A written protocol gets post-ACS patients to LDL target; good intentions do not

Design

cluster-randomised trial, 10 centres allocated 1:1 to protocol-based or standard lipid management (BRIDGE)

Population

329 patients after acute coronary syndrome; mean age 69 years, 18% women, median baseline LDL cholesterol 110 mg/dL

Primary outcome

achievement of LDL cholesterol below 70 mg/dL at 6 months

Effect

86.4% vs 73.7%, difference 12.6 percentage points (95% CI 3.8-21.5), P=0.005; below 55 mg/dL 60.8% vs 34.5%, difference 26.3 points (95% CI 18.5-34.0)

BRIDGE cluster-randomised ten centres, 1:1, to protocol-based or standard lipid management after acute coronary syndrome, enrolling 330 patients between November 2024 and July 2025. In the protocol arm, lipid-lowering therapy was started or intensified during the index admission according to a prespecified algorithm using high-intensity statins, ezetimibe and PCSK9 inhibitors, with LDL cholesterol rechecked at four weeks and escalated if needed. The stated goal in both arms was LDL cholesterol below 70 mg/dL; the protocol arm used about 55 mg/dL as its internal trigger for further intensification. Median baseline LDL cholesterol was 110 mg/dL and mean age 69 years.

At six months, LDL cholesterol below 70 mg/dL was reached by 86.4% against 73.7%, a difference of 12.6 percentage points (95% CI 3.8 to 21.5), P=0.005. Below 55 mg/dL the gap was wider: 60.8% against 34.5%, a difference of 26.3 points (95% CI 18.5 to 34.0). Use of high-intensity statins, ezetimibe and PCSK9 inhibitors was all higher in the protocol arm.

Nothing here is a new drug. Every agent used was already indicated, already recommended and already available, and the control arm had the same target written in the same guideline. The difference was that one group had a written algorithm attached to the admission and a fixed four-week recheck, and the other relied on the treating clinician remembering.

This is the cheapest intervention on this desk today, and the one most likely to be implementable next week. Write the escalation ladder down, attach it to the ACS admission order set, and book the four-week lipid recheck before the patient leaves. Two caveats belong in the reading: the endpoint is LDL cholesterol achievement, not cardiovascular events, and a hospital-level sensitivity analysis of the primary endpoint lost significance (difference 12.8 points, 95% CI -2.0 to 27.6, P=0.08), which is what ten clusters buys you.

• Start or intensify lipid-lowering therapy during the index admission, not at the first outpatient visit
• Put the escalation ladder in writing: high-intensity statin, then ezetimibe, then a PCSK9 inhibitor where affordable and available
• Book the four-week lipid recheck before discharge and make someone responsible for acting on it
• Use a trigger level below the target, so that patients sitting just under 70 mg/dL are still escalated toward 55
• Where PCSK9 inhibitors are out of reach on cost, the statin plus ezetimibe rungs still carry most of this gain and are inexpensive in India

The statistics, in plain English

These are differences in reaching a laboratory target, not in heart attacks or deaths, and the link between the two is inferred from earlier outcome trials of the same drugs rather than shown here. The primary difference of 12.6 percentage points had a confidence interval from 3.8 to 21.5, comfortably above zero, but the hospital-level sensitivity analysis crossed it (-2.0 to 27.6, P=0.08). That matters because randomisation was by centre, not by patient: with only ten clusters, patients within one hospital resemble each other, and the more conservative analysis that accounts for this is the honest one to quote. The direction and size of the effect are consistent across both; the certainty is not.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.