Kang Danbee, Choi Ki Hong, Yang Seongwoo, Kim Hyunsoo, Park Taek Kyu, Lee Joo Myung, Cho Juhee, Yang Jeong Hoon, Song Young Bin, Choi Seung-Hyuk, Gwon Hyeon-Cheol, Hahn Joo-Yong
Center for Clinical Epidemiology (Kang, S. Yang, Kim, Cho), Samsung Medical Center and Department of Clinical Research Design and Evaluation (Kang, Cho), Samsung Advanced Institute for Health Sciences & Technology, and Division of Cardiology, Department of Internal Medicine (K.H. Choi, Park, Lee, J.H. Yang, Song, S.-H. Choi, Gwon, Hahn), Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Center for Clinical Epidemiology (Kang, S. Yang, Kim, Cho), Samsung Medical Center and Department of Clinical Research Design and Evaluation (Kang, Cho), Samsung Advanced Institute for Health Sciences & Technology, and Division of Cardiology, Department of Internal Medicine (K.H. Choi, Park, Lee, J.H. Yang, Song, S.-H. Choi, Gwon, Hahn), Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
CMAJ. 2025 Apr 27;197(16):E442-E452. doi: 10.1503/cmaj.241713.
Differences exist between European and American guideline recommendations regarding targets for low-density lipoprotein cholesterol (LDL-C) levels after percutaneous coronary intervention (PCI), with European guidance advocating for more aggressive reduction to less than 1.4 mmol/L compared with the American guideline, which recommends an LDL-C level of 1.8 mmol/L or greater as the threshold for treatment intensification. We aimed to evaluate clinical outcomes according to percentage reduction of LDL-C levels and to compare the outcomes according to the attained LDL-C levels after PCI.
This nationwide cohort study included adults in South Korea who underwent PCI and health screening within 3 years before and after PCI. Participants were divided into groups with a reduction of LDL-C levels of less than 50% and of 50% or greater. The group with LDL-C reduction of 50% or greater was stratified into categories of LDL-C level after PCI: less than 1.4 mmol/L, 1.4 to less than 1.8 mmol/L, and 1.8 mmol/L or greater. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of cardiovascular death, spontaneous myocardial infarction (MI), repeat revascularization, and ischemic stroke.
We included 135 877 adult participants. A total of 40.1% achieved a reduction of LDL-C levels of 50% or greater ( = 54 551). During a median follow-up of 7.4 years, the group with a reduction of 50% or greater had a multivariable-adjusted hazard ratio (HR) for MACCE of 0.78 (95% confidence interval [CI] 0.76-0.80). Among patients who achieved a reduction of LDL-C levels of 50% or greater, the multivariable-adjusted HR for MACCE was 1.07 (95% CI 1.02-1.13) for the group with LDL-C levels of 1.4 to less than 1.8 mmol/L after PCI and 1.12 (95% CI 1.04-1.21) for the group with levels of greater than 1.8 mmol/L. The risk of spontaneous MI was also higher in the group with LDL-C levels of 1.8 mmol/L or greater than in the group with levels of less than 1.4 mmol/L (HR 1.36, 95% CI 1.14-1.62).
Among patients who underwent PCI, those who achieved a reduction in LDL-C levels of 50% or greater had a reduced risk of MACCE, regardless of baseline LDL-C levels. Among patients with a reduction in LDL-C levels of 50% or greater, compared with patients with an LDL-C level less than 1.4 mmol/L after PCI, those with an LDL-C level of greater than 1.8 mmol/L and a level of 1.4 to less than 1.8 mmol/L had an increased risk of MACCE. These findings suggest that while achieving an LDL-C reduction of 50% or greater remains a critical therapeutic goal, targeting LDL-C levels of less than 1.4 mmol/L after PCI may provide additional clinical benefit.
ClinicalTrials.gov, NCT06338956.
欧洲和美国关于经皮冠状动脉介入治疗（PCI）后低密度脂蛋白胆固醇（LDL-C）水平目标的指南建议存在差异。欧洲指南主张更积极地将LDL-C水平降至低于1.4 mmol/L，而美国指南则建议将LDL-C水平达到1.8 mmol/L或更高作为强化治疗的阈值。我们旨在根据LDL-C水平降低的百分比评估临床结局，并比较PCI后根据达到的LDL-C水平得出的结局。
这项全国性队列研究纳入了韩国成年患者，这些患者在PCI前后3年内接受了PCI和健康筛查。参与者被分为LDL-C水平降低小于50%和降低50%或更高的组。LDL-C降低50%或更高的组根据PCI后的LDL-C水平分层为：低于1.4 mmol/L、1.4至低于1.8 mmol/L以及1.8 mmol/L或更高。主要终点是主要不良心脑血管事件（MACCE），定义为心血管死亡、自发性心肌梗死（MI）、再次血运重建和缺血性卒中的复合事件。
我们纳入了135877名成年参与者。共有40.1%的参与者LDL-C水平降低了50%或更高（n = 54551）。在中位随访7.4年期间，LDL-C水平降低50%或更高的组发生MACCE的多变量调整风险比（HR）为0.78（95%置信区间[CI] 0.76 - 0.80）。在LDL-C水平降低50%或更高的患者中，PCI后LDL-C水平为1.4至低于1.8 mmol/L的组发生MACCE的多变量调整HR为1.07（95% CI 1.02 - 1.13），LDL-C水平大于1.8 mmol/L的组为1.12（95% CI 1.04 - 1.21）。LDL-C水平为1.8 mmol/L或更高的组自发性MI的风险也高于LDL-C水平低于1.4 mmol/L的组（HR 1.36，95% CI 1.14 - 1.62）。
在接受PCI的患者中，LDL-C水平降低50%或更高的患者发生MACCE的风险降低，无论基线LDL-C水平如何。在LDL-C水平降低50%或更高的患者中，与PCI后LDL-C水平低于1.4 mmol/L的患者相比，LDL-C水平大于1.8 mmol/L以及1.4至低于1.8 mmol/L的患者发生MACCE的风险增加。这些发现表明，虽然将LDL-C降低50%或更高仍然是一个关键的治疗目标，但PCI后将LDL-C水平目标设定为低于1.4 mmol/L可能会带来额外的临床益处。
ClinicalTrials.gov，NCT06338956。
