Physicians' Academy for Cardiovascular Education

Nearly all ACS patients reach LDL-c goal when PCSK9i is added to optimal statin therapy

Achievement of ESC/EAS LDL-C treatment goals after an acute coronary syndrome with statin and alirocumab

Literature - Landmesser U, McGinniss J, Steg G, et al. - Eur J Prev Cardiol. 2022 Jun 16;zwac107, doi: 10.1093/eurjpc/zwac107

Introduction and methods


The 2019 ESC/EAS dyslipidaemia guidelines recommend an LDL-c treatment goal of <1.4 mmol/L (and LDL-c reduction >50%) after recent acute coronary syndrome (ACS ) and <1.0 mmol/L in case of additional recurrent CV events within 2 years [1]. However, many ACS patients do not achieve these goals on statins alone. For them, combination treatment is advised.

Aim of the study

The authors examined the actual achievement of the LDL-c goal (<1.4 or <1.0 mmol/L) with the PCSK9i alirocumab and the projected goal achievement with ezetimibe in ACS patients with LDL-c ≥1.4 mmol/L despite optimal statin therapy.


This was a post-hoc analysis of the ODYSSEY OUTCOMES trial. In this multicenter, double-blind, placebo-controlled phase 3 RCT, patients with recent ACS (1–12 months prior to randomization) and hyperlipidemia despite high-intensity or maximum-tolerated statin therapy were randomly assigned (1:1 ratio) to alirocumab 75 mg subcutaneously every 2 months or placebo [2]. This subanalysis comprised 17,589 patients with LDL-c ≥1.4 mmol/L at baseline who did not receive ezetimibe treatment after randomization.


The number of patients who achieved LDL-c <1.4 mmol/L at any post-randomization time point was determined. In a subset of patients with ≥1 other CV event (f.e., MI, unstable angina, stroke, or coronary revascularization) in the 2 years preceding the qualifying ACS, the number of patients who achieved LDL-c <1.0 mmol/L at any post-randomization time point was assessed.

A simulation analysis was used to project the number of patients who would have met new guideline targets at baseline or at least once after randomization if ezetimibe had been added to their treatment (assuming 18±3% reduction of LDL-c levels).

Main results

LDL-c goal <1.4 mmol/L

LDL-c goal <1.0 mmol/L

Projected goal achievement with ezetimibe


Among patients with recent ACS and LDL-c ≥1.4 mmol/L despite optimal statin therapy, addition of alirocumab resulted in 95% achieving the 2019 ESC/EAS guideline LDL-c goal of <1.4 mmol/L and 85% of those with recurrent CV events to achieving <1.0 mmol/L. If ezetimibe had been added to optimal statin therapy instead, only 11% of the patients were projected to achieve LDL-c <1.4 mmol/L. However, 97% would have met this goal if they had received triple therapy consisting of a statin, ezetimibe, and alirocumab.


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Find this article online at Eur J Prev Cardiol.

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