Study cohort

A total of 7556 AMI patients from the biobank database between January 2016 and December 2020 were screened for eligibility. After excluding those without revascularization or statin-based therapy, the remaining 5802 statin users, 801 statin plus ezetimibe users and 170 statin plus evolocumab users (including 95 users without and 75 users with ezetimibe) were selected for this study. Then, 1− and 3-month follow-up data were collected and analyzed, including in-hospital mortality, readmission rate and lipid profiles (Fig. 1).

Fig. 1

Patient selection, propensity score matching and follow-up

As admission LDL level and crowd size vary among different lipid-lowering strategy groups, propensity score matching (PSM) was performed for further analysis. First, PSM was based on statin plus evolocumab therapy, and of these, 95 users were successfully matched with 190 statin users and 190 statin plus ezetimibe users. Second PSM was based on statin plus ezetimibe plus evolocumab (triple) therapy, and of these, 75 users were successfully matched with 150 statin users and 150 statin plus ezetimibe users. The matched groups were well balanced in terms of demographic and clinical characteristics (Appendix Tables 1 and 2, Appendix Figs. 1 and 2).

Baseline characteristics and short-term follow-up in the whole cohort

In the whole cohort, the mean ages were 62.90 ± 11.91, 58.73 ± 12.16, 57.72 ± 11.07 and 54.38 ± 11.77 years among the statin, statin plus ezetimibe, statin plus evolocumab and triple therapy groups. The admission LDL levels were 2.25 ± 0.74, 2.95 ± 1.03, 3.24 ± 0.98 and 3.90 ± 1.45 mmol/L, respectively (Table 1), which is also inconsistent with the basic strategy that higher LDL levels require intensive lipid-lowering therapy in AMI patients. According to 2019 ESC/EAS Guidelines for the management of dyslipidemias [2], for patients at very high cardiovascular risk, LDL reduction of ≥50% from baseline and an LDL goal of < 1.4 mmol/L (< 55 mg/dL) are recommended. We further analyzed the control situation of LDL (< 1.4 mmol/L) among each group. On admission, the target rate was 11.8, 4.0, 3.2 and 1.3% among each group. In the 1-month follow-up, approximately 37.0, 28.8, 79.5 and 55.3% of all patients reached the treatment goal among each group, and after 3 months, 40.6, 29.3, 80.0 and 43.8% of all patients reached the treatment goal, respectively (Table 1). Despite higher LDL levels at admission, AMI patients achieved a promising control rate in short-term PCSK9i treatment Fig. 2.

Table 1 Distribution of demographic and clinical characteristics according to different lipid-lowering strategies in AMI patientsFig. 2

LDL level and compliance rate on admission and short-term follow-up among different lipid-lowering strategies in AMI patients. A. LDL level and compliance rate among different lipid-lowering strategies on admission and at the 1- and 3-month follow-ups. Each point represents one AMI patient’s lipid data. B LDL alterations among different lipid-lowering strategies on admission and at the 1st and 3rd month follow-ups. Data are shown as the mean ± SEM LDL Target Level = 1.4 mmol/L

Approximately 1.9% of AMI patients died with statin alone therapy, and 0.7, 0.8, and 0.0% died among the statin plus ezetimibe, evolocumab dual and triple groups, respectively, during the 3-month follow-up. The readmission rates were 4.0 and 5.3% with PCSK9i treatment and more than 10%, approximately 10.4% in statin users and 14.7% in statin plus ezetimibe users, respectively.

Statin plus evolocumab therapy (dual therapy)-based PSM analysis

Ninety-five statin plus evolocumab users, 190 statin users and 190 statin plus ezetimibe users were well matched for this PSM analysis. The mean age was 59.42 ± 11.66, 58.62 ± 12.73 and 58.53 ± 10.63 among each group, and the admission LDL was 3.11 ± 1.02, 3.24 ± 1.13, and 3.24 ± 0.98 mmol/L, respectively, after PSM adjustments.

On admission, 0.5, 2.1 and 3.2% of AMI patients reached target LDL levels among the statin, statin plus ezetimibe, and statin plus evolocumab groups, respectively. At the 1-month follow-up, the target rates were 31.0, 21.3, and 79.5% and 29.4, 21.4, and 80.0% after 3 months, respectively (Fig. 3A). The mean LDL level was significantly decreased in statin plus evolocumab users compared to the other two groups, with 0.92 ± 0.62, 1.58 ± 0.44, and 1.96 ± 0.82 mmol/L in the 1st month and 1.17 ± 0.73, 1.61 ± 0.49, and 2.10 ± 0.82 months in the 3rd month. (Table 2 and Fig. 3.B). Additionally, a similar trend was observed in the ApoB level, with 0.39 ± 0.20, 0.64 ± 0.16, and 0.70 ± 0.22 g/L in the 1st month and 0.46 ± 0.20, 0.59 ± 0.15, and 0.75 ± 0.22 g/L in the 3rd month follow-up, respectively. Approximately 4.0% of AMI patients were rehospitalized with statin plus evolocumab therapy, and 11.6 and 10.5% readmission rates were observed in the other two groups during the short-term follow-up.

Fig. 3

Lipid profile alterations and short-term follow-up among statin plus evolocumab/statin/statin plus ezetimibe lipid-lowering strategies in AMI patients after PSM adjustment. A LDL level and compliance rate among different lipid-lowering strategies on admission and at the 1- and 3-month follow-ups. Each point represents one AMI patient’s lipid data after PSM adjustment. LDL (B) and ApoB (C) alterations among different lipid-lowering strategies on admission and at the 1- and 3-month follow-ups. Data are shown as the mean ± SEM. D Readmission rate among each group. Ninety-five statin plus evolocumab users, 190 statin plus ezetimibe users and 190 statin users were chosen after 1:2:2 propensity score matching. For statistical analysis, one-way ANOVA followed by Sidak’s multiple comparison test was applied, * P < 0.05, ***P < 0.001

Table 2 Short-term lipid profile alteration among statin plus evolocumab/statin/statin plus ezetimibe lipid-lowering strategies in AMI patients after PSM adjustmentStatin plus ezetimibe plus evolocumab therapy (triple therapy)-based PSM analysis

In the 7556 AMI patients, 75 patients received triple therapy (statin plus ezetimibe plus evolocumab) and were well matched with 150 statin users and 150 statin plus ezetimibe users. The mean age was 52.59 ± 11.92, 53.57 ± 11.29 and 53.67 ± 11.86 among the groups, and the admission LDL levels were 3.59 ± 0.95, 3.82 ± 1.20, and 3.90 ± 1.45 mmol/L, respectively, after PSM adjustments.

Approximately 1.3, 0 and 1.3% of AMI patients reached target LDL levels among the statin, statin plus ezetimibe, and triple therapy groups during admission. At the 1-month follow-up, the achieved rates were 10.7, 28.6, and 55.3% and 0.0, 17.9, and 43.8% after 3 months, respectively (Fig. 4A). Additionally, the mean LDL level was significantly decreased in triple therapy patients compared to the other two groups, with 1.43 ± 1.06, 1.96 ± 0.49, and 2.04 ± 0.81 mmol/L in the 1st month and 1.40 ± 0.50, 2.06 ± 0.42, and 2.37 ± 1.13 mmol/L after the 3-month follow-up (Table 3 and Fig. 4.B). Additionally, a similar decrease was observed in ApoB levels, and triple medication users reached 0.59 ± 0.29 0.61 ± 0.20 g/L in the 1st month and 3rd month, compared to 0.75 ± 0.17 and 0.80 ± 0.13 g/L in the statin group and 0.76 ± 0.20 and 0.83 ± 0.29 g/L in the statin plus ezetimibe group. A total of 5.3% of AMI patients were rehospitalized with triple therapy, which was 6.7 and 6.0% lower than those in statin and statin plus ezetimibe users, respectively.

Fig. 4

Lipid profile alterations and short-term follow-up among statin plus ezetimibe plus evolocumab/statin/statin plus ezetimibe lipid-lowering strategies in AMI patients after PSM adjustment. A LDL level and compliance rate among different lipid-lowering strategies on admission and at the 1- and 3-month follow-ups. Each point represents one AMI patient’s lipid data after PSM adjustment. LDL (B) and ApoB (C) alterations among different lipid-lowering strategies on admission and at the 1- and 3-month follow-ups. Data are shown as the mean ± SEM. D Readmission rate among each group. Seventy-five statin plus ezetimibe plus evolocumab users, 150 statin plus ezetimibe users and 150 statin users were chosen after 1:2:2 propensity score matching. For statistical analysis, one-way ANOVA followed by Sidak’s multiple comparison test was applied, * P < 0.05, ** P < 0.01, *** P < 0.001

Table 3 Short-term lipid profile alteration among statin plus ezetimibe plus evolocumab/statin/statin plus ezetimibe lipid-lowering strategies in AMI patients after PSM adjustment