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Low density lipoprotein-cholesterol (LDL-C) lowering after an acute coronary syndrome

Robert S Rosenson, MD
Section Editors
Christopher P Cannon, MD
Mason W Freeman, MD
Deputy Editor
Gordon M Saperia, MD, FACC


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 "Lipid lowering with diet or dietary supplements", section on 'Summary and recommendations' and "Management of low density lipoprotein cholesterol (LDL-C) in secondary prevention of cardiovascular disease" and "Prevention of cardiovascular disease events in those with established disease or at high risk".)

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 "Management of low density lipoprotein cholesterol (LDL-C) 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 a hypocaloric diet for overweight patients) 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.)

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Literature review current through: Nov 2017. | This topic last updated: Sep 07, 2017.
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