OptimiZation Of Lipid Lowering Therapies Using a Decision Support System In Patients With Acute Coronary Syndrome. (ZODIAC)

January 30, 2026 updated by: Imperial College London

Implementation of a Decision Support System and Its Effect on Early Optimisation of Lipid-Lowering Therapies in Patients With Acute Coronary Syndrome: a Cluster Randomised Controlled Trial

The goal of this clinical trial is to compare implementation of a Decision Support System (DSS) - aligned to the 2019 ESC/EAS Guidelines - in addition to routine clinical care versus routine clinical care without availability of a DSS, in participants aged ≥18 to < 80 years old presenting with Acute Coronary Syndrome (ACS).

The main questions it aims to answer are:

  • to assess whether the availability of a DSS (which provides estimates of risk and estimates of potential benefit through LDL-C lowering) to current practice results in an increase in the early initiation of combination Lipid Lowering Therapies (LLTs) or intensification of LLT regimens compared to current practice alone over a 16-week period after an Acute Coronary Syndromes (ACS) event
  • To estimate in the study cohort the potential benefits of guideline-based LLT intensification via simulation-based methods using estimates of baseline risk: LLT utilisation, additional LDL-C reductions and LDL-C goal achievement, on simulated risk of CV events through modelling.

Participants will give consent to randomised clinical sites to collect their data. The clinical sites will either be randomised to standard of care or the availability of and access to the DSS.

Researchers will compare patients from DSS and Non-DSS sites to see if the availability of the DSS results in implementation of more intensive lipid lowering regimens, resulting in the achievement of lower LDL-C values as well as the proportion of patients who reach target LDL-C levels (<1.4 mmol/L (<55 mg/dL) by Week 16.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Patients with acute coronary syndromes (ACS) including myocardial infarction (MI) remain at risk of future cardiovascular events depending upon the interaction between inherited genetic factors/ and environmental factors including cholesterol over their lifetime. Expert guidelines on secondary prevention such as the ESC therefore increasingly recognise a more individualised approach.

Lowering LDL-C with high intensity lipid lowering therapies (LLTs) initiated within 10 days of an ACS reduces risk more than less intense regimens. In the SWEDEHEART registry which included 40,6007 patients over a median follow up of 3.78 years, patients who achieved the largest absolute reductions in LDL-C or greatest percentage reduction in LDL-C, had the lowest risk of a range of cardiovascular events and mortality. The approach to use of lipid lowering (LLT) was statin based monotherapy with few attaining the recommended cholesterol goals.

The 2019 European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) dyslipidaemia guidelines categorise patients with an ACS event as very-high risk and recommend an LDL-C goal of < 1.4 mmol/L (<55 mg/dL) and >50% reduction in LDL-C in this population. But several studies in European populations have highlighted gaps between clinical practice/ implementation of treatment recommendations compared with evidence based guideline recommendations. In the DA VINCI study representing 5,888 patients prescribed LLT in 18 European countries, LDL-C goal achievement in very-high risk populations was just 39% per 2016 ESC/EAS guidelines of<1.8mmol/L with only about 18% achieving the new recommended lower goal of <1.4mmol/L. It has become clear that greater implementation/ use of available combination therapies will be needed if lower recommended goals are to be achieved. It is unclear what the barriers are to earlier implementation and may include a lack of physician understanding of risk of further CV events or a lack of understanding of the quantifiable benefits from specific magnitudes of LDL-C lowering.

The aim of this trial is to assess whether providing information to those managing ACS patients that quantify absolute risk and the absolute benefit from different lipid lowering regimens through access to a Decision Support Tool (DSS) system is more likely to result in earlier intensification of lipid lowering regimens and thus result in a greater proportion of patients achieving the ESC lipid lowering goals after ACS compared to patients being managed routinely without access to a DSS standard (cluster RCT design). It is well established that unless treatments are initiated through secondary care or as part of acute care pathways, there is considerable inertia in further optimisation of treatment in primary care. Thus, this trial will assess whether presenting quantifiable data on risks and benefits results in behaviour change among secondary care physicians and improves cholesterol management within 4 months of an ACS.

The DSS is available online or remotely accessible via a website intended for clinicians to estimate the clinical benefit of any LLT regimen, whether single or combination therapies. The DSS shows the expected risk, risk reductions and number needed to treat for the various treatments selected by the clinical user on the potential value of initiation of an add-on therapy for reducing the risk of other Cardiovascular (CV) events. This DSS provides a graphical and tabular representation of the time-dependent CV treatment benefit model for LLTs published in a peer-reviewed journal article.

The trial hypothesises that having a pictorial representation of both individual risk and recommended treatments will encourage clinicians to implement clinical guidelines more closely. The clinicians using the DSS will be asked to complete a DSS evaluation at the end of the trial. Implementing the patient-specific recommendation remains at the clinicians' discretion.

Study Type

Interventional

Enrollment (Actual)

1139

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Italy
      • Bologna, Italy, 40133
        • AUSL di Bologna-Ospedale Maggiore
      • Caserta, Italy, 81100
        • Azienda Ospedaliera di Rilievo Nazionale (A.O.R.N.) "Sant'Anna e San Sebastiano" di Caserta
      • Foggia, Italy, 71122
        • A.O.U. Ospedali Riuniti U.O.C. Cardiologia e UTIC
      • Genova, Italy, 16132
        • IRCCS. A.O.U. Policlinico San Martino IST
      • Messina, Italy, 98125
        • Azienda Ospedaliera Universitaria Gaetano Martino
      • Milan, Italy, 20097
        • IRCCS Policlinico San Donato
      • Modena, Italy, 41124
        • A.O.U Policlinico di Modena S.C. di Cardiologia
      • Pisa, Italy, 56124
        • Ospedale di Cisanello - A.U.O.P. Azienda Ospedaliera Universitaria
      • Reggio Emilia, Italy, 42121
        • AUSL-IRCCS di Reggio Emilia
      • Roma, Italy, 00157
        • Ospedale Sandro Pertini - ASL Roma 2
      • Udine, Italy, 33100
        • Azienda Ospedaliero Universitaria Santa Maria della Misericordia
  • Spain
      • Barcelona, Spain, 08025
        • Hospital De La Santa Creu I Sant Pau
      • Barcelona, Spain, 08035
        • Vall d'Hebron University Hospital
      • Córdoba, Spain, 14004
        • Hospital Universitario Reina Sofia
      • Madrid, Spain, 28040
        • Hospital Universitario Fundacion Jimenez Diaz
      • Madrid, Spain, 28046
        • Hospital Universitario La Paz
      • Madrid, Spain, 28007
        • Gregorio Marañón General University Hospital
      • Madrid, Spain, 28003
        • Hospital Universitario La Luz Quiron
      • Madrid, Spain, 28222
        • Puerta de Hierro Majadahonda University Hospital
      • Seville, Spain, 41009
        • Hospital Universitario Virgen Macarena
    • A Coruña
      • Santiago de Compostela, A Coruña, Spain, 15706
        • Hospital Clinico Universitario Santiago de Compostela
    • Coruña
      • A Coruña, Coruña, Spain, 15006
        • University Hospital of A Coruña
    • Madrid
      • Boadilla del Monte, Madrid, Spain, 28660
        • Hospital HM Montepríncipe
      • Móstoles, Madrid, Spain, 28933
        • Hospital Universitario Rey Juan Carlos
    • Murcia
      • El Palmar, Murcia, Spain, 30120
        • Hospital Clínico Universitario Virgen de la Arrixaca
  • United Kingdom
      • London, United Kingdom, W2 1NY
        • Hammersmith Hospital
    • Bedfordshire
      • Luton, Bedfordshire, United Kingdom, LU4 0DZ
        • Luton and Dunstable University Hospital
    • Denbighshire
      • Bodelwyddan, Denbighshire, United Kingdom, LL18 5UJ
        • Glan Glwyd Hospital
    • Dorset
      • Bournemouth, Dorset, United Kingdom, BH7 7DW
        • Royal Bournemouth Hospital
    • East Sussex
      • Brighton, East Sussex, United Kingdom, TN37 7PT
        • Conquest Hospital
    • North Lincolnshire
      • Scunthorpe, North Lincolnshire, United Kingdom, DN15 7BH
        • Scunthorpe General Hospital
    • Northamptonshire
      • Kettering, Northamptonshire, United Kingdom, NN16 8UZ
        • Kettering General Hospital
    • Northen Ireland
      • Portadown, Northen Ireland, United Kingdom, BT63 5QQ
        • Southern Health and Social Care Trust, Craigavon Area Hospital
    • Somerset
      • Bath, Somerset, United Kingdom, BA1 3NG
        • Royal United Hospital
    • Tyne and Wear
      • Newcastle upon Tyne, Tyne and Wear, United Kingdom, NE7 7DN
        • Freeman Hospital
      • North Shields, Tyne and Wear, United Kingdom, NE29 8NH
        • North Tyneside General Hospital
      • Sunderland, Tyne and Wear, United Kingdom, SR4 7TP
        • Sunderland Royal Hospital
    • West Midlands
      • Birmingham, West Midlands, United Kingdom, B71 4HJ
        • Sandwell General Hospital
      • Dudley, West Midlands, United Kingdom, DY12HQ
        • Russell's Hall Hospital
    • West Sussex
      • Worthing, West Sussex, United Kingdom, BN11 2DH
        • Worthing Hospital
    • West Yorkshire
      • Halifax, West Yorkshire, United Kingdom, HX3 0PW
        • Calderdale Royal Hospital
    • Worcestershire
      • Worcester, Worcestershire, United Kingdom, WR5 1DD
        • Worcestershire Royal Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion criteria:

Sites:

  • Manage ACS patients as defined by: Symptoms of myocardial ischemia with an unstable pattern, occurring at rest or with minimal exertion, within 72 hours of an unscheduled hospital admission due to presumed or proven obstructive coronary disease and at least one of the following:

    • Elevated cardiac biomarkers
    • Resting electrocardiographic changes consistent with ischemia or infarction, plus additional evidence of obstructive coronary disease from regional wall motion or perfusion abnormality, 70% or more epicardial coronary stenosis by angiography, or need for coronary revascularization procedure
  • Mange post ACS follow up care of patients including risk factor control
  • Ability to provide follow up information on patient care for a minimum of 16 weeks including blood tests
  • Willing/ able to access and undertake training for the DSS
  • Adequate internet connection at site and the ability to access the DSS
  • No restrictions on use of LLTs (within national guidelines/ reimbursement)
  • Ability to include all essential parameters and patient information for DSS input

Participants:

  • Aged ≥18 to < 80 years old
  • Provide written informed consent
  • Presenting to a study site with ACS as LLT naïve, monotherapy or combination therapy (defined as more than one LLT agent)
  • Willing to take lipid lowering treatments for the secondary prevention of cardiovascular disease
  • Attending the same study site (or same clinical team) for ACS follow up to ensure follow up data can be collected; or ensure that follow up data can be collected from other clinical institutions as part of the clinical pathway.

Exclusion criteria:

Sites:

  • Unable to capture/ provide data on patients with ACS during admission and follow up
  • Unable or unwilling to use lipid lowering treatments other than statins for ACS care

Participants:

  • Unable to provide written informed consent
  • LDL-C measurement < 1.8 mmol/L at admission

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Other
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Other: Decision Support System (DSS)
Patients of this cohort are seen at a site randomised to the availability of the DSS. These patients will be provided routine clinical care including local/national prescribing guidelines during the course of the study. In addition to routine clinical care, the DSS which is available online, is a tool intended for clinicians to estimate the clinical benefit of any LLT regimen, whether monotherapy or combination therapies.
Device: Decision Support System (DSS)

This DSS will provide estimates of potential benefits in terms of ASCVD risk reduction (composite endpoint: combined non-fatal myocardial infarction, non-fatal ischaemic stroke and cardiovascular death) as a function of treatment duration and magnitude of LDL-C lowering.

The DSS does not recommend treatments but shows the expected ASCVD risk, absolute and relative ASCDV risk reductions and number needed to treat for the various treatments selected by the clinical user on the potential value of initiation of an add-on therapy for reducing the risk of recurrent Cardiovascular (CV) events. Implementing the patient-specific recommendation remains at the clinicians' discretion.
No Intervention: Non-Decision Support System (Non-DSS)
Patients of this cohort are seen at a site randomised to no availability of a DSS (Non-DSS). These patients will be provided routine clinical care including local / national prescribing guidelines during the course of the study.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Optimisation of the Intensity of Lipid Lowering Therapy Within 16 Weeks of Index ACS
Time Frame: 16 weeks
Proportion of patients treated with combination therapy, or who receive escalated monotherapy, or escalated combination therapy, within 16 weeks of the index ACS.
16 weeks

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
LDL-C Level
Time Frame: 16 weeks
LDL-C by Week 16
16 weeks
Timing of Initiation
Time Frame: 16 weeks
Timing of initiation of combination therapy or escalation of Lipid lowering therapy in those who met the primary endpoint.
16 weeks
Target LDL-C Reduction
Time Frame: 16 weeks
Proportion of patients reaching target LDL-C level (<1.4 mmol/L (<55 mg/dL) by Week 16
16 weeks

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Imperial College London

Collaborators

Sanofi
Hospital Universitario La Paz
Hippocrates Research
Axtria, Inc.

Investigators

  • Principal Investigator: Kausik Ray, Professor, Imperial College London

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Helpful Links

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

April 3, 2023

Primary Completion (Actual)

December 12, 2024

Study Completion (Actual)

December 12, 2024

Study Registration Dates

First Submitted

April 25, 2023

First Submitted That Met QC Criteria

April 25, 2023

First Posted (Actual)

May 6, 2023

Study Record Updates

Last Update Posted (Actual)

February 19, 2026

Last Update Submitted That Met QC Criteria

January 30, 2026

Last Verified

January 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 22HH7982

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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