL levels, you're measuring not just LDL, you're reacting to it, and you adapt, of course, treatment, and that translates into better outcomes. On the left, you see all-cause deaths. On the right, you see major cardiovascular events with a very similar picture.
Then, of course, we looked at patients with chronic coronary syndromes. You just had the guidelines of the ESC published, and here we see exactly the same thing. If you don't measure it, very high mortality. If you at least measure it once, you react to it after the event, and you improve outcomes. If you measure it several times, the best outcome. This is true for chronic coronary syndromes as well as acute coronary syndromes on the left and right respectively.
Then, of course, there are doctors that are very sleepy after the procedure or they believe they cured the patient and don't prescribe a statin at discharge. You can see that really separates dramatically all-cause deaths on the left. If you don't have a statin, of course, very high mortality. If you have a statin, much lower, and this applies both for all-cause deaths on the left and for MACE on the right. Furthermore, we looked at this again in chronic coronary syndromes on the left and the ACS on the right. Same picture.
It doesn't matter whether you had an acute event or just went for a stenting of angina or ischemia. Same thing. You need a statin to improve outcomes. Furthermore, we looked at the statin dose. You can, of course, prescribe a statin at low dose if you're a very cautious physician or at high dose if you're an aggressive one that wants to achieve everything. You can see, again, if you go for a high-dose statin, on the left, all-cause deaths, on the right, MACE. Again, massive difference.
We need a high-dose statin as the ESC guidelines recommend in high-risk patients. Then, of course, again, if we look at chronic coronary syndromes, a bit lower risk than those with an acute coronary syndrome. The effect size is significant in both. It's a bit more dominant, more pronounced in those with acute coronary syndromes.
Then we looked also at statin adherence and outcomes. Some patients read the fake news in the net and stop their statin. Of course, as you see, this is really not good. If you stop your statin, you have the highest mortality on the left and on the right it relates also to MACE. Again, we looked at the incidence of all-cause deaths in chronic coronary syndromes on the left and acute coronary syndromes on the right.
Clearly, you need to measure your lipids, you need a statin, you need high-dose statin after PCI, and you have to continue it for good. This is the lesson, not just on LDL levels but on mortality and MACE, and this really matters.
Thank you very much for your attention.
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