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Reassess. Intensify. Protect: Timely LDL-C control post-MI can prevent what comes next

For patients recovering from myocardial infarction (MI), early initiation of high-intensity statin therapy is standard. Yet, sustaining LDL-C control in the months and years that follow is often overlooked despite its potential to reduce recurrent cardiovascular events.

Despite clear guideline targets, real-world data show that many post-MI patients fail to achieve or maintain LDL-C levels below 70 mg/dL. Delays in follow-up testing, therapeutic inertia, and disparities in care contribute to this gap. Real-world data suggest that women and older adults may be less likely to receive high-intensity lipid-lowering therapy (LLT) or timely reassessment, reflecting disparities in access or treatment patterns.

For patients who remain above target despite maximally tolerated statins—or who are unable to tolerate them—adjunctive therapies that enhance LDL receptor activity offer a chance to drive LDL-C lower and reduce residual risk. But these benefits hinge on timely recognition of inadequate response and a proactive approach to intensification.

The 2025 AACE lipid management guidelines recommend a treatment goal of LDL-C <70 mg/dL in adults with ASCVD or at increased risk. Reaching—and maintaining—this threshold has been linked to fewer recurrent events, including MI, stroke, and revascularization. But success depends not just on what we prescribe, but on how closely we monitor, reassess, and adapt over time.

How do you coordinate post-MI lipid management in your practice? What prompts you to intensify treatment when targets aren't met?

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  • 4w
    When a patient is seen after a cardiac event:
    • Medication review:
    • Current medications are reviewed to ensure adherence, tolerance, and appropriate dosing.
    • Goals of therapy are discussed with the patient, emphasizing the importance of LDL-C lowering in secondary prevention.
    • Laboratory follow-up:
    • A fasting lipid profile is repeated 6–8 weeks after medication adjustment or initiation to assess therapeutic response.
    • Treatment adjustment:
    • If LDL-C remains >55 mg/dL despite maximally tolerated statin therapy,
    → Ezetimibe should be added.
    • If statins are not tolerated,
    → consider alternative therapies such as ezetimibe or PCSK9 inhibitors.
    • Dose titration and combination therapy are individualized based on tolerance, risk level, and LDL-C goals.
    • Patient counseling:
    • Reinforce adherence, lifestyle modification, and regular follow-up for optimal secondary prevention outcomes.
  • 1mo
    When a patient is seen after cardiac event meds are reviewed and discussed regarding goals of treatment and labs to follow up 6-8 weeks later. If LDL is above 55 on statin or if stations are not tolerated doses are adjusted or other class of meds are added .
  • 1mo
    The secret is to improve compliance through regular and frequent touch points from nurses, APP visits, and to use drugs with longer action like inclisiran and others. I like to get LDL in the 50s or less and this always requires combination therapies. Lifestyle is also paramount to keep lipids and risk low.
  • 1mo
    If a patient had any MI or ASCVD, especially in my patients with T2D, I try to get their LDL as low as possible, at least below 70. If they are on a statin, I usually try adding a PCSK9. If can't use statins, use bempedoic acid.
  • 2mo
    Atherosclerosis pivots around LDL hypothesis and message is lower is better no matter how you get there with all the available arsenal of the meds we have now ! As much Primary Prevention is important but in seconday prevention it is vital to manage it optimally at any cost ! Question comes up what is a good level to achieve( given that all other risk factors have been managed well too) LDL less than 70 is ofcourse very desirable in sec prevention but general reccomendations are to get it below 55 This time and age Lipid management is not complete even and unless adressing the lpa elevation which is a must in secondary prevention if elevated then the scope of management goes beyond LDL reduction alone and consideration should be given to the use of PCSK-9 inhibitors like Repatha ! HORIZON trial with Pellicarsen are going to be out some time this year for secondary prevention with elevated lpa and will set up a new aspect in lpa screening and management ! Also what is important is at what level of LDL was atherosclerosis /event was discovered and still need 30-40 %reduction even if it was near goal or at goal ! Bottom line is lower the better in sec prevention and it is perfectly safe to get there with out any untowards effects ! I being an internist take lot of pleasure in managing lipids and request the cardiologist to defer the management to me and the convenince of this with PCP is also appreciated by the pts
  • 2mo
    Agree with the other colleagues, being "aggressive" is essential to reduce the risk of another CV event. The use of PSK9 inhibitors is critical to achieve appropriate LDL goals. Whether the choice is Repatha, Praluent or Leqvio is less important than the use of "a" psk9i.
    Higher risk patients will not generally not benefit with just an increased in statin dosage.
  • 2mo
    Often patients are discharged on high dose statin. I usually check labs at the 2 month mark. At that point my target LDL is less than 55. If not at that level will either add Zetia if only 19 points above target. Otherwise I add on a PCSK9 inhibitor
  • 2mo
    It is essential to be aggressive and often most folks need combo therapy agfter an event. I like to get LDL below 55 which usually needs statin, zetia, and PCSK9i like Leqvio. Important to have close followup after the event!
  • 2mo
    We are aggressive about the management of post MI patients. All of these patients are discharged on high intensity statin. If this is not tolerated, then we make adjustments after discussion with the patient. We do check a lipid profile two months after discharge and titrate medication’s accordingly. Compliance with therapy is a constant theme of our post hospital visits.
  • 3mo
    Post MI our patients are also discharged on high intensity statin with follow up lipid panel in 2 months. If the patient is not at goal and has been compliant with medical therapy I move forward with Leqvio or Repatha based on shared decision making, ability to self inject, lifestyle, travel, etc. I will only add ezetimibe, Bempedoic acid, etc if the patient defers injections or I need additional lipid lowering therapy.
  • 3mo
    Patients are discharged on high dose high intensity statin. If they are not at goal at 3 months either a PSK9 or ezetimibe is added based on how far they are from goal. if more than 15% PSK9 is added at this time. Dietary and exercise guidance is also recommended. The cardiologist following the patient is responsible for making treatment decisions
  • 3mo
    In my practice, post-MI lipid management begins with initiating high-intensity statins during hospitalization, followed by a lipid panel within 4–6 weeks to assess response. If LDL-C remains ≥70 mg/dL, I intensify treatment by adding ezetimibe or considering PCSK9 inhibitors, especially in high-risk or statin-intolerant patients. I monitor lipid levels every 3–6 months and use EHR alerts and team-based care to ensure timely reassessment and adherence. Treatment decisions are guided by risk level, patient tolerance, and a commitment to reducing disparities in care, recognizing that sustained LDL-C control is key to lowering recurrent cardiovascular events.
  • 3mo
    Post discharge fu and labs, both PCP and cardio are responsible for monitoring labs to achieve the goal. of course, pt education plays a big role
  • 3mo
    Usually it is the first provider that test the lipids and then forwards to all other providers. Another event prompts addtional lipid lowering.
  • 3mo
    Coordinating with cardiology post-MI for lipid management is imperative. I'd say working in family practice, it's probably 50/50 whether we handle the lipids or cardiology does. We check every 3 months until at goal, then yearly thereafter. Intensifying treatment takes place if patient isn't at goal with current statin and are either unwilling or unable to make further lifestyle adjustments. At that point we look at adding ezetimibe, bempedoic acid or a PCSK9-inhibitor.
  • 3mo
    It takes a village... close followup after discharge and almost always more than one drug in combination therapy for lipids, inflammation, and anti platelets are needed. Along with cardiac rehab, nutrition modification, and lifestyle modification. Very frequent touchpoint and lab measurements are needed often in the initial phase and then for the long term
  • 3mo
    All pts of this type are DC'ed on intensive dose statin, and follow up with their cardiologist (me). We check lab work around 1 m post DC and adjust treatment to target LDL less than 55. Depending on how close we are to target we add zetia or repatha. Main impediment is insurance coverage
  • 3mo
    Try to have them do a lipid panel prior to their 4-6 week follow up and see how they are doing on whatever meds they were on at discharge. Motivation is never higher than at this point for patients and their providers.
  • 3mo
    We reach out to patients after d/c and assess compliance and remind them to get FU blood work done which we review with them in person at next visit
  • 3mo
    I usually let the cardiologist initiate high intensity, statin medication after an MI and then I will adjust and manage it on a return visit to my office
  • 3mo
    test
  • 3mo
    This is often shared responsibility between primary care and Cardiology. If Cardiology hasn’t had an opportunity to address, I will. I usually work closely with a specialty team to make sure the patient’s LDL is at goal.

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