Optimising lipid-lowering therapy for acute coronary syndrome using a decision support system: insights from a cluster randomised trial
File(s)
Published version
Author(s)
Type
Journal Article
Abstract
AIMS: Lipid-lowering therapy (LLT) after acute coronary syndrome (ACS) typically follows stepwise intensification, delaying use of combination therapies and LDL-C goal attainment. We assessed whether access to a Decision Support System (DSS) altered the intensity of LLT prescribing vs standard-of-care (SoC).
METHODS: Pragmatic, multinational, parallel 1:1 cluster-randomised controlled trial of ACS patients comparing
mandatory access to a DSS (providing estimates of cardiovascular events and benefits from different LLT scenarios) to SoC. The primary endpoint was the proportion receiving intensified monotherapy or initiated/escalated combination LLT by week 16 compared to pre-admission LLT; secondary endpoints included individual components of the primary endpoint, proportions at goal (LDL-C<1.4mmol/L), and timing of LLT
escalations.
RESULTS: 42 sites from UK, Italy and Spain were randomised, enrolling 1139 participants, 79% male, median age 62 years (IQR: 55, 69), 84% without prior CVD, 69% LLT-naïve at admission, median admission LDL-C 3.0 mmol/L (IQR: 2.46, 3.75). The primary endpoint was met in 71.7% (DSS) vs 65.7% (SoC), risk ratio (RR) 1.11 (95%CI:0.92-1.33, p=0.29). Intensification of monotherapy occurred in 9.0% vs 13.1% (RR:0.68, 95%CI:0.46-1.00), combination LLT in 61.6% vs 50.6% (RR:1.35, 95%CI:0.93-1.98). LDL-C goal achievement was 54.8% vs 50.3% (RR 1.06, 95%CI: 0.88-1.28), with LLT escalation before discharge in 64.8% vs 60.7%.
CONCLUSIONS: Access to a DSS, in hospitals managing ACS, did not improve LLT intensification within 16 weeks or LDL-C goal attainment, but revealed a favourable trend towards earlier combination LLT use, which merits larger, longer studies in other settings.
METHODS: Pragmatic, multinational, parallel 1:1 cluster-randomised controlled trial of ACS patients comparing
mandatory access to a DSS (providing estimates of cardiovascular events and benefits from different LLT scenarios) to SoC. The primary endpoint was the proportion receiving intensified monotherapy or initiated/escalated combination LLT by week 16 compared to pre-admission LLT; secondary endpoints included individual components of the primary endpoint, proportions at goal (LDL-C<1.4mmol/L), and timing of LLT
escalations.
RESULTS: 42 sites from UK, Italy and Spain were randomised, enrolling 1139 participants, 79% male, median age 62 years (IQR: 55, 69), 84% without prior CVD, 69% LLT-naïve at admission, median admission LDL-C 3.0 mmol/L (IQR: 2.46, 3.75). The primary endpoint was met in 71.7% (DSS) vs 65.7% (SoC), risk ratio (RR) 1.11 (95%CI:0.92-1.33, p=0.29). Intensification of monotherapy occurred in 9.0% vs 13.1% (RR:0.68, 95%CI:0.46-1.00), combination LLT in 61.6% vs 50.6% (RR:1.35, 95%CI:0.93-1.98). LDL-C goal achievement was 54.8% vs 50.3% (RR 1.06, 95%CI: 0.88-1.28), with LLT escalation before discharge in 64.8% vs 60.7%.
CONCLUSIONS: Access to a DSS, in hospitals managing ACS, did not improve LLT intensification within 16 weeks or LDL-C goal attainment, but revealed a favourable trend towards earlier combination LLT use, which merits larger, longer studies in other settings.
Date Issued
2026-03-01
Date Acceptance
2025-11-10
Citation
European Heart Journal: Digital Health, 2026, 7 (2)
ISSN
2634-3916
Publisher
Oxford University Press
Journal / Book Title
European Heart Journal: Digital Health
Volume
7
Issue
2
Copyright Statement
© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
License URL
Identifier
10.1093/ehjdh/ztaf135
Publication Status
Published
Article Number
ztaf135
Date Publish Online
2025-11-17