Highlights
- •“Lower is better”, “less is more” or “lowest is best” are strong valid concepts for LDL-C treatment targets after ACS.
- •Statin, ezetimibe and PCSK9 monoclonal antibodies are recommended lipid-lowering treatment strategies in the setting of ACS.
- •Current evidence suggests that decreasing LDL-C to reach the recommended target of <1.8 mmol/l markedly improves prognosis after ACS.
Abstract
Low-density lipoprotein-cholesterol (LDL-C) is a well-accepted causal risk factor
for athero-thrombotic cardiovascular disease, as demonstrated in large epidemiological
studies, including Mendelian randomization data. Several randomized controlled trials
and meta-analyzes have shown that lipid lowering therapies, such as statins and more
recently the non-statin agents ezetimibe and Proprotein Convertase Subtilisin Kexin
type 9 (PCSK9) monoclonal antibodies (mAb), reduce cardiovascular events across a
broad range of baseline LDL-C levels. Over time, the recommended target for LDL-C
has become more stringent, moving from 2.6 mmol/l to 1.8 mmol/l in very high-risk
patients. It is currently recommended to start high intensity statin treatment immediately
after acute coronary syndromes (ACS) to maximally and rapidly reduce LDL-C. The novel
treatment options enable the achievement of very low LDL-C levels below 1 mmol/l,
with no reported safety issues, in particular with regard to neurocognitive events.
However, current evidence supports the use of PCSK9 mAb treatment in ACS patients
only after an initial 2–3 month run-up treatment adaptation period with maximally
tolerated statin. The use of PCSK9 mAb immediately in the acute phase of ACS (<1 month)
remains to be studied. Some data suggest that circulating PCSK9 increases coronary
plaque vulnerability, inflammation as well as platelet aggregation in the acute phase
of ACS, potentially justifying earlier PSCK9 mAb treatment initiation. As the use
of novel treatment combinations in ACS is further explored to widen the perspectives
of a more personalized approach for the management of ACS based on individual patient
risk profile and baseline LDL-C values, their relative cost-effectiveness will also
need to be assessed.
Keywords
Abbreviations:
ACS (acute coronary syndromes), PCSK9 (proprotein convertase subtilisin kexin 9)To read this article in full you will need to make a payment
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Article Info
Publication History
Published online: June 22, 2018
Accepted:
June 20,
2018
Received in revised form:
March 27,
2018
Received:
January 8,
2018
Identification
Copyright
© 2018 Published by Elsevier B.V.
