[Management of hypercholesterolemia in patients with acute coronary syndrome: current mechanisms and future perspectives].
Acute coronary syndromes (ACS) are a major health problem both in industrialized countries and in developing ones, and a leading cause of death and disability. The pathogenesis of ACS is multifactorial and complex, with approximately 65-70% of cases caused by the abrupt occlusion of a coronary vessel. This usually occurs as a result of thrombus formation over a vulnerable, lipid-rich atherosclerotic plaque, which undergoes rupture or erosion. High levels of LDL-cholesterol (LDL-C) are a well known risk factor for the development of atherosclerosis, and the reduction in plasma LDL-C is a fundamental treatment both in primary and secondary prevention. Statins are the most extensively used lipid-lowering drugs. They have been associated with reduced progression of coronary atherosclerosis and a decreased incidence of new ACS episodes or post-ACS major cardiovascular events. For ACS patients, the European Society of Cardiology (ESC) has suggested an early treatment - starting with the acute phase - together with a well defined target value of LDL-C level, which should be achieved during the follow-up. While statin therapy has significantly lowered cardiovascular risk, several cardiovascular events are still not prevented and a residual risk remains also after intensive therapy. In addition, a significant proportion of high-risk patients do not achieve the LDL-C target recommended by the ESC guidelines or present with statin intolerance, which does not allow a continuative and effective treatment. This is the main reason why innovative lipid-lowering therapies might become a new opportunity in ACS patients. The recently published results of the IMPROVE-IT trial have shown that the association statin + ezetimibe is superior to statin alone in preventing cardiovascular death, non-fatal myocardial infarction, rehospitalization for unstable angina, coronary revascularization and stroke in a population of medium to high-risk patients stabilized after ACS. Monoclonal antibodies targeting human PCSK9 are currently being tested on top of statins in patients with ACS, to investigate their superiority in reducing major cardiovascular adverse events as compared with statins alone at the maximally tolerated dose. The results, expected for 2017, will hopefully benefit the treatment of patients in secondary prevention and contribute to a better outcome of ACS patients worldwide.
Dipartimento Cardiovascolare, Humanitas Research Hospital, Rozzano (MI).
Maddalena
M
Lettino
D054058:Acute Coronary Syndrome / Q000150:complications* / Q000188:drug therapy; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D005544:Forecasting; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D006937:Hypercholesterolemia / Q000150:complications* / Q000188:drug therapy*; D000071449:Proprotein Convertase 9; D043484:Proprotein Convertases / Q000276:immunology; D012307:Risk Factors; D012697:Serine Endopeptidases / Q000276:immunology
D000911:Antibodies, Monoclonal; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; C472125:PCSK9 protein, human; D000071449:Proprotein Convertase 9; D043484:Proprotein Convertases; D012697:Serine Endopeptidases