High intensity lipid‐lowering therapy after acute coronary syndromes: room for improvement

Effective therapies are available, but too few patients are receiving them

There is a significant amount of evidence that intensive statin therapy reduces the likelihood of cardiovascular events in people who have had an acute coronary syndrome (ACS), and such therapy is given the highest grade of recommendation in Australian clinical practice guidelines.1 Post hoc analyses of randomised trials of treatment with statins, statins and ezetimibe, or, more recently, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors indicate that patients who achieve very low low‐density lipoprotein cholesterol (LDL‐C) levels are at very low risk of cardiovascular events after an ACS, and that the rates of adverse events related to attaining such levels are not increased.2,3 In the Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE‐IT), the combination of simvastatin and a non‐statin LDL‐lowering treatment (ezetimibe) reduced LDL‐C levels to a median 1.4 mmol/L, and this was associated with reduced numbers of clinical events.4 In the Odyssey Outcomes trial, a combination of statins and alirocumab (a PCSK9 inhibitor) reduced LDL‐C levels to below 1.0 mmol/L and this was associated with reduced numbers of major adverse cardiovascular events.3 These trials provide further support for the LDL‐C hypothesis of cardiovascular risk, which suggests that the risk of a cardiovascular event is reduced by about 22% for each 1.0 mmol/L reduction in LDL‐C levels.2