Intensive lipid lowering therapy strategies in acute coronary syndrome patients in contemporary clinical practice – The benefit of the “strike early, strike strong” approach

INTRODUCTION AND OBJECTIVES: Current guidelines recommend a stepwise, low-density lipoprotein cholesterol (LDL-C) guided lipid-lowering therapy (LLT) approach for patients after acute coronary syndrome (ACS). This study aimed to assess whether an early intensive "strike early, strike strong" strategy with upfront combination LLT improves LDL-C goal attainment. METHODS: This single-center retrospective study included 211 consecutive ACS patients admitted between January and October 2020, with a median follow-up of six months. Metabolic profiles were assessed during hospitalization and at follow-up. Patients were grouped by follow-up LDL-C levels (<55 mg/dL and ≥55 mg/dL). Discharge medication, adherence, and LDL-C reduction were compared. RESULTS: A total of 211 patients were included in the analysis, with a mean age of 65±12 years; 74% were male. LDL-C on target (<55 mg/dL) was achieved in 36% of patients during a median follow-up of six months. This group was more commonly medicated with combination therapy [high-intensity statin (HI-statin) plus ezetimibe] at discharge (46% vs. 31%, p=0.040), had higher adherence rates (94% vs. 81%, p<0.001) and had significantly greater LDL-C reduction (80±48 mg/dL vs. 49±53 mg/dL, p<0.001). The combination therapy was the only independent predictor for LDL-C on target during follow-up (OR=2.054, 95% CI: 1.063-3.969, p=0.032). CONCLUSION(S): Low-density lipoprotein target attainment was suboptimal at median follow-up of six months. The LDL-C target group was associated with combination therapy with HI-statins plus ezetimibe upfront, better adherence and greater LDL-C reduction. These findings support the "strike early, strike strong" approach in very high-risk patients.