Guideline-directed Low-density Lipoprotein Cholesterol Management After Acute Coronary Syndrome in Patients With Mental Illness: a Population-based Study

Background: Despite increased cardiovascular morbidity among patients with mental disorders, real-world data on lipid-lowering therapy (LLT) use and low-density lipoprotein cholesterol (LDL-C) target attainment after acute coronary syndrome (ACS) remain limited. We evaluated disparities in LLT utilization and LDL-C target attainment among patients with and without mental disorders following ACS in a real-world setting. Methods: Data of consecutive ACS hospitalizations in a large healthcare system (2013–2023) were analyzed. Patients were stratified by mental illness and compared with controls. LDL-C target attainment and LLT use were assessed at baseline and during early (1–4 months) and late (6–12 months) post-discharge periods. Multivariable logistic regression evaluated independent associations. Results: Among 9,192 patients surviving ≥ 1 year after ACS, 32.1% had mental illness. These patients were older, more often female, and had higher atherosclerotic burden (p < 0.001). LDL-C target attainment was lower in patients with mental illness both early (49% vs. 54%) and late (44% vs. 49%) after discharge, with fewer achieving ≥ 50% LDL-C reduction (p < 0.001). High-intensity statin and early ezetimibe use were less frequent (p = 0.005), and non-adherence was higher (9.7% vs. 6.3%, p = 0.001). In adjusted analyses, mental illness was not independently associated with LDL-C target attainment but was linked to lower use of moderate- and high-intensity statins (OR 0.87 and 0.83) and higher likelihood of no LLT use (OR 1.48; p < 0.01). Conclusions: Mental disorders were associated with lower LLT intensity and greater treatment gaps after ACS, without independent differences in LDL-C attainment. LDL-C control and combination LLT use remained suboptimal, highlighting persistent gaps in secondary prevention.