Achieving Optimal LDL-C Helps Prevent Neoatherosclerosis, Late Stent Failure in Patients With STEMI

Low-density lipoprotein cholesterol (LDL-C) levels emerged as an independent predictor of neoatherosclerosis 3 years following drug-eluting stent (DES) implantation for patients with ST-segment elevation myocardial infarction (STEMI), according to investigators of a multivariable predictor analysis study (NCT03440801) published in JAMA Cardiology.^1,2

Patients who underwent intensive LDL-C-lowering treatment and achieved guideline-recommended on-treatment LDL-C levels had less frequent emergence of neoatherosclerosis compared with those not on treatment. The results demonstrate the essential nature of LDL-C lowering to prevent the formation of neoatherosclerosis in patients with STEMI.¹

What Did the Investigators Find?

The study was a post hoc analysis of CONNECT, a randomized clinical trial in Switzerland and Japan that randomized 239 patients with STEMI to percutaneous coronary intervention (PCI) with biodegradable- or durable-polymer everolimus-eluting stents. Neoatherosclerosis prevalence was assessed using optical coherence tomography 3 years following a primary PCI.¹

The authors primarily sought to compare the prevalence of neoatherosclerosis in patients with versus without the achievement of guideline-endorsed target LDL-C levels. Multivariable predictor analysis was performed to determine whether on-treatment LDL-C levels were associated with the occurrence of neoatherosclerosis.¹

A total of 178 patients underwent OCT at 3 years; among these, 98 patients (55%) achieved target LDL-C levels, and 80 patients (45%) did not. Mean on-treatment LDL-C levels for each group were 48 mg/dL and 87 mg/dL, respectively.¹

Prevalence of neoatherosclerosis was lower in patients who achieved the target LDL-C level as compared with patients who did not (7 patients [7%] versus 15 patients [19%], respectively; odds ratio [OR] for patients not achieving the LDL-C target level, 3.00; 95% CI, 1.19–8.24; P = .02). Furthermore, on-treatment LDL-C level (per 25 mg/d increase) emerged as an independent determinant of neoatherosclerosis at 3 years, according to the results from a multivariable logistic regression analysis (OR, 1.46; 95% CI, 1.09–2.01; P = .01).¹

What is Neoatherosclerosis, and What Role Does LDL-C Play in its Development?

Neoatherosclerosis is the development of atherosclerotic plaque inside of a coronary stent many years after implantation. It can sometimes cause in-stent restenosis and acute thrombotic occlusion originating from the stent segment. Despite the utilization of drug-eluting stents significantly reducing the rates of target vessel revascularization, neoatherosclerosis can emerge as a development of ongoing stent failure.^3,4

LDL-C is a classic indicator and primary driver of atherosclerosis, where high levels can lead to the buildup of plaque in the arteries. Neoatherosclerosis can be difficult to observe because it can be hidden behind the presence of a stent, which could allow high LDL-C levels to be hidden for years until an event occurs. Crucially, lipid levels are a modifiable risk factor for the prevention of CV events.⁵

Pharmacists, especially those in community settings, can take a proactive role in counseling patients on the benefits of a healthy diet and exercise to lower LDL-C, especially in patients at high risk. For patients with STEMI who have undergone stent implantation, they should be informed on best practices and standard-of-care options for controlling LDL-C and achieving recommended lipid levels. Consistent lipid control should remain a key aspect of post-stent care in patients with STEMI.

REFERENCES

1. Häner JD, Kakizaki R, Taniwaki M, et al. Low-density lipoprotein cholesterol levels and neoatherosclerosis after STEMI: a secondary analysis of the CONNECT randomized clinical trial. JAMA Cardiol. Published Online December 17, 2025. doi:10.1001/jamacardio.2025.4723

2. A randomized comparison of long-term healing between biodegradable- versus durable-polymer everolimus-eluting stents in STEMI (CONNECT). ClinicalTrials.gov Identifier: NCT03440801. Last Updated September 8, 2025. Accessed December 19, 2025. https://clinicaltrials.gov/study/NCT03440801

3. Komiyama H, Takano M, Hata N, et al. Neoatherosclerosis: Coronary stents seal atherosclerotic lesions but result in making a new problem of atherosclerosis. World J Cardiol. 2015;7(11):776-783.

4. Zhang BC, Karanasos A, Regar E. OCT demonstrating neoatherosclerosis as part of the continuous process of coronary artery disease. Herz. 2015;40:845-854. doi:10.1007/s00059-015-4343-y

5. Why LDL-C matters. Attack Heart Disease. Accessed December 22, 2025. https://www.attackheartdisease.com/hcp/address-ldl-c/why-ldl-c-matters#:~:text=of%20CV%20events,ethnic%20group%2C%20and%20geographic%20region