# Optimizing lipid-lowering therapy for acute coronary syndrome using a decision support system: insights from a cluster randomized trial

## TL;DR

A study tested if a decision support system improved cholesterol-lowering treatment after heart attacks but found no major benefits, though earlier combination therapy use showed promise.

## Contribution

The study evaluated a decision support system's impact on lipid-lowering therapy in acute coronary syndrome patients through a multinational cluster-randomized trial.

## Key findings

- Access to the DSS did not significantly improve LLT intensification or LDL-C goal attainment within 16 weeks.
- A favorable trend toward earlier use of combination lipid-lowering therapy was observed in the DSS group.
- LDL-C goal achievement was slightly higher in the DSS group, but not statistically significant.

## Abstract

Lipid-lowering therapy (LLT) after acute coronary syndrome (ACS) typically follows stepwise intensification, delaying use of combination therapies and low-density lipoprotein cholesterol (LDL-C) goal attainment. We assessed whether access to a decision support system (DSS) altered the intensity of LLT prescribing vs. standard-of-care (SoC).

Pragmatic, multinational, parallel 1:1 cluster-randomized controlled trial of ACS patients comparing mandatory access to a DSS (providing estimates of cardiovascular events and benefits from different LLT scenarios) to SoC. The primary endpoint was the proportion receiving intensified monotherapy or initiated/escalated combination LLT by Week 16 compared to pre-admission LLT; secondary endpoints included individual components of the primary endpoint, proportions at goal (LDL-C < 1.4 mmol/L), and timing of LLT escalations. 42 sites from UK, Italy, and Spain were randomized, enrolling 1139 participants, 79% male, median age 62 years (IQR: 55, 69), 84% without prior CVD, 69% LLT-naïve at admission, and median admission LDL-C 3.0 mmol/L (IQR: 2.46, 3.75). The primary endpoint was met in 71.7% (DSS) vs. 65.7% (SoC) and risk ratio (RR) 1.11 (95%CI:0.92–1.33, P = 0.29). Intensification of monotherapy occurred in 9.0% vs. 13.1% (RR: 0.68, 95%CI: 0.46–1.00), combination LLT in 61.6% vs. 50.6% (RR: 1.35, 95%CI: 0.93–1.98). LDL-C goal achievement was 54.8% vs. 50.3% (RR 1.06, 95%CI: 0.88–1.28), with LLT escalation before discharge in 64.8% vs. 60.7%.

Access to a DSS, in hospitals managing ACS, did not improve LLT intensification within 16 weeks or LDL-C goal attainment but revealed a favourable trend towards earlier combination LLT use, which merits larger, longer studies in other settings.

Graphical AbstractThe ZODIAC trial evaluated whether a decision support system improves lipid-lowering therapy after acute coronary syndrome. While not significantly improving overall therapy intensification or low-density lipoprotein cholesterol goal attainment, trends toward earlier combination therapy use were observed, suggesting potential value in settings with suboptimal guideline implementation.Visualizations of the primary and secondary endpoints with a map of countries taking part in the trial.

The ZODIAC trial evaluated whether a decision support system improves lipid-lowering therapy after acute coronary syndrome. While not significantly improving overall therapy intensification or low-density lipoprotein cholesterol goal attainment, trends toward earlier combination therapy use were observed, suggesting potential value in settings with suboptimal guideline implementation.