to catch a flight, but I will share that patients coming to the CAF lab for coronary interventional and peripheral procedures are high-value targets because you have their attention. So for SCAI to promote secondary prevention is really, really important. So let me get started. The first part I want to mention is that although LDL is a major causal factor for ASCVD, there is no lower level of LDL that is yet to be defined that would be not effective. So I'll speak about this. And the second pet peeve that I have developed these days is getting away from the terms and concept of primary and secondary prevention. The reason I say this is that patients who are accumulating high burden of atherosclerosis but not have had an event, should they be not treated the same way or aggressively? And the ESC has actually defined high-risk patients with ASCVD based on imaging burden, which is something that will continue to evolve. If you think about it along this continuum is that patients with minimal or no atherosclerosis, patients with significant amount of atherosclerotic burden, for example, with imaging, and those who have not had an event yet and those with an ASCVD event, should they all be treated along a continuum instead of defining them very strictly based on primary and secondary prevention? So I think let's share some data about underuse. There's a lot of published literature. The one I'm going to focus on is directly related to patients in the cath lab undergoing coronary and peripheral procedures having acute events. And even within the very high-risk category of patients, there is a differential and patients who have more than one or more than two major ASCVD events, their event rates in the next year are extremely high compared to other very high-risk patients. So they are very important targets. So let me share with you how we are doing most recently. So all data that I'll show you is derived from 2018 to 2023. This is one of the largest publications showing the use of lipid-lowering therapy in ASCVD patients from the United States in 2019. You can see the top line that patients with recent ACS events in the last one year, just about a half of those patients received intensive statin therapy. And we are going to delve deep into the reasons behind this. PAD patients, I will not even state, is under 15%. And of course, the use of non-statin-based therapies to achieve goals is also extremely low. So why is this happening? We all prescribe statins to our patients. And I think the reason it is not happening is because patients are not getting treated in time based on levels that are getting defined based on the therapies they are receiving. And the timeliness of retesting patients after your first intervention is really, really important. Because most patients who have a first event are likely to have their follow-up event soon after. You know, this was the inspiration behind my premier trial for LDL-A aphoresis after ACS event from the PROMIS trial about more than a decade ago. And this remains true today. Most patients have events early on. Now, how are we doing? This is Medicare data. And you can see on to your left that nearly 80% of patients who, after an ACS and ASCVD event discharged from hospital, these are Medicare patients, do not get retested. So we are checking our boxes that we have prescribed a statin or added azetamide to their statin therapy. But what is not happening is they're not reaching their goals because they're not getting retested in time. And if you look at the proportion of patients who are actually having the recurrent event, most of them, 77% of them, are those who have their LDL levels not at goal. For PLE patients, the story is very, very similar. Most patients with peripheral artery disease have their morbid or mortal events from coronary events, from coronary artery disease and ACS events. And you can see 76% of those patients, after an ASCVD event, are not getting tested. This is contemporary data. This is happening around us in our hospitals today. This is the ASCVD event, recurrent timing of events in ASCVD patients. I show this slide for two reasons. One, to impress upon you that 50% of patients are going to have a second event very soon, as I've shown. And the second point here is that you can very, very easily query your local data and derive granular information about your own region or consortium of hospitals. You cannot really drill down to one single hospital, but to a consortium of hospitals in your region. So you can compare how your Medicare patients are framing. And maybe it is time to change our benchmarks from how many, what proportion of patients are receiving intensive therapy to what goals they're achieving. That's a conversation for the future. If you look at PAD patients, 90% of PAD patients who have recurrent ACS events or ASCVD events are those who do not achieve the goals prescribed to them. Nine zero. So I think there's a lot of opportunity of improving our care in this area. The story of stroke patients is no different. Vascular surgery and other specialties are doing stroke interventions, TCARs, or even interventional cardiologists. I think most of those patients are not getting retested and are not reaching their goals. And the event rates of those patients who do not reach their goals is extremely high. So why is this happening? And there are many reasons for it. And this slide outlines those reasons. But for me, the most important question is, are we defining the risks of those patients appropriately? You know, at our institution, under interventional cardiology resides the lipid clinic. It's quite strange to say, and we have just started our preventive lipid fellowship. And I think I'm discovering more and more heterozygous FH patients that I've ever seen in my life have been missed. And they've been wondering why their young family members early on are having repeated events. I think David would address that far better. The second gap that I've seen that they've tried to address is risk is a continuum. So you have to provide some quantifiable measure of risk. This is a very recent publication from our group in Jack Advances, about 470,000 VA patients who had their first time of contact with cardiology. And we estimated, based on the SMART risk score, which uses clinically derived, easily derived variables to determine the score, and then compare it to their actual score. And this publication is on, and I suggest that you take a look at it. This will provide a longitudinal framework of reference to measure risk, both at baseline and also based upon interventions, when you modify a risk. It can be used by both patients and providers. I have indicated this earlier. There is a need to harmonize recommendations. Burden of atherosclerosis versus just ASCVD events, those categories need to be reconciled. And there is a disconnect at this point between European and U.S. guidelines. This is an informal survey from our lipid clinic and providers who refer patients to us regarding barriers. And I think the clinical inertia part is quite high, along with other barriers. But I think that at your place of work, if you can help identify some of these barriers, you can develop plans to address it. The most common question I get is, how low is low? My patient's intensive therapy, the LDL is 38. Should I withdraw some therapy? And the answer for me at this point is no. I've outlined the evidence of various studies that have taken these LDL levels to under 30, with no significant difference in terms of outcomes of these patients and no indication of harm yet. However, this is an evolving target, and there does not yet appear to be a too low a level of LDL. The PROMPT lipid trial, this is a pragmatic trial being run and just published by Duke investigators that have used EMR. I can tell you that EMR PROMPTS are very, very important. However, there is a lot of inertia to use, and about 30% of people who use such PROMPTS opt out of those PROMPTS. So I think we have to develop some better ways to trigger these secondary prevention. This is a snippet of my trial that I did. I was, as an interventionist, I took patients after ACS at five VA centers funded by the VA. They got ACS intervention. We identified a target vessel. We randomized them to intensive lipid-lowering therapy, to standard medical intensive therapy. And the intensive lipid-lowering arm was actually LDL aphorism done within 48 to 36 hours after the ACS event, and then they came back at 90 days to re-measure the target area plaque regression. So I am very, very passionate about intensive lipid-lowering in ACS patients and in CAD and PAD patients. In summary, I would like to leave you with these thoughts that CAD and PAD patients are at a high risk of recurrent events, and they are highly under-treated based on current target LDL levels achieved. There are true barriers to intensifying therapy and thinking about non-statin therapies. These are modifiable risks, and identifying these metrics for your own region and institution can help close these gaps based upon the most effective strategies that you can develop and evolve. And I do emphasize this word, there are no universal strategies based upon where you practice and where you work, and the administrative structure of institutions, you will need to develop unique and tailored therapies for your group and for your patients. Thank you very much for having me. I'm sorry I may have to leave, but I really enjoyed this opportunity for interacting and providing this forum for talking about prevention. Thank you.

ASCVD prevention

lipid-lowering therapy

non-statin therapies

clinical inertia

atherosclerosis management