Comparative efficacy of Statin Monotherapy, Statin–Ezetimibe Dual Therapy, and Statin–Ezetimibe–Bempedoic Acid Triple Therapy in patients with Acute Coronary Syndrome: A Prospective comparative study
TL;DR
Triple therapy consisting of a statin, ezetimibe, and bempedoic acid achieved significantly greater LDL-C reduction and superior LDL-C target attainment compared with statin monotherapy or statin–ezetimibe dual therapy in patients with ACS.
Abstract
Background: Patients with acute coronary syndrome (ACS) remain at very high risk for recurrent cardiovascular events despite contemporary therapy. Current guidelines recommend aggressive low-density lipoprotein cholesterol (LDL-C) reduction following ACS. Although statins remain the cornerstone of lipid-lowering therapy, many patients fail to achieve recommended LDL-C targets with statin monotherapy. Ezetimibe and bempedoic acid provide additional LDL-C lowering through complementary mechanisms and may improve target attainment in high-risk patients. Objectives: To compare the efficacy of statin monotherapy, statin plus ezetimibe therapy, and statin plus ezetimibe plus bempedoic acid therapy in reducing LDL-C levels and achieving guideline-recommended LDL-C targets among patients with ACS. Methods: This prospective comparative study was conducted in 300 patients with ACS between July 2024 and March 2026. Eligible patients with elevated LDL-C levels and no prior lipid-lowering therapy were allocated into three treatment groups: statin monotherapy (n=100), statin plus ezetimibe (n=100), and statin plus ezetimibe plus bempedoic acid (n=100). LDL-C levels were assessed at baseline, 1 month, and 3 months. The primary outcome was percentage reduction in LDL-C levels. Secondary outcomes included absolute LDL-C reduction and achievement of LDL-C target <55 mg/dL. Results: All treatment groups demonstrated significant reductions in LDL-C levels during follow-up. At 3 months, mean LDL-C levels decreased to 53.0 ± 16.6 mg/dL in the statin monotherapy group, 44.8 ± 14.2 mg/dL in the statin plus ezetimibe group, and 36.6 ± 16.1 mg/dL in the triple therapy group. Percentage LDL-C reductions were 52.0%, 60.6%, and 75.7%, respectively. LDL-C target attainment (<55 mg/dL) at 3 months was achieved in 64.2% of patients receiving statin monotherapy, 80.7% receiving statin plus ezetimibe, and 90.9% receiving triple therapy. Intergroup differences were statistically significant (ANOVA F=23.43, p<0.001). Conclusion: Triple therapy consisting of a statin, ezetimibe, and bempedoic acid achieved significantly greater LDL-C reduction and superior LDL-C target attainment compared with statin monotherapy or statin–ezetimibe dual therapy in patients with ACS. Early intensive combination lipid-lowering therapy may represent an effective strategy for achieving guideline-recommended LDL-C goals in very high-risk patients.