Effective management of low-density lipoprotein cholesterol (LDL-C) is crucial for preventing recurrent cardiovascular (CV) events in patients with chronic coronary syndrome (CCS). Sex may impact the LDL-C management.

We examined sex-specific LDL-C management in CCS patients, assessing target achievement rates and their implications for CV outcomes.

In the international CLARIFY registry, we included 22,134 CCS patients with baseline LDL-C measurements. LDL-C levels were monitored annually over the 5-year follow-up period. Target LDL-C was set at 100 mg/dL, in line with prevailing recommendations at that time. Sex-specific differences in LDL-C were adjusted forage, geographical region and indication for lipid lowering drugs (stroke, MI, PAD). The primary endpoint was the incidence of MACE, defined as CV death or MI during the 5-year follow-up, evaluated using multivariable analysis adjusted for known predictors of recurrent CV events in CCS patients.

Of 22,134 patients, 21.6% were women. Upon inclusion (6.5±6.3 years after CCS diagnosis), women were more likely than men to have LDL-C levels above the recommended threshold (45.6% vs. 37.4%; aOR 1.47, 95%CI 1.38–1.58, P<0.001, Fig. 1) and less likely to receive statin treatment (82.7% vs. 85.4%, P<0.001). The discrepancies endured over the 5-year observation period, with women consistently showing lower likelihood of achieving LDL-C targets at 1, 2, 3, 4, and5 years post-inclusion (P<0.001 for all time points). Overall, women were less likely than men to have all available LDL-C concentrations within the target range (37.8% vs. 44.6%; aOR 0.70, 95% CI 0.64–0.76, P<0.001) and more likely to never reach the target LDL-C goal during follow-up (22.6% vs. 17.5%; aOR 1.43, 95% CI 1.32–1.55, P<0.001). Failing to achieve at least one LDL-C concentration below100 mg/dL was associated with an increased risk of subsequent MACE (adjusted HR 1.57, 95%CI 1.38–1.77, P<0.001), with similar associations observed in both men (aHR 1.66, 95% CI 1.44–1.91, P<0.001) and women (aHR 1.31, 95% CI 1.01–1.70, P=0.05).

In patients with CCS, women consistently showed lower likelihood of reaching LDL-C targets throughout follow-up compared to men. Women were more likely to have no LDL-C concentration within recommended range during follow-up, which is particularly concerning given its association with an increased risk of CV events.