Paradoxical impact of decreased low-density lipoprotein cholesterol level at baseline on the long-term prognosis in patients with acute coronary syndrome

Abstract

Although statin therapy is beneficial in the setting of acute coronary syndrome (ACS), a substantial proportion of patients with ACS still do not receive the guideline-recommended lipid management in contemporary practice. We hypothesize that the low-density lipoprotein cholesterol (LDL-C) level at the time of admission might affect patient management and the subsequent outcome. Nine-hundred and forty-two consecutive patients with ACS who underwent percutaneous coronary intervention were analyzed retrospectively. The study patients were first divided into two groups based on the LDL-C level on admission: group A (n = 267), with LDL-C < 100 mg/dL; and group B (n = 675), with LDL-C ≥ 100 mg/dL. Each group was then further divided into those who were prescribed statins or not at the time of discharge from the hospital. The primary endpoint was all-cause death. In addition, we analyzed the serial changes of LDL-C within 1 year. Patients in group A were significantly older and more likely to have multiple comorbidities compared with group B. The proportion of patients who were prescribed statin at discharge was significantly smaller in group A compared with group B (57.7 vs. 77.3%, p < 0.001). During the median 4-year follow-up, there were 122 incidents of all-cause death. Multivariate Cox proportional hazard analysis revealed that LDL-C < 100 mg/dL on admission [hazard ratio (HR), 1.61; 95% confidence interval (CI), 1.09-2.39; p < 0.05] and prescription of statins at discharge (HR, 0.52; 95% CI, 0.36-0.76; p < 0.001) were associated significantly with all-cause death. Under these conditions, increasing LDL-C levels were documented during follow-up in those patients in group A when no statins were prescribed at discharge (79 ± 15-96 ± 29 mg/dL, p < 0.001), whereas these remained unchanged when statins were prescribed at discharge (79 ± 15-77 ± 22 mg/dL, p = 0.30). These results demonstrate that decreased LDL-C on admission in ACS led to less prescription for statins, which could result in increased death, probably due to underestimation of the baseline LDL-C.

Impact of decreased ankle-brachial index on 30-day bleeding complications and long-term mortality in patients with acute coronary syndrome after percutaneous coronary intervention

“…The details of the study population have been described previously [15]. In brief, from November 2006 to October 2014, 1115 consecutive patients with ACS who underwent emergent coronary angiography were analyzed retrospectively.…”

“…Platelet glycoprotein IIb/IIIa receptor inhibitors were not used because these were, and continue to be, unavailable in Japan. Postprocedural administration of antiplatelet therapy has been described elsewhere [15]. All patient data, including the clinical records, laboratory results, and angiograms, were reviewed independently by two cardiologists.…”

“…Calculation of REPLACE bleeding score included the following variables: age, sex, estimated glomerular filtration rate, anemia, administration of low-molecular-weight heparin within 48 h pre-PCI, use of glycoprotein IIb/IIIainhibitors, and intra-aortic balloon pump. Anemia was defined as admission hemoglobin <13 g/dL in men or <12 g/dL in women [15]. Full details on the calculation of the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines (CRU-SADE) bleeding score are reported elsewhere [11].…”

Malnutrition Affects Cholesterol Paradox in Coronary Artery Disease: a 41,229 Chinese Cohort Study

“…Similarly, the results suggest cholesterol paradox may due to other clinical characteristics. Reddy et al, Al-Mallah et al and Nakahashi et al demonstrated that lower baseline LDL-C level was associated with higher mortality before and after adjusting for baseline confounders [5][6][7]. All ve studies attempted to explore the mechanisms behind the paradox by taking baseline confounding factors into account, which included demographic information and comorbidities.…”

“…Elevated low density lipoprotein cholesterol (LDL-C) concentration constitutes a major risk factor for poor prognosis of coronary artery disease [1,2]. Recent studies found that low levels of LDL-C were paradoxically associated with poor prognosis in patients with ACS, which was called "cholesterol paradox" [3][4][5][6][7]. LDL-C concentration was highly correlated with total cholesterol level which is an indicator of nutritional status [8,9].…”