Dyslipidemia Treatment in Patients with Acute Coronary Syndrome: Is It Time to Move to Combination Therapy?

Dyslipidemia is a major modifiable risk factor in patients with acute coronary syndrome (ACS), and effective management is essential to reduce the risk of recurrent cardiovascular events. Recent guidelines emphasize early, intensive lipid-lowering therapy (LLT) and increasingly recommend combination regimens to achieve ambitious low-density lipoprotein cholesterol (LDL-C) targets. This review evaluates current evidence and recommendations for dyslipidemia treatment in ACS, with a focus on the rationale, timing, and selection of combination therapy. We conducted a comprehensive review of recent clinical guidelines, randomized controlled trials, and observational studies addressing lipid management in ACS. The analysis included data on LDL-C targets, efficacy and safety of high-intensity statins, adjunctive non-statin therapies (ezetimibe, PCSK9 inhibitors), and the impact of dietary interventions. Early and intensive LLT, initiated within 24-48 h of ACS, is associated with significant reductions in recurrent events and mortality. High-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) are first-line, with combination therapy (statin plus ezetimibe and/or PCSK9 inhibitor) recommended for patients not achieving LDL-C < 1.4 mmol/L (<55 mg/dL) or >50% reduction from baseline. Evidence supports further LDL-C lowering (<1.0 mmol/L) in very high-risk patients. The Mediterranean and DASH diets provide additional benefit in lipid profile optimization and risk reduction. Statins also confer pleiotropic effects, including anti-inflammatory and plaque-stabilizing actions. Recent studies and real-world data confirm the efficacy and safety of combination approaches but highlight the need for individualized therapy based on residual risk, comorbidities, and tolerability. Achieving guideline-recommended LDL-C targets in ACS patients often requires early initiation of combination lipid-lowering therapy. Optimal management should be individualized considering both LDL-C levels and broader risk profiles. Ongoing research is needed to refine patient selection for combination therapy and to integrate novel agents into clinical practice.