Expert opinion of the Polish Cardiac Society on therapeutic targets for LDL cholesterol levels in secondary prevention of myocardial infarction

Cardiovascular diseases account for 43% of deaths in Poland. The COVID-19 pandemic increased the number of cardiovascular deaths by as much as 16.7%. Lipid metabolism disorders are observed in about 20 million Poles. Lipid disorders are usually asymptomatic, they cause a significant increase in the risk of cardiovascular diseases. Up to 20% of patients who experience acute coronary syndrome (ACS) may experience a recurrence of a cardiovascular event within a year, and up to 40% of these patients may be re-hospitalized. Within 5 years after myocardial infarction, 18% of patients suffer second ACS and 13% from a stroke. Lipid-lowering therapy is an extremely important element of comprehensive management, both in primary and secondary prevention, and its main goal is to prevent or delay the onset of heart or vascular disease and reduce the risk of cardiovascular events. A patient with a history of ACS belongs to the group with very high risk of cardiovascular events due to atherosclerosis. In this group of patients, low-density lipoprotein cholesterol levels should be maintained below 55 mg/dl (1.4 mmol/l). Many scientific guidelines define the extreme risk group, which includes not only patients with two cardiovascular events within two years, but also patients with a history of ACS and additional clinical factors: peripheral vascular disease, multivessel disease (multilevel atherosclerosis), or multivessel coronary disease, or familial hypercholesterolemia, or diabetes with at least one additional risk factor: elevated Lp(a) >50 mg/dl or hs-CRP >3 mg/l, or chronic kidney disease (eGFR <60 ml/min/1.73 m(2)). In this group of patients, the low-density lipoprotein cholesterol level should be maintained below 40 mg/dl (1.0 mmol/l). Achieving therapeutic goals in patients after ACS should occur as soon as possible. For this purpose, a high-dose potent statin should be added to the therapy at the time of diagnosis, and ezetimibe should be added if the goal is not achieved after 4-6 weeks. Combination therapy may be considered in selected patients from the beginning. After 4-6 weeks of combination therapy, if the goal is still not achieved, adding a proprotein convertase subtilisin/kexin type 9 protein inhibitor or inclisiran should be considered. In order to increase com-pliance with the recommendations, the Polish Cardiac Society and the Polish Lipid Society propose to attach in the patient's discharge letter a statement clearly specifying what drugs should be used and what LDL-C values should be achieved. It is necessary for the doctor to cooperate with the patient so that the patient follows the recommendations and takes medicines regularly to achieve and maintain therapeutic goals.