Low density lipoprotein-cholesterol (LDL-C) lowering after an acute coronary syndrome
- Robert S Rosenson, MD
Robert S Rosenson, MD
- Professor of Medicine
- Mount Sinai School of Medicine
- Director, Cardiometabolic Disorders
- Mount Sinai Heart
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- Mason W Freeman, MD
Mason W Freeman, MD
- Section Editor — Lipids
- Professor of Medicine
- Harvard Medical School
All patients with coronary heart disease, including those with an acute coronary syndrome (ACS), should receive long-term, intensive lipid-lowering therapy starting with a statin. In addition, all such patients should receive dietary instruction, which has the potential to lower elevated levels of LDL-C. (See "Clinical trials of cholesterol lowering in patients with cardiovascular disease or diabetes" and "Prevention of cardiovascular disease events in those with established disease or at high risk", section on 'Diet' and "Lipid lowering with diet or dietary supplements", section on 'Summary and recommendations'.)
This topic will discuss issues related to the use of lipid-lowering agents in patients with ACS. Cholesterol treatment recommendations for other patients with coronary heart disease are discussed separately. (See "Treatment of lipids (including hypercholesterolemia) in secondary prevention" and "Intensity of lipid lowering therapy in secondary prevention of cardiovascular disease".)
●We believe that patients with an acute coronary syndrome (ACS) should have their LDL-C lowered to approximately 50 mg/dL (1.3 mmol/L). (See 'Subsequent therapy' below.)
●For all patients with an ACS not on treatment with a statin, we initiate high-intensity statin therapy (80 mg of atorvastatin or 20 to 40 mg of rosuvastatin daily) regardless of the baseline LDL-C level and continue it indefinitely (table 1). In most patients, we start with atorvastatin for reasons of cost. For patients with prior intolerance to atorvastatin, baseline elevation in liver transaminase levels, those who are taking medications that might interact with atorvastatin but not rosuvastatin, or those for whom a greater lowering of LDL-C is needed, rosuvastatin is used.
We start therapy as soon as possible after the diagnosis. If the LDL-C remains above 70 mg/dL (1.8 mmol/L) on a low fat diet and high-intensity statin, we add ezetimibe 10 mg daily. For occasional patients who still have a persistently elevated LDL-C despite high-dose statin and ezetimibe, one should consider adding a PCSK9 inhibitor. (See 'Initial therapy' below and 'Subsequent therapy' below.)
●For the uncommon patient whose baseline LDL-C is <50 mg/dL (1.29 mmol/L), there are no data to support a specific recommendation regarding statin therapy. We treat these patients with a low dose of statin (table 1).
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