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Funding Acknowledgements Type of funding sources: None. BACKGROUND Current guidelines recommend intensive low-density-lipoprotein cholesterol (LDL-C) lowering by ≥50% to target LDL-C &amp;lt;1.4mmol/L after acute coronary syndrome (ACS). Residual distance to LDL-C target can help select treatment strategy after initial statin therapy. PURPOSE We aimed to evaluate residual distance to guideline recommended target LDL-C and the proportion of ACS patients who are projected to reach target LDL-C by different statin and non-statin lipid lowering strategies. METHODS We retrospectively analyzed 46,114 patients admitted with ACS who survived 1 year from 18 acute hospitals in Hong Kong between Jan 2014 and Dec 2018. Patients were divided into (i) high potency (HP-S; rosuvastatin ≥20mg, atorvastatin ≥40mg or simvastatin ≥80mg); (ii) non-high potency (NHP-S; other statin doses) statin users and (iii) no statin therapy. We calculated the mean distance and percentage LDL-C reduction required to reach dual LDL-C targets (&amp;gt;50% reduction from baseline and &amp;lt;1.4mmol/L). We assumed up-titration from NHP-S to HP-S would further reduce LDL-C by approximately 5-10%; addition of ezetimibe 15-20% and PCSK-9 inhibitor 50-60%. RESULTS Of 46,114 patients (60.7% males, mean age 76.2 ± 13.3 years), 80.4% (n = 10945/13614) had LDL-C ≥1.4mmol/L at 12-months after index ACS with 60.2% (n = 18319/30450), 31.9% (n = 9726/30450) and 8.0% (2405/30450) of patients on no statin, NHP-S and HP-S, respectively. 86% of HP-S and 93% of NHP-S users did not reach dual LDL-C targets at 12-months. Among patients on NHP-S and HP-S, the mean LDL-C at 12-months was 2.0 ± 0.7 and2.1 ± 0.9 mmol/L; mean residual distance to target 0.64 ± 0.7 and0.66 ± 0.9 mmol/L; and mean percentage LDL-C reduction required to reach dual LDL-C targets was 22.4 ± 33% and 18.8 ± 36%, respectively. 13% of statin users required &amp;gt;50% further LDL-C reduction to reach targets. Projected proportion of NHP-S users to reach LDL-C targets is 11% (n = 430/3966) by up-titrating to HP-S, 21% (n = 828/3966) by up-titration to HP-S plus ezetimibe and 100% (n = 3966/3966) with PCSK-9 inhibitor plus HP-S and ezetimibe. Projected proportion of HP-S users to reach LDL-C targets is 13% (n = 143/1099) by ezetimibe and 100% (n = 1099/1099) with addition of PCSK-9 inhibitor.  CONCLUSION The use of high-potency statin was low and almost all statin users did not reach dual LDL-C targets at 12-months after index ACS. High potency statin plus ezetimibe is projected to bridge about a fifth of these patients to target LDL-C. PCSK-9 inhibitor is likely needed in the majority of patients who have not achieved target LDL-C at 12-months after ACS to reach guideline recommendations.

How to bridge residual distance to target low-density-lipoprotein cholesterol in acute coronary syndrome patients after initial statin therapy?