Background: Despite the widespread use of statins, approximately 40% to 50% of Canadian patients with known cardiovascular disease do not achieve the low-density lipoprotein cholesterol (LDL-C) goal. Guidelines Oriented Approach to Lipid lowering (GOAL) is an investigator-initiated study aiming to ascertain the use of second-and third-line therapy and its impact on LDL-C goal achievement in a realworld setting. Methods: GOAL enrolled patients with clinical vascular disease or familial hypercholesterolemia and LDL-C > 2.0 mmol/L despite maximally tolerated statin therapy. During follow-up, physicians managed patients as clinically indicated but with online reminders of guideline recommendations.

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Background: Despite practice guidelines, strategies for lowering LDL-C are often poorly adopted in clinical practice. Materials and Methods: Five countries (Brazil, Kuwait, Mexico, Saudi Arabia, and UAE) enrolled 2,422 patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH) with low density lipoprotein cholesterol level (LDL-C) above 1.4 mmol/L. Patients were followed at 6 ± 2 months intervals to assess LDL-C level and treatment with ezetimibe and/or proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i). Results: 2422 patients 60.4 ± 11.7 years old and 29% women were enrolled from 87 participating cardiology sites. Overall, 91.1% of patients had coronary artery disease and FH in 12.3%. At baseline LDL-C was 2.96 ± 1.36 mmol/L and 1.87 ± 1.28 mmol/L (p<0.0001) at last available observation (n=2014). Proportion of patients achieving LDL<1.4 mmol/L (primary endpoint) increased from zero to 41.4% (p<0.0001). At baseline, 99.2% of patients were on statin (81.3% high intensity statin), 34.4% on ezetimibe and its use increased significantly (62.9%, p<0.0001). PCSK9i use increased to 35.0% from baseline to last follow up (p<0.0001). Clinical outcomes such as ACS, CVA/TIA, PCI, CABG, or hospitalization for ASCVD reasons were recorded in 10.7% of patients during the follow up. Patients with no event had an overall LDL-C of 1.90 ± 1.3 mmol/L while those with an event had LDL-C significantly higher at the visit immediately prior to event (2.70 ± 1.35, p=0.0001). Conclusion: The results indicate the feasibility of overcoming treatment inertia and improving LDL-C control which should help to achieve reduction in cardiovascular morbidity and mortality in ASCVD patients.