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Background Lipid management is a cornerstone of secondary prevention in acute coronary syndrome (ACS). Despite established national guidelines, real-world practice often reveal gaps in lipid monitoring and intensification of lipid-lowering therapy. This study investigated these challenges in a large tertiary centre, proposing a streamlined pathway to address these gaps.Methods A retrospective analysis was conducted in 225 ACS patients (92 STEMI and 133 NSTEMI) from July-August 2023. We assessed lipid monitoring on admission and 2–3 months post-discharge, prescription rates of high-intensity statins and use of alternative lipid-lowering therapies. Multivariate logistic regression evaluated the relationship between high-intensity statin initiation and lipid monitoring rates on admission and follow-up, adjusted for comorbidities.Results Initial guideline adherence was strong, with 83.1% having lipids checked on admission and 83.6% prescribed high-intensity statins ( table 1). After adjusting for ACS type and comorbidities, patients started on high-intensity statin were nearly twice as likely to have lipids checked on admission (90.4% vs. 45.9%, p<0.001). Notably, patients not receiving high-intensity statins were more likely to have a prior history of ACS (43.2% vs 26.1%, p=0.035). Despite the perceived higher severity of STEMI, there was no significant difference in post-discharge lipid-checking rates between STEMI and NSTEMI patients (51.1% vs 53.4%, p=0.735). In terms of follow-up, only 52.4% of patients had lipids rechecked post-discharge, leaving almost half without adequate monitoring. Neither high-intensity statins nor ezetimibe initiation increased the likelihood of follow-up lipids. Among 118 patients with follow-up lipid assessment, 69.5% achieved target levels. However, of the 36 patients (30.5%) not meeting targets, only 3 (8.3%) had therapy intensified limited to the use of ezetimibe, highlighting a critical gap in care.Abstract 7-010 Table 1 Variables Total number (n=225) Percentage (%) Lipid checked on admission 187 83.1 High intensity statin Rx 188 83.6 STEMI 92 40.9 NSTEMI 133 59.1 Hyperlipidaemia 66 29.3 2nd episode of ACS 65 28.9 Statin intolerance 13 5.8 Alternative to statin 38 16.9 Lipids repeated 12/52 118 52.4 Abstract 7-010 Figure 1Proposed flow-chart of lipid managementAbstract 7-010 Table 2 Not started on high-intensity statin (37) Started on high-intensity statin (188) p value Hyperlipidaemia 15 (40.5) 51 (27.1) NS Prior ACS 16 (43.2) 49 (26.1) NS Lipids checked on admission 17 (45.9) 170 (90.4) <0.001 Offered alternative to statin 12 (32.4) 26 (13.8) NS Ezetimibe started 12 (32.4) 28 (14.9) 0.011 STEMI 16 (43.2) 76 (40.4) NS Lipids repeated in 2 months 16 (43.2) 102 (54.3) NS Abstract 7-010 Figure 2Conclusion This study highlights the dichotomy between strong initial guideline adherence and significant lapses in follow-up care and therapy intensification. Whilst this single-centre study limits generalisability, several interesting observations emerged. The association between high-intensity statin prescription and admission lipid check highlights the importance of fostering a culture of guideline adherence, where attention to one aspect of care positively influences others. Patients with prior ACS were less likely to receive high-intensity statins, potentially due to perceived stability on existing regimen, leading to missed opportunities for therapy intensification. More strikingly, nearly half of the cohort lacked adequate lipid monitoring on follow-up with restricted use of lipid-lowering therapies. This highlights the need for a structured approach involving cardiac rehabilitation and primary care team via the proposed pathway ( figure 1) to ensure better lipid management in this high-risk cohort.