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Abstract Background Guidelines recommend that patients with coronary artery disease (CAD) lower their low-density lipoprotein cholesterol (LDL-C) using maximally tolerated statin therapy to prevent recurrent events. Methods We analyzed the prevalence of statin nonuse and an LDL-C ≥70 mg/dL in patients ≥18 years of age in the Get With The Guidelines-CAD registry with known CAD who were hospitalized for a new myocardial infarction or unstable angina in 2023-2024. Data collection on statin use and LDL-C at arrival is optional in the registry. Results Among 34,003 patients included (mean age 68 years; 71% male; 73% white), 31.6% did not use a statin before admission. The prevalence of statin nonuse was higher in women than in men (adjusted prevalence ratio [aPR] 1.08; 95% confidence interval [95%CI] 1.04, 1.14). LDL-C was not documented in 30.7% of patients. Among patients not using and using a statin, 74.6% and 49.8%, respectively, had an LDL-C ≥70 mg/dL. Women were more likely than men to have an LDL-C ≥70 mg/dL, whether using or not using a statin (aPR 1.18 [95%CI 1.13, 1.24] and 1.08 [95%CI 1.04, 1.12], respectively). Black and Hispanic patients were more likely to have an LDL-C ≥70 mg/dL compared to their white counterparts (aPR 1.30 [95%CI 1.24, 1.37] and 1.11 [95%CI 1.03, 1.19], respectively) among those using a statin. There were no statistically significant differences in LDL-C by race/ethnicity among those not using a statin. Conclusion Targeted quality improvement initiatives are needed to address ambulatory cholesterol treatment gaps in patients with known CAD. Clinical Perspective What Is New? In a contemporary national registry of patients with known coronary artery disease hospitalized for recurrent acute coronary syndromes, about one-third were not using statin therapy prior to admission. Approximately three-quarters of statin nonusers and one-half of statin users had an LDL-C level ≥70 mg/dL at admission, indicating substantial residual risk despite current guideline recommendations. Women and Black and Hispanic patients were more likely to have inadequately controlled LDL-C, particularly among those already receiving statin therapy. What Are the Clinical Implications? Preventable ambulatory cholesterol treatment gaps frequently occur before recurrent coronary events, underscoring the need for more guideline-recommended outpatient lipid management. Routine LDL-C monitoring and timely intensification of lipid-lowering therapy, including high-intensity statins and add-on therapies when indicated, should be prioritized after coronary events. Targeted quality improvement strategies in the ambulatory setting are needed to address persistent cholesterol treatment gaps in secondary prevention care, including sex- and race/ethnicity-related disparities.