ESC Congress 2026 Abstract · Oct 26, 2026

Recurrence of cardiovascular events despite achieving LDL-C <1.4 mmol/L i in patients with coronary artery disease

By Kataoka Y, Nicholls SJ, Kitahara S et al.

Background: The current ESC/EAS guideline recommends lowering LDL-C <1.4 mmol/L for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in very high-risk patients. However, despite favourable LDL-C control, atherosclerosis still continues to progress, which eventually causes cardiovascular events. Therefore, identification of factors associated with the aforementioned residual cardiovascular risks is clinically needed. Purpose: To characterize patients with CAD who experienced recurrence of ASCVD despite achieving LDL-C levels <1.4 mmol/L. Methods: The current study was a multi-center, retrospective analysis of 780 patients with CAD who achieved on-treatment LDL-C <55 mg/dL after PCI. MACE was defined as a composite of cardiac death, non-fatal MI and clinically driven coronary revascularization at non-culprit segments. Clinical demographics were compared between patients with and without MACE. Results: During the observational period [median=1632 days], MACE occurred in 6.2% (=48/780) of study population. Following the control of LDL-C <55 mg/dL, 81.2% (=39/48) of MACE mainly occurred within 2 years after PCI (Figure 1). There were no significant differences in the frequency of traditional coronary risk factors between the two groups. Patients experiencing MACE more likely exhibited polyvascular disease (72.9 vs. 17.3%, p<0.001). In particular, the concomitance of LEAD (54.2 vs. 4.0%, p<0.001) and both LEAD and CVD (12.5 vs. 1.6%, p<0.001) was more frequently observed in patients experiencing MACE. Statin and high-intensity statin were frequently used in both groups (statin=94.8%, p=0.218, high-intensity statin=73.3%, p=0.198), whereas patients with MACE less likely received ezetimibe (45.8 vs. 63.2%, p=0.023) (Figure 1). Consequently, a lower proportion of on-treatment LDL-C <40 mg/dL was observed in those with MACE (16.7 vs. 33.2%, p=0.018). On multivariate analysis, polyvascular disease (HR=10.74, 95%CI=5.65-20.39, p<0.001) and on-treatment LDL-C <40 mg/dL (HR=0.37, 95%CI=0.17-0.81, p=0.012) were independently associated with MACE (Figure 1). Notably, the concomitance of LEAD (HR=21.03, 95%CI=10.74-41.17, p<0.001) but not cerebrovascular disease (HR=1.63, 95%CI=0.46-5.75, p=0.447) elevated a risk of MACE. In patients with polyvascular disease (n=162), on-treatment LDL-C <40 mg/dL was associated with a lower frequency of MACE (HR=0.35, 95%CI=0.14-0.87, p=0.024) (Figure 2). Conclusions: On-going cardiovascular risks existed despite achieving LDL-C <55 mg/dL. Multivariate analysis emerged polyvascular disease as an independent factor associated with cardiovascular outcomes after the attainment of LDL-C <55 mg/dL. Given the association of on-treatment LDL-C <40 mg/dL with a reduced risk of MACE, further lower LDL-C level may be more favourable therapeutic goal for the secondary prevention of ASCVD in patients with CAD.

doi.org/10.1093/eurheartj/ehag785.3304Open accessPopulations