ZODIAC: Can we improve lipid-lowering strategies in ACS?

The ZODIAC study did demonstrate that decision support system can improve the early uptake of lipid-lowering combination therapies or increase the rate of patients achieving their LDL-cholesterol goals.

“Most patients with a myocardial infarction (MI) are lipid-lowering therapy-naïve at admission,” said Prof. Ray Kausik (Imperial College London, UK) [1]. “Furthermore, only 1 in 4 post-MI patients reaches their LDL-cholesterol goals on monotherapy within 3 months of their event.” Prof. Kausik argued that the use of combination therapy could increase the rate of patients achieving LDL-cholesterol goals. “The ideal scenario is to reach the lipid goals quickly and durably since this is associated with the best cardiovascular outcomes.” Prof. Kausik further explained that the current lipid-lowering therapy guidelines use a step-wise approach, starting with monotherapy and only adding an extra therapy if the goal is not achieved after 4–6 months.

Prof. Kausik and colleagues aimed to improve this process by developing a decision support system based on estimated cardiovascular risks and potential benefits of lipid-lowering therapies. Participants with ACS from Spain, Italy, and the UK (n=1,139) were randomised 1:1 to usual care or the decision support system. The primary endpoint was the rate of patients receiving combination therapy, intensification of monotherapy, or escalated combination therapy within 16 weeks of their ACS.

At 16 weeks, 54.7% of the participants in the experimental arm and 48.7% of those in the control arm had achieved their LDL-cholesterol goals, which was a numerical but non-significant difference (adjusted RR 1.15; 95% CI 0.93–1.41). Notably, the early use of combination therapies was high in the usual care arm, higher than reported in historical data, as mentioned by Prof. Kausik.

“Although the results were not significant, favourable trends were observed for the decision support system,” concluded Prof. Kausik. “This matter requires further investigation, including the possibility of implementing the decision support system in other settings.”

“A large proportion of participants in the control arm was already on therapies with considerable LDL-lowering potential,” commented Prof. Tracy Wang (PCORI, Washington DC, USA). “The question is whether routine practice has already changed or whether we are looking at a Hawthorne effect.”

1. 
   
   1. Kausik R, et al. Imperial: Optimisation of lipid lowering therapies using a decision support system in patients with acute coronary syndrome (ZODIAC): a randomised trial. LBS.06, AHA Scientific Sessions 2024, 16–18 November, Chicago, USA.

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Posted on 3 February 2025