Post-treatment level of LDL cholesterol and all-cause mortality in patients with atherosclerotic cardiovascular disease: evidence from real-world setting

Abstract

Aims This study aimed to evaluate the safety of currently recommended target of LDL-C control on mortality in patients with atherosclerotic cardiovascular disease (ASCVD). Methods Using deidentified electronic health record data, we conducted a multicenter retrospective cohort study involving individuals with documented ASCVD who had received statin treatment for at least 3 months across China. The primary outcomes assessed encompassed all-cause mortality, cardiovascular mortality, and non-cardiovascular mortality. Relationships between post-treatment LDL-C concentrations and outcomes were evaluated using restricted cubic spline (RCS) curves based on Cox proportional hazards regression analyses. Additionally, competitive risk models were employed to explore associations between LDL-C levels and cause-specific mortality. Results Among 33,968 participants, we identified nearly linear associations of post-treatment LDL-C level with all-cause mortality and CV mortality during a median follow-up of 47 months. Notably, patients who achieved the recommended target of LDL-C (<1.4 mmol/L) were at significant lower risks of all-cause mortality (HR, 0.77; 95%CI, 0.69-0.86) and CV mortality (sHR, 0.68; 95%CI, 0.58-0.79), compared with those with LDL-C ≥ 3.4 mmol/L. This survival benefit was consistent in patients with different intensity of LDL-C reduction and other subgroup analyses. And no correlation was found between post-treatment LDL-C concentration and non-CV mortality. Conclusions Our findings supported the safety of currently recommended target of LDL-C control and the “lower is better” principle in patients with ASCVD.