ABSTRACT
Acute coronary syndrome (ACS) induces a pro-inflammatory and pro-atherogenic state, increasing the risk of recurrent major adverse cardiovascular events (MACE). Rapid reduction of llow-density lipoprotein cholesterol (LDL-C) is an important therapeutic strategy for stabilizing vulnerable atherosclerotic plaques and reducing inflammation. Current clinical guidelines classify patients with a recent ACS as being at extremely high risk and recommend an LDL-C target of <55 mg/dl, together with a reduction of >50% from baseline. This paper evaluates lipid-lowering therapies, including statins, ezetimibe, PCSK9 monoclonal antibodies, inclisiran, and bempedoic acid. It examines their efficacy in lowering LDL-C, their effects on major adverse cardiovascular events (MACE), the management of statin intolerance, and their mechanisms of action. High-dose statin therapy has lipid-lowering and anti-inflammatory effects. Ezetimibe reduces LDL-C levels and cardiovascular events by selectively inhibiting the intestinal protein Niemann-Pick C1-Like 1. PCSK9 inhibitors, such as evolocumab and alirocumab, provide substantial additional reductions in LDL-C when used in combination with standard therapy, promoting plaque regression and reducing the rate of MACE. Inclisiran provides sustained hepatic inhibition of PCSK9 via small interfering RNA (siRNA), with a twice-yearly dosing regimen, helping to address issues related to treatment nonadherence. Patients with statin intolerance require alternative lipid-lowering strategies, such as bempedoic acid, which provides an option for achieving LDL-C targets. Early implementation of combination therapy during the acute phase optimizes vascular remodeling, reduces inflammation, and reduces the risk of recurrent ischemic events.