Introduction
Adults with prior myocardial infarction (MI) remain at substantial risk for recurrent cardiovascular events, with long-term mortality exceeding 70% within ten years.1 Effective secondary prevention is therefore central to reducing morbidity and prolonging survival in this population.2 Updated clinical practice guidelines have underscored the importance of intensive secondary prevention, emphasizing stringent, guideline-recommended targets for cardiovascular risk factors, particularly among individuals at highest risk.3–5 Despite these recommendations, contemporary national data evaluating whether U.S. adults with prior MI are meeting guideline-recommended targets are lacking.
Methods
We analyzed pooled National Health and Nutrition Examination Survey (NHANES) data from 2015–2023. Adults aged ≥18 years with self-reported prior MI were included. Primary outcomes were the proportion of adults with blood pressure, hemoglobin A1c (HbA1c), and low-density lipoprotein cholesterol (LDL-C) below guideline-recommended secondary prevention targets: specifically, blood pressure <130/80 mm Hg per 2025 American College of Cardiology/American Heart Association (ACC/AHA) guidelines,3 HbA1c <7% among adults with diabetes per American Diabetes Association (ADA) guidelines,6 LDL-C <70 mg/dL per 2025 ACC/AHA Acute Coronary Syndrome (ACS) guidelines,4 and LDL-C <55 mg/dL per 2026 ACC/AHA Dyslipidemia guidelines.5
In additional analyses, we evaluated the proportion of adults with blood pressure or HbA1c below alternative thresholds reflecting previous or less stringent guideline targets. We assessed blood pressure <140/90 mmHg, consistent with targets recommended before the 2017 ACC/AHA guideline update, and HbA1c <8%, a more permissive target recommended by the ADA for selected older adults with established cardiovascular or microvascular complications.6
IRB review was not required given the use of publicly available de-identified data, as per institutional policy. NHANES complex sampling design was used to generate nationally representative estimates. Analyses were conducted in R version 4.3.0.
Results
The study included 1,015 adults with prior MI, representing an estimated 8.4 million U.S. adults from 2015 to 2023 (mean age, 65.4 years; 34.1% female). Overall, guideline-recommended secondary prevention targets were infrequently met. Only half of adults had a blood pressure <130/80 mm Hg (50.0% [95% CI, 44.7%–55.3%]). Among those with diabetes, 52.6% (95% CI, 45.6%–59.6%) had a HbA1c<7%. LDL-C targets were even less frequently met, with 30.3% (95% CI, 23.3%–37.4%) below 70 mg/dL and 17.4% (95% CI, 11.7%–23.2%) below 55 mg/dL (Figure 1).
Figure 1. Secondary Prevention Targets Among U.S. Adults With Prior Myocardial Infarction.
The figure shows survey-weighted proportions of U.S. adults with a history of MI below guideline-recommended secondary prevention levels using NHANES 2015–2023 data. NHANES data collection occurs in two stages: a household interview followed by a separate visit to the mobile examination center (MEC), where physical measurements and laboratory specimens are collected. Pooled weights were proportionally adjusted by cycle duration, consistent with National Center for Health Statistics (NCHS) analytic guidelines. The 2017-March 2020 cycle used pre-pandemic weights provided by NCHS. Blood pressure, HbA1c, and LDL-C were each analyzed using the appropriate NCHS-recommended weights. LDL-C was measured in the randomly assigned fasting subsample (~one-half of MEC participants). Each target was estimated using outcome-specific complete-case denominators. Unweighted sample sizes: blood pressure, n=840; LDL-C, n=423 (fasting subsample); HbA1c (among those with diabetes), n=371; the diabetes subgroup among those with MI comprised 433 unweighted participants (representing an estimated 3,559,335 U.S. adults). Diabetes was defined as a hemoglobin A1c ≥6.5% or a healthcare diagnosis of the condition. Bars represent weighted percentages; error bars indicate 95% confidence intervals.
In additional analyses, 73.0% (95% CI, 69.9%–76.1%) had a BP <140/90 mm Hg, and 78.3% (95% CI, 72.6%–84.0%) of adults with diabetes had a HbA1c <8%.
Discussion
This nationally representative analysis of U.S. adults with prior MI found that many do not meet guideline-recommended secondary prevention targets. Blood pressure and glycemic control were suboptimal, with only about half of MI survivors below current thresholds. Lipid control was furthest from target, with fewer than 1 in 3 below an LDL-C of 70 mg/dL and fewer than 1 in 7 below 55 mg/dL. The last nationally representative U.S. analysis of secondary prevention in MI examined trends from 1999–2012, projecting cholesterol control rates to reach 100% by 2020.7 Our results suggest that secondary prevention remains exceedingly poor, despite the availability of novel pharmacotherapies such as PCSK9 inhibitors, bempedoic acid, and inclisiran.
These findings are particularly salient in the context of newly updated guidelines that emphasize more intensive risk factor control for high-risk individuals. The 2025 ACC/AHA hypertension guidelines provide a Grade 1 recommendation for a systolic blood pressure target <130 mmHg and encourage consideration of even lower targets (SBP<120 mmHg) among those at elevated cardiovascular risk.3 In parallel, the 2025 ACC/AHA guidelines for patients after ACS newly recommend the addition of non-statin lipid-lowering therapy when LDL-C remains ≥70 mg/dL despite maximally-tolerated statin therapy, and consideration of LDL-C targets <55 mg/dL in very high-risk patients.4 The 2026 ACC/AHA dyslipidemia guidelines also endorse a <55 mg/dL goal for patients who have experienced MI;5 this is in line with European guidelines which have advocated for a more stringent goal of LDL-C<55 mg/dL since 2019 and reemphasize this goal in their 2025 focused update, with a target of LDL-C < 40 mg/dL in extreme risk patients.8
Despite these evolving guidelines and the availability of highly effective therapies, our findings suggest a profound implementation gap in secondary prevention in the United States.2 Notably, in additional analyses using thresholds from earlier guideline recommendations (blood pressure <140/90 mm Hg; HbA1c <8.0%), the proportion of adults meeting secondary prevention targets increased substantially to approximately 75%, highlighting an opportunity for implementation strategies to close remaining gaps. Strategies, including protocolized treatment intensification, team-based care models with pharmacist support, and system-level interventions that reduce therapeutic inertia are urgently needed. Moreover, simultaneous rather than staged institution of multidrug treatment (e.g. statin + ezetimibe) and polypill strategies have improved outcomes in this population.9 Finally, at the policy level, reducing prior authorization barriers and cost-sharing for high-value preventive therapies could help address access barriers.
Limitations include that MI history was identified by self-report, which may introduce misclassification, and an unknown time interval between MI and NHANES examination, precluding differentiation between early post-MI care and long-term secondary prevention. NHANES excludes institutionalized populations, limiting generalizability to those settings. Because guideline-recommended thresholds evolved during the study period, estimates should be interpreted as benchmarks relative to contemporary targets rather than assessments of historical quality of care. Finally, prescription medication data were unavailable for the most recent NHANES cycle (2021–2023), precluding consistent assessment of statin use; however, prior analyses of U.S. adults have found poor lipid control even amongst individuals taking statins.2,10
Achieving contemporary guideline targets represents a critical opportunity to reduce recurrent events and long-term mortality among millions of U.S. adults with prior MI.
What is the clinical question being addressed?
What proportion of U.S. adults with prior MI have blood pressure, glycemic, and lipid levels below guideline-recommended thresholds?
What is the main finding?
Fewer than half had blood pressure or glycemic levels below target, and fewer than one-third had LDL-C below recommended thresholds.
Social Medial Tweet :
Among U.S. adults with prior MI, blood pressure, glycemic, and lipid levels remain far from guideline-recommended thresholds. Fewer than half had BP or glycemic levels at target, fewer than 1 in 3 had LDL-C below 70 mg/dL, and fewer than 1 in 7 were below 55 mg/dL, highlighting persistent gaps in post-MI secondary prevention.
Funding/Support:
This study was supported by the NIH/NHLBI R01HL164561 (Wadhera), American Heart Association Established Investigator Award Grant 24EIA1258487 (Wadhera), T32HL007208 (Gong), and 5T32HL007604–40 (Chiu).
Footnotes
Disclosures: Dr Wadhera is the Principal Investigator of grants from National Heart, Lung, and Blood Institute (R01HL164561, R01HL174549) and the National Institute of Nursing Research (R01NR021686) at the National Institutes of Health, American Heart Association Established Investigator Award (24EIA1258487), and the Donaghue Foundation, and has also received support from the Richard A. and Susan F. Smith Center for Outcomes Research, where he serves as the Associate Director. He also reports serving as a consultant to Abbott Vascular and Chambercardio outside the submitted work. Dr. Libby is an unpaid consultant to, or involved in clinical trials for Abcentra, Amgen, DrugFarm, Esperion, Incyte, Kowa, Novartis, NovoNordisk, Ventyx. Dr. Libby is a member of the scientific advisory board for Abcentra, Amgen, Novartis, Olatec, Xbiotech, Polygon, Soley Therapeutics. Dr. Libby’s laboratory has received research funding in the last 2 years from Novartis, Novo Nordisk and Genentech. Dr. Libby declines all personal compensation from pharma or device companies. Dr. Libby is on the Board of Directors of Abcentra, Inc. Dr. Libby has a financial interest in Xbiotech, a company developing therapeutic human antibodies, in TenSixteen Bio, a company targeting somatic mosaicism and clonal hematopoiesis of indeterminate potential (CHIP) to discover and develop novel therapeutics to treat age-related diseases, in Soley Therapeutics, a biotechnology company that is combining artificial intelligence with molecular and cellular response detection for discovering and developing new drugs, currently focusing on cancer therapeutics. Dr. Libby’s interests were reviewed and are managed by Brigham and Women’s Hospital and Mass General Brigham in accordance with their conflict-of-interest policies. Dr. Libby receives funding support from the National Heart, Lung, and Blood Institute (R01HL170000, 1R01HL163099–01, R01AG063839, R01HL151627, R01HL157073, R01HL166538), and the RRM Charitable Fund. Dr. Bhatt discloses the following relationships - Advisory Board: Angiowave, Antlia Bioscience, Bayer, Boehringer Ingelheim, CellProthera, Cereno Scientific, E-Star Biotech, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, NirvaMed, Novo Nordisk, Repair Biotechnologies, Stasys, SandboxAQ (stock options), Tourmaline Bio, Viatris; Board of Directors: American Heart Association New York City, Angiowave (stock options), Bristol Myers Squibb (stock), DRS.LINQ (stock options), High Enroll (stock); Consultant: Alnylam, Altimmune, Broadview Ventures, Corcept Therapeutics, Corsera, GlaxoSmithKline, Hims, SERB, SFJ, Summa Therapeutics, Worldwide Clinical Trials; Data Monitoring Committees: Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research, Boston Scientific (Chair, PEITHO trial), Cleveland Clinic, Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ABILITY-DM trial, funded by Concept Medical; for ALLAY-HF, funded by Alleviant Medical), Novartis, Population Health Research Institute; Rutgers University (for the NIH-funded MINT Trial); Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol-Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), CSL Behring (AHA lecture), Duke Clinical Research Institute, Engage Health Media, HMP Global (Editor in Chief, Journal of Invasive Cardiology), Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (Course Director, Comprehensive Review of Interventional Cardiology), Philips (Becker’s Webinar on AI), Population Health Research Institute, WebMD (CME steering committees), Wiley (steering committee); Other: Clinical Cardiology (Deputy Editor, unpaid); Progress in Cardiovascular Diseases (Deputy Editor, unpaid); Added Health (Editorial Board; stock options); Patent: Sotagliflozin (named on a patent for sotagliflozin assigned to Brigham and Women’s Hospital who assigned to Lexicon; neither I nor Brigham and Women’s Hospital receive any income from this patent); Research Funding: Abbott, Acesion Pharma, Afimmune, Alnylam, Amarin, Amgen, AstraZeneca, Atricure, Bayer, Boehringer Ingelheim, Boston Scientific, CellProthera, Cereno Scientific, Chiesi, Cleerly, CSL Behring, Faraday Pharmaceuticals, Fractyl, Idorsia, Janssen, Javelin, Lexicon, Lilly, Medtronic, Merck, MiRUS, Moderna, Novartis, Novo Nordisk, Pfizer, PhaseBio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, 89Bio; Royalties: Elsevier (Editor, Braunwald’s Heart Disease); Site Co-Investigator: Cleerly. Dr. Chiu and Dr. Gong have no disclosures to report.
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