AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
DECIDE-ACS: An Online Lipid Optimization Algorithm for Cardiologists Managing Post-ACS Patients
By Gupta M, Sedlak T, Aggarwal S et al.
BACKGROUND: Lipid guidelines recommend prompt attainment of LDL-C targets in patients after acute coronary syndrome (ACS); however, timely goal achievement remains challenging. METHODS/RESULTS: We developed DECIDE-ACS, a lipid management algorithm for cardiologists evaluating post-ACS patients at a first post-discharge visit. The tool integrates multi-society guideline recommendations and incorporates a validated 10-year CV risk score with treatment prompts. Cardiologists were invited to use DECIDE-ACS for five consecutive post-ACS patients. Treatment decisions were recorded after presentation of guideline-endorsed LDL-C targets, after guideline-based intensification recommendations, and after risk score calculation. In total, 104 cardiologists enrolled 501 patients (74% male; mean age 66 years) at a median of 16 weeks post-discharge. Index events included NSTEMI (53%), STEMI (31%), and unstable angina (16%). Revascularization occurred in 90% of patients (PCI 73%, CABG 17%). CV risk factors included smoking (18%), hypertension (72%), and diabetes (35%). Prior ASCVD included MI (19%), revascularization (20%), stroke (6%), and peripheral artery disease (4%). Median LDL-C and non-HDL-C at the DECIDE-ACS visit were 61.9 and 85.1 mg/dL respectively; 36% and 62% of patients exceeded LDL-C thresholds of 70 and 55 mg/dL, respectively. ApoB levels were available in 39% of patients, median 0.7 g/L. Lipoprotein(a) was measured in 32% of patients, with 37% >100 nmol/L. Lipid therapy included statin monotherapy (70%), statin plus ezetimibe (28%), and PCSK9 modulation (2.8%); high-intensity statins were used in 88% of patients. Desired LDL-C targets reported by cardiologists were <70 mg/dL in 73% and <55 mg/dL in 27%. Following guideline LDL target prompts, treatment changes occurred in 42% of patients. Guideline-endorsed recommendation prompts led to revisions in 16%. Cardiologist-estimated risk was concordant with SMART-REACH in 35% of cases, overestimated in 9%, and underestimated in 56%. Risk score prompts resulted in treatment changes for an additional 16% of patients. Overall, treatment decisions were modified in 55.7% of patients entered into DECIDE-ACS. Follow-up lipid testing was ordered in 87% of patients, and 97% had a clinic visit scheduled within 6-12 weeks. CONCLUSIONS: At 16 weeks post-ACS, 36-62% of patients had not achieved LDL-C goals despite 88% use of high-intensity statin therapy. Cardiologists underestimated validated 10-year risk in 56% of patients. Use of DECIDE-ACS integrating multi-society guidelines and validated risk scoring substantially altered management, with treatment revisions in 55.7% of patients; this effect is likely underestimated given that 41% lacked risk scoring. Structured multi-society guideline prompts combined with risk calculation may improve timely post-ACS lipid management.