Frontiers in cardiovascular medicine · 2026
Real-world assessment of low-density lipoprotein cholesterol goal, disease burden and financial burden among patients with atherosclerotic cardiovascular disease in Singapore-A single-centre retrospective cohort study.
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Ho Aaron Kh, Leow Aloysius Sheng-Ting, Tan Sarah Ming-Li, Sim Vincent Wei Jun, Yan Qian, Sia Ching-Hui, Simon Oliver, Poh Kian-Keong
Аннотация
BACKGROUND: Despite strong evidence supporting intensive low-density lipoprotein cholesterol (LDL-C) lowering in high- and very-high-risk patients to reduce atherosclerotic cardiovascular disease (ASCVD), real-world attainment of recommended lipid targets remains poor, particularly in Asian populations. This study aims to evaluate LDL-C goal attainment, treatment patterns, and the clinical and economic burden among post-myocardial infarction patients in Singapore.
MATERIALS AND METHODS: We conducted a retrospective, observational cohort study of 300 consecutive post-myocardial infarction patients admitted to the National University Heart Centre, Singapore, between January and June 2022, using electronic medical records to assess LDL-C goal attainment, disease burden, and direct healthcare costs. The primary outcome was attainment of prespecified LDL-C thresholds, including <2.6 mmol/L according to local Ministry of Health guidance and <1.4 mmol/L according to ESC/EAS very-high-risk recommendations. Attainment of <1.8 mmol/L was analysed as an additional intermediate threshold. Secondary outcomes included treatment patterns, major adverse cardiovascular events (MACE), healthcare utilisation, and costs. Comparisons were made using chi-square tests for categorical variables and independent samples t-tests or Mann-Whitney U-tests for continuous variables.
RESULTS: The mean age was 60.9 ± 12.2 years, 82.0% were male, and baseline LDL-C was 3.1 ± 1.3 mmol/L. At one year, 80.7% achieved <2.6 mmol/L, 47.3% achieved <1.8 mmol/L, and 18.3% achieved <1.4 mmol/L. High-intensity statin use increased from 23.0% at baseline to 95.7% at discharge, while ezetimibe and PCSK9 inhibitor use remained low at 13.0% and 0%, respectively. LDL-C control was not significantly associated with MACE at one year (p = 0.412). Estimated combined annualised direct costs were SGD 1,003 per patient, including statin therapy, ED attendance/inpatient admission, and outpatient care.
CONCLUSION: These findings demonstrate that LDL-C target attainment in Singapore remains suboptimal, particularly among very high-risk ASCVD patients, despite widespread statin use. Clinically, this supports earlier protocol-driven combination lipid-lowering therapy rather than delayed statin-only escalation. Early ezetimibe initiation, timely lipid reassessment within 4-12 weeks, and prompt consideration of PCSK9 inhibitors or other novel agents for persistently above-target patients should be embedded into structured follow-up pathways. Broader access and subsidy for advanced therapies may help improve LDL-C target attainment and reduce residual cardiovascular risk in Singapore.
MATERIALS AND METHODS: We conducted a retrospective, observational cohort study of 300 consecutive post-myocardial infarction patients admitted to the National University Heart Centre, Singapore, between January and June 2022, using electronic medical records to assess LDL-C goal attainment, disease burden, and direct healthcare costs. The primary outcome was attainment of prespecified LDL-C thresholds, including <2.6 mmol/L according to local Ministry of Health guidance and <1.4 mmol/L according to ESC/EAS very-high-risk recommendations. Attainment of <1.8 mmol/L was analysed as an additional intermediate threshold. Secondary outcomes included treatment patterns, major adverse cardiovascular events (MACE), healthcare utilisation, and costs. Comparisons were made using chi-square tests for categorical variables and independent samples t-tests or Mann-Whitney U-tests for continuous variables.
RESULTS: The mean age was 60.9 ± 12.2 years, 82.0% were male, and baseline LDL-C was 3.1 ± 1.3 mmol/L. At one year, 80.7% achieved <2.6 mmol/L, 47.3% achieved <1.8 mmol/L, and 18.3% achieved <1.4 mmol/L. High-intensity statin use increased from 23.0% at baseline to 95.7% at discharge, while ezetimibe and PCSK9 inhibitor use remained low at 13.0% and 0%, respectively. LDL-C control was not significantly associated with MACE at one year (p = 0.412). Estimated combined annualised direct costs were SGD 1,003 per patient, including statin therapy, ED attendance/inpatient admission, and outpatient care.
CONCLUSION: These findings demonstrate that LDL-C target attainment in Singapore remains suboptimal, particularly among very high-risk ASCVD patients, despite widespread statin use. Clinically, this supports earlier protocol-driven combination lipid-lowering therapy rather than delayed statin-only escalation. Early ezetimibe initiation, timely lipid reassessment within 4-12 weeks, and prompt consideration of PCSK9 inhibitors or other novel agents for persistently above-target patients should be embedded into structured follow-up pathways. Broader access and subsidy for advanced therapies may help improve LDL-C target attainment and reduce residual cardiovascular risk in Singapore.