Real-world efficacy of current strategies for lowering LDL cholesterol after acute coronary syndrome. Changing the treatment paradigm

Current guidelines on the management of dyslipidemias of the European Society of Cardiology/European Ath-erosclerosis Society recommend reducing low-density lipoprotein cholesterol (LDL-C) in patients after an acute coronary syndrome (ACS) by ???50% compared to baseline values with a LDL-C level below 1.4 mmol/l (55 mg/dl) (class I recommendation, level of evidence A). However, in the real world, a low proportion of patients is treated according to the recommended lipid-lowering therapies and, as a consequence, very few people reach these targets. We analyzed seven recent studies reporting data on lipid control in 36 354 patients who were at very high risk because of a previous ACS in Europe. Overall, only 12.1% (95% confidence interval 9.8-13.5) of the patients achieved the recommended LDL-C levels, highlighting the gap between guidelines and current clinical practice. Indeed, the so-called stepwise strategy, although effective from a theoretical point of view, seems hardly applicable in the real world, underlying the need for new therapeutic strategies and algorithms. Based on these observations, a protocol has been proposed for the appropriate management of LDL-C levels in post-ACS patients both in terms of therapeutic choice and timing of treatment use.