Appropriateness of Dyslipidemia Management Strategies in Post-Acute Coronary Syndrome: A 2023 Update

Abstract

It has been consistently demonstrated that circulating lipids and particularly low-density lipoprotein cholesterol (LDL-C) play a significant role in the development of coronary artery disease (CAD). Several trials have been focused on the reduction of LDL-C values in order to interfere with atherothrombotic progression. Importantly, for patients who experience acute coronary syndrome (ACS), there is a 20% likelihood of cardiovascular (CV) event recurrence within the two years following the index event. Moreover, the mortality within five years remains considerable, ranging between 19 and 22%. According to the latest guidelines, one of the main goals to achieve in ACS is an early improvement of the lipid profile. The evidence-based lipid pharmacological strategy after ACS has recently been enhanced. Although novel lipid-lowering drugs have different targets, the result is always the overexpression of LDL receptors (LDL-R), increased uptake of LDL-C, and lower LDL-C plasmatic levels. Statins, ezetimibe, and PCSK9 inhibitors have been shown to be safe and effective in the post-ACS setting, providing a consistent decrease in ischemic event recurrence. However, these drugs remain largely underprescribed, and the consistent discrepancy between real-world data and guideline recommendations in terms of achieved LDL-C levels represents a leading issue in secondary prevention. Although the cost-effectiveness of these new therapeutic advancements has been clearly demonstrated, many concerns about the cost of some newer agents continue to limit their use, affecting the outcome of patients who experienced ACS. In spite of the fact that according to the current recommendations, a stepwise lipid-lowering approach should be adopted, several more recent data suggest a "strike early and strike strong" strategy, based on the immediate use of statins and, eventually, a dual lipid-lowering therapy, reducing as much as possible the changes in lipid-lowering drugs after ACS. This review aims to discuss the possible lipid-lowering strategies in post-ACS and to identify those patients who might benefit most from more powerful treatments and up-to-date management.

Analysis of predictors of recurrent acute cardiovascular events in patients with acute coronary syndrome

“…после выписки, однако большей части больных требовалась интенсификация ГЛТ (чаще в группе пациентов с ККТ), которая была рекомендована в рамках повторного визита. Тем не менее к первому году наблюдения отмечалось снижение доли пациентов, продолживших прием прогностически необходимой терапии, причем в группе пациентов с ККТ это наблюдалось значимо чаще по сравнению с пациентами без ККТ, что, несомненно, влияет на прогноз [18].…”

“…По результатам проведенного исследования выявлено, что комбинация несоблюдения рекомендуемой ГЛТ с ранее перенесенным вмешательством на стволе ЛКА продемонстрировала значимо меньшую свободу от ККТ в сравнении с остальными пациентами. Прогностическое значение отсутствия приема необходимой ГЛТ известно [18], однако нами не было найдено опубликованных данных, в которых был бы продемонстрирован вклад ранее перенесенной реваскуляризации миокарда с указанием конкретного бассейна коронарной артерий в прогноз пациентов с ОКС, в т. ч. и в комбинации с несоблюдением прогноз-модифицирующей терапии.…”

Italian Association of Hospital Cardiologists Position Paper ‘Gender discrepancy: time to implement gender-based clinical management’

“…Inclisiran is a first-in-class small interfering RNA targeting the mRNA of PCSK9 specifically in the liver, owing to the conjugation with triantennary N -acetylgalactosamine. 240 The main advantage over conventional pharmacotherapy and anti-PCSK9 monoclonal antibodies is its favourable administration regimen, with a subcutaneous dosing schedule of once every six months after the initial and 3-month doses (0–90–180 days), which should lead to much better compliance. 241 , 242 …”

Exploring the Perioperative Use of DOACs, off the Beaten Track

“…Assessing parameters such as troponin, natriuretic peptides, von Willebrand factor, C-reactive protein, proteinuria, and D-Dimer could be helpful in evaluating stroke risk in subjects categorized as at low-risk, including those with a single non-sex CHA2DS2-VASc risk factor [ 15 , 16 ]. Obesity [ 17 ], hyperlipidemia [ 18 ], metabolic syndrome [ 19 ], smoking, sleep apnea [ 20 ], hypertrophic cardiomyopathy (HCM) [ 21 ], amyloidosis (CA) [ 22 ] and Anderson–Fabry disease (AFD) [ 23 ] have been shown to be associated with a greater thrombotic risk. Moreover, echocardiographic parameters, including left atrium (LA) dilatation, spontaneous echo-contrast or thrombus in LA, low LA auricle velocities, and complex aortic plaque, have been recognized as thrombotic risk factors [ 24 , 25 ].…”