What is the recommended lipid management (including target LDL-C (low-density lipoprotein cholesterol) levels, medication regimen, and follow‑up) for a patient with established coronary artery disease who has undergone coronary stenting?

Lipid Management for Coronary Artery Disease with Stenting

Target LDL-C Goal

All patients with coronary artery disease who have undergone stenting must achieve an LDL-C level <55 mg/dL (1.4 mmol/L) with at least a 50% reduction from baseline. 1, 2 This represents the most aggressive evidence-based target for very high-risk patients and is supported by the 2024 ESC guidelines showing that each 1.0 mmol/L reduction in LDL-C produces a 20-25% reduction in cardiovascular mortality and non-fatal myocardial infarction. 1

For patients who experience a second vascular event within 2 years while on maximum tolerated statin-based therapy, consider an even lower LDL-C goal of <40 mg/dL (1.0 mmol/L). 1

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Initial In-Hospital Management (Before Discharge)

Start high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) before hospital discharge in every patient. 1, 3 High-intensity statins reduce LDL-C by 45-50% on average and decrease major vascular events by approximately 15% compared to moderate-intensity statins. 1

Consider adding ezetimibe 10 mg at discharge (Class IIb recommendation) for extremely high-risk patients to accelerate LDL-C lowering. 1, 3 This upfront combination approach represents a paradigm shift from traditional stepwise escalation, particularly for patients with very high baseline LDL-C, recent acute coronary syndrome, multivessel disease, or diabetes. 1

Starting lipid-lowering therapy before discharge markedly increases the likelihood that patients will remain on therapy and achieve LDL-C targets compared with initiating treatment after discharge. 3

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Follow-Up Lipid Assessment and Treatment Algorithm

Recheck lipid panel 4-8 weeks after discharge or after any medication change to guide further therapy. 1, 3

If LDL-C <55 mg/dL on maximally tolerated statin:

• Continue high-intensity statin without de-escalation. 1, 3
• Very low LDL-C levels (even <25 mg/dL) demonstrate ongoing cardiovascular benefit without safety concerns. 3, 2
• Never reduce statin dose solely because LDL-C is very low; large randomized trials show persistent benefit at levels well below conventional targets. 3

If LDL-C 55-69 mg/dL on maximally tolerated statin:

• Add ezetimibe 10 mg daily (Class IIa recommendation). 1, 3
• Ezetimibe provides an additional 15-25% LDL-C reduction by blocking intestinal cholesterol absorption. 1, 3

If LDL-C ≥70 mg/dL on maximally tolerated statin:

• Add ezetimibe 10 mg daily immediately (Class I, Level A recommendation). 1, 3
• The combination of statin with ezetimibe resulted in a 6.4% relative risk reduction in fatal and non-fatal cardiovascular events in the IMPROVE-IT trial. 1
• Recheck LDL-C 4-8 weeks after adding ezetimibe. 3

If LDL-C ≥70 mg/dL despite statin + ezetimibe:

• Add a PCSK9 inhibitor (evolocumab, alirocumab, or inclisiran) after clinician-patient discussion of net benefit, safety, and cost (Class I recommendation). 1, 3
• PCSK9 inhibitors lower LDL-C by an additional 50-60% when added to statin therapy. 1, 3
• These agents reduce non-fatal cardiovascular events by approximately 15% over 2-3 years, with greater absolute benefit when started closer to the acute coronary event. 1, 3
• Inclisiran offers twice-yearly dosing after initial and 3-month injections, which may improve adherence. 3

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Management of Statin-Intolerant Patients

Non-statin lipid-lowering therapy is mandatory (Class I, Level B-R) for patients who cannot tolerate statins. 3

Confirm true complete statin intolerance by objectively testing at least two different statins (including one at the lowest approved dose); true complete intolerance occurs in <3% of patients. 1, 3

Bempedoic acid is the preferred non-statin agent with outcomes data. 3, 4

• Bempedoic acid 180 mg daily reduces LDL-C by 15-25% through hepatic ATP citrate lyase inhibition. 3, 4
• The CLEAR Outcomes trial demonstrated a 13% reduction in major adverse cardiovascular events in statin-intolerant patients. 3, 4
• Monitor serum uric acid and watch for gout; check liver function tests periodically. 3, 4

For statin-intolerant patients, start a fixed-dose combination of bempedoic acid 180 mg plus ezetimibe 10 mg daily immediately. 1, 3

• This combination achieves approximately 35% LDL-C reduction. 1, 3
• If LDL-C remains ≥70 mg/dL after 4-6 weeks, add a PCSK9 inhibitor (if not contraindicated). 3

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Long-Term Monitoring Schedule

Once LDL-C is stable and at target, repeat lipid panel every 6-12 months to ensure continued adherence and efficacy. 3

Never de-escalate statin intensity during follow-up in patients who tolerate treatment, regardless of how low LDL-C falls. 1, 3

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Special Populations

Patients with Diabetes or Metabolic Disorders:

• Consider upfront combination therapy with pitavastatin plus ezetimibe, which may reduce new-onset diabetes risk while achieving significant LDL-C reduction. 1
• Alternatively, use a lower dose of high-intensity statin (rosuvastatin 20 mg or atorvastatin 40 mg) with ezetimibe as a fixed-dose combination. 1
• If target not achieved, add bempedoic acid, which may help optimize both LDL-C and glucose control. 1

Patients with Recurrent Events:

• Patients experiencing a myocardial infarction plus another vascular event within the last 2 years, or acute coronary syndrome with multivessel disease, peripheral artery disease, familial hypercholesterolemia, or diabetes with additional risk factors are considered "extremely high-risk." 1
• These patients should receive at least dual therapy (maximally tolerated statin + ezetimibe) immediately, with preferably triple therapy (adding PCSK9 inhibitor) to achieve LDL-C <40 mg/dL as early as possible. 1

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Critical Pitfalls to Avoid

Do not accept suboptimal LDL-C levels. Only approximately 22% of very high-risk secondary prevention patients in Europe achieve LDL-C <55 mg/dL, and another 22% receive no lipid-lowering therapy at all. 1, 3 This therapeutic inertia contributes to the fact that approximately 20% of acute coronary syndrome patients experience a recurrent cardiovascular event within 24 months. 1, 3

Do not delay intensification of lipid therapy. Patients treated with PCSK9 inhibitors closer to their acute coronary event experience greater absolute cardiovascular benefit. 3

Do not postpone non-statin therapy while conducting multiple statin trials. Once complete statin intolerance is confirmed, start non-statin therapy promptly. 3

Do not use dipyridamole as an antiplatelet agent in stable angina. Usual oral doses can enhance exercise-induced myocardial ischemia. 1

Statins should not be given when pregnancy is planned, during pregnancy, or during breastfeeding. 1

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Adjunctive Therapies

Antiplatelet therapy: Aspirin 75-325 mg daily should be used routinely in all patients with coronary artery disease without contraindications. 1 Clopidogrel is reserved for patients who cannot take aspirin. 1

ACE inhibitors: Consider ACE inhibitors for vasculoprotective effects in patients with coronary artery disease, particularly those with diabetes. 1

Lifestyle modification: Exercise, diet, and weight control favorably affect blood lipid levels and are recommended for all patients. 1