Optimal Management of Residual Cardiovascular Risks After Acute Coronary Syndrome

Post-acute coronary syndrome (ACS) patients have a high incidence of recurrent ischemic events, especially within the first year, largely due to residual cardiovascular risks. These include vulnerable non-culprit lesions, a heightened thrombotic state, residual dyslipidemia—especially elevated low-density lipoprotein cholesterol (LDL-C)—and persistent inflammation. Accurate assessment of the morphological and functional characteristics of non-culprit lesions, using various intracoronary imaging modalities and fractional flow reserve, enables precision revascularization strategies and improves procedural and clinical outcomes. Post-ACS patients are recommended 1-year standard dual antiplatelet therapy, followed by a de-escalation to balance ischemic and bleeding risks. In patients at high bleeding risk, abbreviated dual antiplatelet therapy with aspirin (or indobufen for aspirin intolerance) plus clopidogrel is preferred, followed by extended antiplatelet monotherapy. LDL-C-lowering using statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, and small interfering RNA, alone or in combination, is recommended to achieve LDL‑C targets, consistent with the principle of earlier, more intensive, and longer‑duration LDL‑C lowering. High-dose eicosapentaenoic acid may provide additional benefit, especially in statin-treated patients with persistently elevated triglycerides. Inflammation represents a common pathway in many cardiovascular diseases, and anti-inflammatory therapy has emerged as a novel treatment approach. Evidence supports low‑dose colchicine, whereas data on interleukin-1β or interleukin-6 inhibitors remain limited. Emerging strategies, including regulatory T-cell-based therapies and modulation of the gut microbiome, have shown potential in early studies in addressing residual risk after ACS. Future efforts should focus on identifying novel biomarkers to improve risk stratification and on developing targeted therapeutic strategies. This mini-review summarizes the roles of non-culprit lesion instability and residual thrombotic, dyslipidemic, and inflammatory risks, and discusses their prognostic and therapeutic implications in post-ACS patients.