Neoatherosclerosis is a major mechanism of late DES failure and contributes to adverse cardiac events after percutaneous coronary intervention (PCI). While LDL-C lowering reduces plaque progression in native coronary arteries, its association with neoatherosclerosis after DES implantation has remained uncertain. A post hoc analysis of the CONNECT randomized clinical trial, published in JAMA Cardiology, evaluated this relationship in patients with ST-segment elevation myocardial infarction (STEMI).

The analysis included 178 patients with STEMI who underwent optical coherence tomography (OCT) imaging 3 years after primary PCI. Patients received statin therapy according to country-specific guidelines. Of the cohort, 98 patients (55%) achieved guideline-endorsed LDL-C targets, while 80 patients (45%) did not. Mean on-treatment LDL-C levels were 48 mg/dL in the target-achievement group and 87 mg/dL in the non-achievement group.

Neoatherosclerosis was less frequent among patients who achieved LDL-C targets compared with those who did not (7% vs 19%). Failure to achieve the LDL-C target was associated with higher odds of neoatherosclerosis, with an odds ratio of 3.00 and a 95% confidence interval of 1.19 to 8.24. The difference was statistically significant.

In multivariable logistic regression analysis, on-treatment LDL-C level emerged as an independent determinant of neoatherosclerosis at 3 years. Each 25 mg/dL increase in LDL-C was associated with higher risk, with an odds ratio of 1.46 and a 95% confidence interval of 1.09 to 2.01. These findings indicate that lower achieved LDL-C levels are associated with reduced neoatherosclerosis following DES implantation for STEMI.