PENELOPE 1-year follow-up: legacy effect of a short protocol-led LDL-C-lowering strategy in patients after myocardial infarction

Objective: Lowering low-density lipoprotein cholesterol (LDL-C) reduces the risk of developing atherosclerotic cardiovascular disease (ASCVD). In the PENELOPE study, a guideline-based, protocol-led LDL-C-lowering strategy was applied in patients after myocardial infarction and resulted in 87% reaching target LDL‑C levels of ≤ 1.8 mmol/l within a median of 45 days. This study evaluated PENELOPE’s legacy effect on LDL‑C levels after 1 year. Methods: In the PENELOPE study, 999 patients with a myocardial infarction and a history of ASCVD and/or diabetes mellitus were included. If LDL-C > 1.8 mmol/l, lipid-lowering therapy was intensified in three consecutive steps: (1) high-intensity statin (HIST) monotherapy, (2) HIST + ezetimibe, and (3) HIST + ezetimibe + proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i). LDL‑C levels were monitored 4–6 weeks after each step. The primary objective of this study was to assess the prevalence of the LDL‑C target level of ≤ 1.8 mmol/l being maintained after 1 year. Results: Data of 738 patients (74%) were available for 1‑year follow-up. The target LDL‑C level was met in 471 patients (64%). Median LDL‑C levels changed from 1.5 (1.2–1.7) mmol/l immediately after implementation of the protocol-led strategy to 1.6 (1.3–2.0) mmol/l after 1 year. Major treatment regimens were statin (58%), statin + ezetimibe (30%) and PCSK9i + ezetimibe (+ statin) (7%). Conclusion: After a myocardial infarction, implementation of a protocol-led LDL-C-lowering strategy resulted in 87% of patients attaining the LDL‑C target level of ≤ 1.8 mmol/l within a median of 45 (32–77) days. At 1‑year follow-up, 64% maintained this target level and the median LDL‑C increased by 0.1 mmol/l.