In the first year of lipid lowering among patients with ACS, who are at the highest risk, half the relative benefit of later years can be achieved using a combination of statin and PCSK9i.
Key Takeaway
- Patients with ACS have the highest risk in the first year after the event and would need to achieve lower LDL-C levels.
- Statin monotherapy will be ineffective alone if the targeted goal is <1.8 mmol/L (70 mg/dL) and certainly for <1.4 mmol/L (55 mg/dL).
- Real-world data suggest that with high residual risk with life span exposure, there is poor goal attainment, and many events are preventable by correcting CV risk factors as well as environmental and genetic factors.
- Greater use of combination therapy, particularly statins + PCSK9i, will improve LDL-C control post-ACS, thus likely reducing CV events.
Key Highlights
- Thus, instead of following a stepwise approach, a combinatorial approach would prove helpful
- The relative benefit per 1 unit change in LDL-C is lower in the first year of treatment than in later years; therefore, greater absolute reductions in LDL-C are needed during this early period
- With this approach, goal attainment was 45% with high-intensity statins, 54% with ezetimibe combination, and 67% with PCSK9i combination
- With this approach, goal attainment was 45% with high-intensity statins, 54% with ezetimibe combination, and 67% with PCSK9i combination
- Thus, approximately half the patients would require a PCSK9i
- In one-quarter of patients who were on statins from admission to discharge, not intensifying lipid-lowering therapy would lead to the worst outcomes among all patients
- A simulation study reported that 4 out of 5 patients with recent MI would be eligible for escalated lipid-lowering therapy according to the 2019 ESC/EAS guidelines (<55 mg/dL) at 6–10 weeks after the event
- Of these, 50% would be eligible for additional treatment with PCSK9i after inadequate LDL-C control with maximally tolerated statins and ezetimibe therapy
ACS, acute coronary syndrome; AHA/ACC, American College of Cardiology/American Heart Association; ASCVD, atherosclerotic cardiovascular disease; CVD, cardiovascular disease; ESC/EAS, European Society of Cardiology/European Atherosclerosis Society; LDL-C, low-density lipoprotein cholesterol; mAb, monoclonal antibody; MI, myocardial infarction; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitors.
Ray KK. Why compromise for less- Should PCSK9 inhibitors be initial therapy? Presented at American Heart Association (AHA) Scientific Sessions 2021 on November 28, 2021.
MAT-KW-2400020/v1/Jan 2024