Triple versus dual oral lipid lowering therapy after ACS

ESC Preventive Cardiology 2025 – In the Spanish ES-BempedACS trial, adding bempedoic acid to high-potency statin and ezetimibe early after an ACS did not improve the proportion of patients reaching the LDL-c target at 8 weeks.

This summary is based on the presentation of Sergio Raposeiras-Roubín, MD, PhD (Vigo, Spain) at ESC Preventive Cardiology 2025 – Efficacy and safety of bempedoic acid in patients with acute coronary syndrome.

Introduction and methods

The first months after an ACS, patients are at increased risk of recurrent ischemic events. Early reduction of LDL-c is associated with lower rates of recurrent events. Nevertheless, a large proportion of patients with ACS fail to reach their LDL-c goal. The goal of the ES-BempedACS trial was to evaluate the efficacy and safety of the addition of bempedoic acid to statin-ezetimibe therapy after ACS.

The Spanish ES-BempedACS trial was an independent, investigator-initiated, multicenter, prospective, pragmatic, randomized, open-label, evaluator-blinded clinical trial in which 206 patients within the first 72 hours after hospital admission for ACS were randomized to triple oral lipid-lowering therapy (LLT; n=101) or dual oral LLT (n=105), on top of standard of care. Triple oral LLT was defined as high-potency and high-intensity statin plus ezetimibe plus bempedoic acid, whereas the dual oral LLT was defined as high-potency and high-intensity statin plus ezetimbe. The primary outcome was the percentage of patients achieving the LDL-c target of <1.4 mmol/l (<55 mg/dL) at 8 weeks.

Mean LDL-c was 133.6 ±28.8 mg/dL at baseline and 51.5% of the acute MI patients had STEMI. At 8 weeks, data on LDL-c were available for 96 patients in the intervention group and in 98 patients in the control group.

Main results

• A similar proportion of patients receiving triple oral LLT achieved the LDL-c target of 55 mg/dL compared to those assigned to dual oral LLT (59.4% vs. 53.1%; P=0.375).
• The absolute reductions in LDL-c from baseline to 8 weeks were comparable between the two groups (-57.5% in the triple oral LLT group and -56.9% in the dual oral LLT group; P=0.823).
• At 8 weeks, there were no differences in non-HDL-c and triglycerides between the two groups.
• The most frequent adverse event was hyperuricemia, which occurred at similar rates between the triple oral LLT group and the dual oral LLT group (7.3% vs. 5.1%; P=0.527).

Conclusion

In ES-BempedACS, the addition of bempedoic acid to high-potency statin plus ezetimibe did not increase the proportion of post-ACS patients reaching the LDL-c target of 55 mg/dL at 8 weeks. Triple oral LLT appeared to be safe after an ACS.

- Our reporting is based on the information provided at the ESC Preventive Cardiology 2025 -