Received: 5 January 2023 | Accepted: 29 January 2023 DOI: 10.1002/clc.23988 CLINICAL INVESTIGATIONS Addressing current challenges in optimization of lipid management following an ACS event: Outcomes of the ACS EuroPath III initiative Alberico L. Catapano MD, PhD1 | Raffaele De Caterina MD, PhD2 | J. Wouter Jukema MD, PhD3,4 | Robert Klempfner MD5 | Ulf Landmesser MD, PhD6 | François Schiele MD, PhD7 | Alessandro Sionis MD, PhD8,9 1 Department of Pharmacological and Biomolecular Sciences, University of Milan, Abstract Milan, Italy Background: Low‐density lipoprotein cholesterol (LDL‐C) lowering is key to reduce 2 Division of Cardiovascular, Department of Cardiothoracic and Vascular, Pisa University atherosclerotic disease progression and recurrent events for patients after acute Hospital, University of Pisa, Pisa, Azienda coronary syndrome (ACS). However, LDL‐C management for post‐ACS patients Ospedaliero‐Universitaria Pisana, Pisa, and Fondazione Villaserena per la Ricerca, Città remains challenging in clinical practice. Sant'Angelo, Pescara, Italy Hypothesis: The ACS EuroPath III project was designed to optimize LDL‐C 3 Department of Cardiology, Leiden University management in post‐ACS patients by promoting guideline implementation and Medical Center, Leiden, The Netherlands 4 translating existing evidence into effective actions. Netherlands Heart Institute, Utrecht, The Netherlands Methods: Three surveys targeting cardiologists (n = 555), general practitioners (GPs; 5 Cardiac Rehabilitation Institute, Sheba n = 445), and patients (n = 662) were conducted in Europe, with the aim of capturing Medical Center, Tel‐Aviv University, Tel Aviv, information on patient characteristics and treatment during acute phase, discharge Israel 6 and follow‐up. GPs’ and patients’ opinions on key treatment aspects were also Department of Cardiology, Charité University Medicine Berlin, German Centre for collected. Based on survey results, international experts and clinicians identified areas Cardiovascular Research (DZHK), Partner Site of improvement and generated prototype solutions. Participants voted to select the Berlin, Berlin Institute of Health (BIH), Berlin, Germany most feasible and replicable proposals for co‐development and implementation. 7 Department of Cardiology, University of Results: Five key areas of improvement were identified: (1) inappropriate treatment Burgundy Franche‐Comte, University Hospital Jean Minjoz, Besançon, France prescribed at discharge; (2) lack of lipid guidance in the discharge letter; (3) 8 Department of Cardiology, Hospital de la inadequate lipid‐lowering therapy (LLT) optimization; (4) gaps in guideline knowledge Santa Creu i Sant Pau, IIB‐Sant Pau, and lack of referral practices for GPs; (5) patients’ concerns about lipid management. Universitat Autònoma de Barcelona, Barcelona, Spain Proposed solutions for these focus areas included development of a treatment 9 Centro de Investigación Biomédica en Red de algorithm for the acute phase, a standardized GP discharge letter, an assessment tool Enfermedades Cardiovasculares (CIBERCV), for LLT efficacy at follow‐up, an education plan for GPs/patients and a patient Madrid, Spain engagement discharge kit. The standardized GP discharge letter and treatment algorithm have been selected as the highest priority solutions for development. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2023 The Authors. Clinical Cardiology published by Wiley Periodicals LLC. Clin Cardiol. 2023;46:407–415. wileyonlinelibrary.com/journal/clc | 407 408 | CATAPANO ET AL. Correspondence Alessandro Sionis, Hospital de la Santa Creu i Conclusion: These initiatives have the potential to improve adherence to guidelines Sant Pau, II‐B Sant Pau, CIBER‐CV, Universitat and patient management after ACS. Autònoma de Barcelona, Barcelona, Spain. Email: ASionis@santpau.cat KEYWORDS Funding information acute coronary syndromes, cardiovascular risk, LDL cholesterol, lipid‐lowering treatments, Sanofi myocardial infarction, PCSK9 inhibitors 1 | INTRODUCTION The ACS EuroPath III initiative aimed at identifying and selecting five focus areas for possible improvement, based on data from the Cardiovascular disease (CVD) is the commonest cause of death in specifically designed surveys described briefly above. Members of Europe, causing over 4 million deaths annually.1 Acute coronary the ACS EuroPath III forum worked together via a digital ideation syndromes (ACS), including unstable angina and myocardial infarction platform and a series of “hackathon” (hacker marathon) remote (MI), are life‐threatening manifestations of CVD.2,3 Approaches in the meetings to research, develop and define appropriate solutions for acute‐phase management of ACS (including interventional and each key area. Solutions were intended to be universally applicable, pharmacological treatment) have evolved over time, and post‐MI regardless of factors relating to regional practice or local healthcare 4,5 mortality has fallen, but could still be reduced further. systems. A total of 42 international experts from 18 countries Management of low‐density lipoprotein cholesterol (LDL‐C) level engaged in the ACS EuroPath III initiative (full details in Section S3), is one of the least controlled modifiable risk factors in post‐ACS and the five final solutions were pitched to participants during the patients.6–9 Current guidelines recommend new LDL‐C reduction goals third and final hackathon meeting, after which participants voted on for patients post‐ACS.6 To this end, these goals were lowered from solutions to prioritize for detailed development and implementation. 1.8 mmol/L (70 mg/dL) to 1.4 mmol/L (55 mg/dL) for all patients with ACS, with the additional aim of achieving at least 50% reduction from baseline; an even lower goal of 1 mmol/L (40 mg/dL) is recommended 3 | RESULTS for patients with recurrent events.6 It is now important to ensure the implementation of current guidelines into clinical practice, so as to 3.1 | Key findings from the surveys reduce the risk of negative outcomes in patients post‐ACS.7 Based on this background, the ACS EuroPath project (initiatives 3.1.1 | ACS EuroPath I (i.e., cardiology) survey I–III) was designed to help optimize post‐ACS lipid management and improve clinical outcomes. Details of the ACS EuroPath I and II Results from the Cardiology survey have been reported in full forums have been published previously10,11; a brief overview can be previously.10 In brief, 555 physicians participated and the study found in Section S1. The aim of the ACS EuroPath III initiative enrolled 2775 patients with ACS. For patients in acute phase, 91% of (2020–2021) was to translate existing evidence and guidelines on key patients were tested for lipid levels, mostly (73%) within the first day topics into accessible, effective, and well‐structured solutions, to of hospitalization. During hospitalization, 93% received an LLT; of address identified gaps and optimize post‐ACS lipid management in them, 37% were already under LLT and 56% were statin‐naïve clinical practice. Here we describe the proposed solutions, filtered patients. Of patients who received statins, the majority (64%) received through a pre‐ordered process involving European cardiologists, them on day 1 of hospitalization; however, the average was 2.3 days. general practitioners (GPs) and patients. At discharge, only 66% of the patients received a high‐intensity statin (HIS) therapy. For follow‐up, few (14%) patients had a follow‐up within 4–6 weeks of discharge, with 3 months as an average timeframe. 2 | M E TH O D S The majority of patients (77.6%) at the first follow‐up had LDL‐C > 70 mg/dL; of them, 41% had no change to their LLT. Similar The ACS EuroPath I survey was conducted in 2018, with 555 data were observed during the second follow‐up visit. cardiologists participating.10 Two further surveys were conducted by Ipsos MORI in 2020, targeting GPs and patients. These surveys were completed by 445 GPs providing data on 1780 patient cases, and 662 3.1.2 | GP survey patients. These surveys captured information on patient character- istics and treatment during acute phase, at discharge and during Key demographics are shown in Table 1A. A total of 445 GPs follow‐up; GPs and patients also provided feedback on their own participated in the survey, contributing data from 1757 patients. knowledge base, confidence level regarding treatment and what they Average length of hospitalization was 11 days. Slightly less than half considered to be key aspects of treatment. Full methodological (46%) of patients were newly initiated on LLT at discharge from details are provided in Section S2. hospital (typically an HIS monotherapy), while 36% who were already CATAPANO ET AL. | 409 TABLE 1 Key demographics for the (A) GP and (B) patient TABLE 1 (Continued) surveys. B A Patient survey GP survey Admission for most recent heart attack 100% Total number of GPs included 445 Timing of most recent heart attack France 103 6–9 months previously 40% UK 117 10–13 months previously 34% Spain 117 14–18 months previously 26% Italy 108 Abbreviations: ACS, acute coronary syndrome; CVD, cardiovascular Average number of years in practice 17 disease; GP, general practitioner. Secondary specialties (number of GPs) Internal medicine 45 on LLT maintained their therapy with adjustments. The first follow‐up Cardiology 41 consultation after discharge was equally likely to be with a GP or a Diabetology 34 cardiologist; the majority (43%) had their first follow‐up with a GP within 6 weeks of discharge. Nearly half (47%) of the patients had lipid Other/no second specialty 325 levels 71–100 mg/dL at follow‐up, and 27% of patients had lipid levels Average 3‐month caseload of patients with ACS (number of 32 at 55–70 mg/dL. Over half (58%) of patients were currently receiving patients) an HIS, with only 3% receiving a PCSK9 inhibitor. Combination therapy Total number of patient records included 1757 was prescribed to less than 10% of patients. Overall, 68% of patients Average age, years 66 had their LLT reassessed across all follow‐ups; the main reason GPs Sex, male 74% gave for reassessing LLT was to check patient compliance (54%) rather than maximize LDL‐C reduction (42%). Overall, changes were made to Comorbidities patient LLT in 27.3% of cases across all follow‐ups. Hypertension 73% Most (94%) GPs of the survey indicated that they believe managing Obesity 47% lipid levels is very important; however, a lower proportion (66%) felt very Type 2 diabetes 42% confident in their ability to manage them. The main barriers to optimal lipid management for patients with ACS (from a GP perspective) were Family history of CVD 41% identified to be patient lack of understanding (58%), patient nonadher- Experiencing first ACS event 87% ence (56%) and GPs’ inability to prescribe PCSK9 inhibitors (42%). Most B (94%) GPs discuss lipid levels with their patients during consultations Patient survey (always, 53%; regularly, 41%). Lipid management information is received Total number of patients included 662 by 73% of GPs, generally embedded with other information. More than France 143 half (60%) of GPs surveyed are aware of clinical guidelines for managing ACS patient lipid level, with most (~70%) feeling confident in implement- UK 150 ing the ESC/EAS recommendations. The main reason given for Spain 123 nonimplementation (by 48% of respondents) is that GPs are unable to Italy 150 initiate/prescribe PCSK9 inhibitors. Netherlands 48 Sweden 48 3.1.3 | Patient survey Average age, years 57 Sex, male 76% Key demographics are shown in Table 1B. Overall, 662 patients Comorbidities participated. The majority (90%) of patients stated the belief that managing cholesterol levels is important to prevent another CV High cholesterol 39% event. During hospitalization, high cholesterol is the main CV risk High blood pressure/hypertension 32% factor discussed with healthcare professionals (HCPs). Most (90%) Overweight 26% patients discussed cholesterol management with cardiologists during Diabetes 21% hospitalization and most (89%) were satisfied with the discussion. Half were taking a statin before their most recent event, while Family history of CVD 59% at discharge this proportion increased to over 60%. Approximately 410 | CATAPANO ET AL. one‐third of the patients received no prior treatment before their five solutions (one to address each key area of unmet need most recent ACS event. Patients spent a mean of 6.3 nights in highlighted by the surveys) were proposed, as follows: hospital, and approximately half of respondents (46%) experienced only positive emotions at discharge (20% experienced only negative emotions). Discharge letters were received by most (94%) patients’ 3.2 | Inappropriate treatment prescription at GPs, with the majority (46%–48%) including information on LLT discharge prescribed, cholesterol levels, and timings for next consultation. Most (84%) patients were satisfied with the follow‐up care after their most 3.2.1 | Survey findings recent heart attack. A total of 61% of patients had their first follow‐ up within 6 weeks of discharge, with the next 2–3 follow‐up Key issues identified in the Cardiologist survey included the lack of consultations generally falling within 3 months of discharge. Patients lipid blood test within 1 day of admission and high number of patients were most likely to see a cardiologist at their first 3 follow‐up who received statin therapy on day 2 or later. In addition to this, consultations (53%, 48%, and 40% of patients at the first, second and approximately one‐third of patients were not receiving HIS at third consultations, respectively), and a cardiac rehabilitation doctor discharge or had LDL‐C > 70 mg/dL at the first follow‐up; data from thereafter (48%, 54%, and 66% of patients at the fourth, fifth and the GP survey support the last two points. Current guidelines sixth consultations, respectively). Rehabilitation programs were recommend that HIS should be initiated as soon as possible following planned at discharge for 70% of patients. Most programs were an ACS event,4,5 and that a lipid profile should be obtained after 4–6 planned to start within 6 weeks of discharge, lasting on average weeks postdischarge to determine if the therapeutic goal has been 10 weeks. reached. If not, optimization of the LLT with ezetimibe and/or PCSK9 inhibitor is needed.4,6 Viewing these survey data in the light of current guideline recommendations, action is needed to address 3.1.4 | The ACS EuroPath III initiative inappropriate treatment prescription at discharge. The five key focus areas for ACS EuroPath III initiative were: (1) inappropriate treatment prescribed at discharge; (2) lack of lipid 3.2.2 | Proposed solution management guidance in the discharge letter; (3) inadequate LLT optimization; (4) gaps in knowledge of clinical guidelines and lack of We propose the development of an algorithm for use by hospital referral practices for GPs; and (5) patients’ concerns about blood lipid cardiologists during the acute phase to clarify the LDL‐C goal and the management (Table 2). Following completion of the ideation phase, recommended LLT treatment approach (based on the “Fire early TABLE 2 Key areas for improvement; concerns supporting selection of these areas. Key areas for improvement Concerns supporting this selection (1) Inappropriate treatment prescribed at discharge • Lack of lipid blood test in some patients during acute phase • Delayed introduction of statins • Lack of LLT prescribed at discharge after an ACS event in some patients • Consequences of inappropriate treatment at discharge (i.e., patients not at LDL‐C goal) • Suboptimal LLT intensification before discharge (2) Lack of guidance in the discharge letter • Late communication/delivery of discharge letter to GPs • Lack of consistent lipid management guidance in discharge letter • Inconsistent communication of discharge letter information to patient (3) Inadequate LLT optimization • Late 1st follow‐up (>6 weeks) for majority of patients • LDL‐C levels above goal at 1st follow‐up • Suboptimal LLT treatment • Inconsistent LDL‐C assessment at 1st follow‐up (4) Gaps in knowledge of clinical guidelines & lack of referral • Lack of GP awareness of clinical guidelines practices for GP • Lack of knowledge regarding optimal lipid treatment management • Lack of GP comfort in prescribing nonstatin therapies • Lack of GP comfort in referral (to another GP or to specialist) (5) Patient's concerns about blood lipids management • Lack of patient knowledge regarding cholesterol level management • Patient nonadherence to LLT • Lack of patient education on lipid management Abbreviations: ACS, acute coronary syndrome; LDL‐C, low‐density lipoprotein C; LLT, lipid‐lowering therapy; GP, general practitioner. CATAPANO ET AL. | 411 according to risk and follow to goal/target” approach). This encom- 3.3.2 | Proposed solution passes lifestyle, HIS, ezetimibe, and PCSK9 inhibitors, and should involve a systematic follow‐up visit (by a cardiologist or a GP) at 4–6 Clear rules on how to prepare an optimal discharge letter are needed. weeks after introduction of the LLT to determine the clinical and This may take the form of a template of a standardized discharge biological tolerance and efficacy. We recommend that physicians letter for GPs, focusing on the individualized status and risk of the should take full advantage of recent openings in permission to patient, the importance of treating to goal, and clear recommenda- prescribe PCSK9 inhibitors even in the hospitalization phase in tions for LLT and follow‐ups. A list of proposed strategies for various European countries. addressing LLT approaches in a discharge letter is provided in Table 3. 3.2.3 | Key comments/takeaways 3.3.3 | Key comments/takeaways Using a dedicated algorithm, treatment with HIS plus ezetimibe GPs receiving a standardized discharge letter with key information should be initiated as soon as possible following an ACS event in all relating to lipid management will benefit from clear, individualized patients. Selected patients may require additional LLT (i.e., a PCSK9 guidance on each patient's risk status and recommended LLT. Such a inhibitor) during hospitalization, as per 2019 ESC/EAS recommenda- standardized discharge letter might help all the clinicians involved in tion.6 At follow‐up, the threshold for adding PCSK9 inhibitors can be the post‐ACS patient management. Patients will benefit from an determined based on various criteria: (1) according to ESC guidelines, efficient, standardized, and time‐sensitive approach to treatment, when LDL‐C remains above the therapeutic LDL‐C goal (>1.4 mmol/L which may improve adherence and achievement of LDL‐C goals to [55 mg/dL]); (2) according to the design of the clinical studies with reduce recurrence of cardiovascular events. PCSK9 inhibitors, when LDL‐C is >1.8 mmol/L (70 mg/dL); or (3) according to local rules, because the conditions of availability and reimbursement vary across European countries (Section S4). If 3.4 | Inadequate LLT optimization needed, PCSK9 inhibitors should be considered and introduced early after ACS based on the findings of the ODYSSEY‐OUTCOMES study. 3.4.1 | Survey findings Patients should be monitored closely by the physician responsible for their follow‐up care (i.e., specialist or GP) after being discharged, to Data from the Cardiologist survey indicate that almost half of patients assess LLT tolerance, adherence, effectiveness, and whether further who had not achieved LDL‐C target at first follow‐up had no LLT intensification is required. To this end, a 4–6‐week follow‐up subsequent change made to their LLT treatment regimen. In the GP visit is recommended; this makes it possible to initiate management survey, respondents noted that their main aim in reassessing LLT was of statin‐associated muscular symptoms if needed and enables LLT to check patient compliance, and changes were made to patient LLT in optimization. Cardiologist follow‐up should be considered for approximately one‐quarter of cases. Almost half of all patients whose selected patients. data were included in the GP survey saw a GP at the first follow‐up. The fact that follow‐up may be conducted by one of many different HCPs, in diverse settings, makes it hard to ensure LLT is being 3.3 | Lack of lipid management guidance in the thoroughly assessed, especially since one‐third of GPs expressed a lack discharge letter of confidence in their own ability to manage patient lipid levels. In addition to this, timing of the first follow‐up visit was variable; 3.3.1 | Survey findings guidelines suggest that patients should be seen for follow‐up 4–6 weeks after an ACS event,6 but average time from discharge to first In the GP survey, the majority (90%) of respondents confirmed that follow‐up in the Cardiologist survey was 3 months, with few patients their patients received discharge letters, usually within 7 days. meeting the timeframe suggested in guidelines. These data suggest Overall, 64% of respondents reported that lipid management that there is a need to improve the process by which LLT is optimized. guidance was included in the discharge letter; this information included details of specific LDL‐C goal, when the next measurement of LDL‐C levels should be carried out, lipid treatment guidance and 3.4.2 | Proposed solution appropriate timing for follow‐up visits. Interestingly, 41% of respon- dents reported that the lack of lipid management information in the A structured process enabling the systematic assessment of the discharge letter was a barrier to optimal lipid management. efficacy of LLT at the 4–6‐week follow‐up, regardless of the setting Respondents recommended that inclusion of information on specific in which it is conducted. Telemedicine appointments are a feasible LDL‐C goal, lipid treatment algorithm, timing of next LDL‐C alternative and could be used to evaluate the results during follow‐ measurement, and optimal hospital follow‐up time in the discharge up.12 At this stage, the results are shared and the next steps for letter would help them to optimally manage patients with ACS. optimal management are discussed. 412 | CATAPANO ET AL. T A B L E 3 Strategies for addressing lipid lowering treatment 3.5 | Gaps in knowledge of clinical guidelines and approaches in a patient's discharge letter. lack of referral practices for GPs Use clear and concise language to make the document readable for general practitioners and patients 3.5.1 | Survey findings Include a short summary, either at the beginning or at the end of the document, stating the cause of the admission, the management GPs face a major challenge when striving to keep up to date with strategy, and the individual risk of the patient current guidelines in all fields of medicine and may have limited time Provide information regarding LDL‐C levels at admission and previous for research and consultation. As such, data from the GP survey LLT treatment indicate that 40% of respondents are not familiar with the 2019 ESC/ State individualized LDL‐C goals (both mg/dL and mmol/L) and a EAS clinical guidelines. percentage of LDL‐C reduction from baseline (e.g., your desired LDL‐C goal is 1.4 mmol/L) Give precise instructions that are easy for patients to follow (e.g., name 3.5.2 | Proposed solution of the drug, dose, posology, route of administration and duration of treatment) A three‐step plan to educate GPs and patients to update them Stress the importance of reaching the goals as soon as possible (e.g., with current guidelines, the safety and efficacy of LLT, and according to current scientific evidence, the LDL‐C goal should be generate a call‐to‐action to ensure effective post‐ACS lipid achieved as soon as possible in order to reduce the patient's management: residual cardiovascular risk) Stress the importance of treatment adherence (e.g., the effectiveness of ‒ Awareness campaign by well‐known GPs, cardiologists and the treatment is highly dependent on good adherence and will offer lifelong protection) influencers on the goals and importance of post‐ACS lipid management. Mention the timing (ideally between 4 and 6 weeks after discharge) and ‒ Clearer protocols that enable GPs to assess goal attainment and place of the planned follow‐up visits and blood analysis refer patients when needed. Offer a referral pathway for patients that do not reach the desired ‒ Emphasizing of safety and substantial benefit of LLT in achieving cardiovascular risk factors goals or experience drug‐related adverse events (e.g., statin‐related muscle symptoms) guideline goals and engaging both patients and GPs as guardians of the evidence‐based lipid goals. Be proactive and, whenever possible, engage your patient in a structured cardiac rehabilitation program Suggest trusted sources of information that are easily accessible for your patient, as the information received by patients during the 3.5.3 | Key comments/takeaways admission is usually very fragile Priming GPs on the need for change, ensuring that patients and Abbreviations: LDL‐C, low‐density lipoprotein C; LLT, lipid‐lowering therapy. GPs are on the same page with regard to the importance and key elements of their care, and using credible sources (e.g., ESC, EAS and national cardiac society websites) to reinforce how treatment 3.4.3 | Key comments/takeaways is strictly linked to patient outcomes, will have a positive impact on GPs' workload and patient outcomes. Establishing simple All patients should be discharged on high‐intensity LLT. Follow‐ referral criteria for lipid management consultations is likely to up blood test and visits should be scheduled according to a improve consultation rates, as well as easing LLT manage predefined process (e.g., regular intervals between visits, with ment modifications. To this end, it would be worthwhile to specified times at which particular blood tests should be carried consider ways to remove any existing bureaucratic barriers. out), and the patient should be engaged in the follow‐up process. Referral for consultation from within the medical record could It should be noted that for most patients, the maximum level of potentially reduce the amount of time physicians spend entering LLT will be the maximum tolerated statin dose, plus ezetimibe. In redundant information into numerous forms, and the use of patients at very high CV risk who are predicted not to reach well‐designed asynchronous tele‐consultation platforms would target LDL‐C levels, the option also exists to add PCSK9 inhibitor also be of benefit. Further to this, tools that have the capacity to treatment at discharge.6 If access to follow‐up appointment with integrate with a patient's electronic medical record could be cardiologists is limited, visits should be scheduled with alternative used to highlight lipid values above goal and help provide HCPs according to patient risk and predicted need for ongoing reminders for laboratory retesting, thus improving standard– adjustments to LLT. ization of care. CATAPANO ET AL. | 413 3.6 | Patient concerns about blood lipid and the patient engagement discharge kit and standardized GP management discharge letter as being most easily implemented in clinical practice. The participants voted to prioritize the standardized GP discharge 3.6.1 | Survey findings letter and treatment algorithm for development and implementation. Over the last two decades there has been a progressive shortening of the length of hospital admissions in patients with ACS.4,13 Current 4 | D IS CU SS IO N guidelines recommend an early discharge (<48–72 h in low‐risk patients after an ACS), although the data on hospital stay from the GP In the ACS EuroPath III forum, participants agreed that implementation and Patient surveys (ranging from 6 to 11 days) show that in practice of a Patient engagement discharge kit and treatment algorithm would patients may remain for longer. Whatever their length of stay, have the greatest impact on clinical outcomes, but decided to prioritize patients may be fatigued/overwhelmed and emotionally variable, the standardized GP discharge letter and treatment algorithm for initial with around one‐third of patients experiencing a mixture of positive development and implementation. Evidence from a recent review of and negative emotions. It is reasonable to suggest that many patients eight European initiatives to optimize post‐ACS lipid management may be less able to absorb necessary information and key messages suggests that the application of treatment algorithms, standardized about their ongoing treatment on their own at the point of discharge, identification of high‐risk patients, routine screening for familial and that some assistance might be usefully supplied. hypercholesterolemia and intensification of LLT can significantly increase the achievement of LDL‐C goals, as well as decrease CV risk of recurrent events.7 The here‐described forum decided to identify the 3.6.2 | Proposed solution five most relevant possible areas of intervention and to rank them in terms of priority, feasibility and importance. Develop a “patient engagement discharge kit” designed to be offered The use of GP discharge letters has previously been investigated, to patients during their discharge briefing. The “discharge kit,” should most notably in the Discharge Communication Study; as part of this include concise written and visual instructions summarizing the key study, factors influencing the perceived usefulness of a latter were information, the importance of following instructions, as well as links identified.14 Key “useful” factors included reason for admission, to trusted websites for additional supporting information. This will patient diagnosis, a list of procedures performed and test/examina- enable HCPs to deliver the following key messages: reasons why the tion results. It was noted that the use of clear language in discharge patient experienced an ACS, what steps they need to follow going letters is essential for safe and effective transition of care, and that forward, and potential consequences if they do not follow these such letters should be concise and understandable (for both GP and steps (i.e., Why did you have an ACS? What happens now? What will patient).14 Therefore, development of a standardized discharge letter you have to do to reduce the risk of a recurrent event? What happens taking into account previously‐identified “useful” elements would be if you do not do it?). The discharge instructions for the patient should logical. One such standardized letter template has previously been ideally include a recommended LDL‐C goal. suggested in a position paper endorsed by ILEP and includes suggestions relating to timings of GP/cardiologist follow‐up, advice on ongoing treatment/monitoring and next steps if LDL‐C goals are 3.6.3 | Key comments/takeaways not met.15 In the opinion of authors, the concept of a standardized GP discharge letter for patients post‐ACS is worth developing Having access to a patient engagement discharge kit will enable further, ideally at a pan‐European level. cardiologists and other HCPs (e.g., nurses) to provide patients with a The use of treatment algorithms in healthcare is widespread, with package of clear, simple instructions on next steps, thus potentially different clinical areas developing approaches as needed16,17; it has benefitting both parties. If possible, it would be good to link the been suggested that an ideal treatment algorithm should be explain- patient discharge kit to a digital platform (e.g., CardioSmart, LipidApp) able, dynamic, precise, autonomous, fair and reproducible.18 The ACS offering addition information/detail as needed. EuroPath III forum suggests that the widespread uptake and utilization of a treatment algorithm for the acute‐phase ACS management would be beneficial in terms of patient outcomes and also aid hospital 3.6.4 | Ranking and prioritization of pitched cardiologists in making effective clinical decisions at an early stage. solutions Ideally, such an algorithm should be locally adapted to accommodate for the different reimbursement policies in European countries. Following discussion, the hackathon participants voted for their The ACS EuroPath III initiative identified key unmet needs in post‐ preferred pitch solutions, based on their potential to improve post‐ ACS lipid management according to the feedback from both physicians ACS lipid management and their applicability to clinical practice. (cardiologists and GPs) and patients. The survey results, together with Participants ranked the patient engagement discharge kit and the those of ACS EuroPath I, provided a relatively comprehensive view of treatment algorithm as being most likely to improve lipid management, the gaps in care between clinical practice and guidelines from both the 414 | CATAPANO ET AL. physicians’ and patients’ perspectives. Solutions were developed by a accredited) meetings sponsored by Amarin, Amgen, Athera, Biotronik, broad group of 42 experts from 18 European countries, which will Boston Scientific, Dalcor, Daiichi‐Sankyo, Lilly, Medtronic, Merck‐ greatly benefit GPs in implementing lipid management guidelines in Schering‐Plough, Novartis, Novo Nordisk, Pfizer, Roche, Sanofi their daily practice. However, it should be of note that regional Aventis, the Netherlands Heart Foundation, CardioVascular Research differences may lead to difficulties in implementation of chosen the Netherlands (CVON), the Netherlands Heart Institute and the solutions and adjustments according to regional variation may be European Community Framework KP7 Program. required. In addition, the possibility of selection bias (inherent to all Robert Klempfner: gave sponsored lectures and/or received observational studies) should be considered. consultation fees from Sanofi and AstraZeneca. Ulf Landmesser: reports research grants to the institution from Amgen, Bayer and Novartis. Speaker or advisory honorary from 5 | C ONC LUS I ON S Amgen, Daiichi‐Sankyo, Novartis, Sanofi. François Schiele: reports personal fees from Amgen, AstraZeneca, In the authors’ opinion, all the solutions proposed here would have a Bayer, BMS, MSD, Pfizer, Lilly, Novartis, Mylan, Sanofi and Servier. positive impact on clinical outcomes and will help to improve optimal Alessandro Sionis: reports speaker fees and nonfinancial support lipid management for both HCPs and patients post‐ACS. It is hoped from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi‐ that there will be widespread uptake of the proposed standardized Sankyo, Ferrer, Novartis, Sanofi and Servier; research grants from: discharge letter and treatment algorithm, and that improvements in AstraZeneca, Daiichi‐Sankyo, Ferrer, GE Health Care and Zoll. lipid management will become evident for patients post‐ACS. Future steps might be to monitor changes in practice, as suggested by these DATA AVAILABILITY STATEMENT considerations, and their effects on measurable outcomes, such as Qualified researchers may request access to patient level data and the achievement of LLT goals and the time to achieve them from related study documents including the clinical study report, study patients’ discharge after an ACS. protocol with any amendments, blank case report form, statistical analysis plan, and dataset specifications. Patient level data will be A U T H O R C O N TR I B U T I O N S anonymised and study documents will be redacted to protect the All authors equally involved in study concept and design, acquisition privacy of our trial participants. Further details on Sanofi's data of data, analysis and interpretation of data, drafting of the manuscript sharing criteria, eligible studies, and process for requesting access can and critical revision of the manuscript for important intellectual be found at https://www.vivli.org/. content. All authors had access to relevant data, and participated in the writing, review, and approval of the manuscript. ORC I D J. Wouter Jukema http://orcid.org/0000-0002-3246-8359 A C KN O W L E D G M E N T S Alessandro Sionis http://orcid.org/0000-0003-0843-9512 Medical writing support was provided by Hanna Mourad‐Agha, PhD, of Fishawack Communications Ltd, part of Fishawack Health, and RE F ER EN CES was funded by Sanofi. We thank Megan Loy, Kaja Pol and Wanda 1. Movsisyan NK, Vinciguerra M, Medina‐Inojosa JR, et al. Cardiovas- Stipek (Sanofi) for coordination of the development, facilitating cular diseases in central and eastern Europe: a call for more surveillance and evidence‐based health promotion. Ann Glob Health. author discussions, and critical review of this manuscript. This work 2020;861:21. was supported by Sanofi. 2. Sanchis‐Gomar F, Perez‐Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl CO NFL I CTS OF I NTEREST STATEM ENT Med. 2016;4:256. Alberico L. Catapano: has received honoraria, lecture fees, or 3. Eisen A, Giugliano RP, Braunwald E. Updates on acute coronary syndrome: a review. JAMA Cardiology. 2016;1:718‐730. research grants from: Aegerion, Amgen, Amryt, AstraZeneca, Bayer, 4. 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