28/09/2025
🚀 Intensive Lipid-Lowering Therapy After ACS: The Earlier, The Better
After a heart attack (acute coronary syndrome, ACS), the clock starts ticking.
Time is cholesterol.
Every day we delay lowering bad cholesterol (LDL-C), the heart and arteries remain at high risk. The first few weeks after a heart attack are the most dangerous, and that is exactly when cholesterol-lowering treatment has the biggest impact.
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⌛ Why Acting Early Matters
• Right after ACS, the plaques in arteries are unstable – ready to rupture again.
• Rapid lowering of LDL makes these plaques more stable and less likely to cause another heart attack.
• Large studies show: For every 40 mg/dL fall in LDL, the chance of another heart attack, stroke, or death drops by about 22%.
In short → The lower the LDL, the safer the patient.
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📊 What the Evidence Shows
Recent clinical trials tell us that starting early and starting strong really works:
• EVOPACS, PACMAN-MI, HUYGENS → Using PCSK9 inhibitors along with statins right after ACS helps patients reach target LDL in just a few weeks and even shows plaque regression and stabilization.
• LAI-REACT trial → A combination of statin + ezetimibe + bempedoic acid (three oral tablets) lowered LDL by ~60% in just one week.
• Real life, however, looks different: less than half of patients after angioplasty/PCI reach their LDL target because therapy is often delayed, or doctors don’t use combination medicines early enough.
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💊 Building the Wall Against Cholesterol: Step by Step
Think of LDL as a monster trying to attack the heart again. We need layers of defense:
1. High-Intensity Statins
• (Atorvastatin 40–80 mg or Rosuvastatin 20–40 mg)
• First line, lowers LDL by 50–55%.
2. Ezetimibe
• Adds another 18–20% reduction.
• IMPROVE-IT trial proved benefit in heart attack patients.
3. Bempedoic Acid
• Oral, non-statin option.
• Lowers LDL by 18–25%.
• CLEAR Outcomes 2023 showed it works even in people who cannot take statins.
4. PCSK9 Inhibitors (Evolocumab, Alirocumab)
• Very powerful injectables.
• Reduce LDL by 50–60%.
• FOURIER & ODYSSEY: Lowered heart attacks and strokes by ~15%.
5. Inclisiran
• A new injectable (siRNA therapy).
• Twice a year dosing, LDL lowered by ~50%.
• Great for adherence and long-term control.
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📌 Key Message for Doctors & Patients
• Don’t wait until the first outpatient visit.
• Start combination therapy while the patient is still in the hospital.
• Aim for LDL