Strike Early and Strike Strong: application of a strategy comprising first-line combination of high-intensity statins and ezetimibe for patients with acute myocardial infarction in routine practice

Abstract Aim Rapid and intense LDL-c reduction for patients with acute myocardial infarction (AMI) using a systematic combination of high intensity statins and ezetimibe, dubbed "Strike Early and Strike Strong" (SESS), has been proposed in a position paper endorsed by ESC. The applicability of this strategy in routine practice, and the tolerance and biological efficacy of such lipid lowering treatment (LLT) are poorly documented. Methods Single-center, prospective, observational study including 500 consecutive patients admitted for AMI. Unless there was known intolerance, a SESS policy was advocated at admission for AMI, irrespective of baseline LDL-c. Actual discharge LLT, LDL-c level during follow-up (3 to 8 months) and the rate of patients at ESC LDL-c target were recorded. We considered LLT to be maintained when observed LDL-c level at follow-up (FU) was not 20% higher than that expected from baseline LDL- and LLT intensity at discharge. Results Between January 2020 and July 2021, 527 patients were included, 387(75%) were male, 110(22%) had diabetes, mean age was 63±12 years. Admission LDL-c was 127±44mg/dL, 431(78%) had no previous LLT. At discharge, 456 (97%) a high intensity statin, and combined with ezetiibe in 430/456(92%). The mean capacity of the discharge LLT to decrease LDL-c was 63±10%. 12-month FU with biology was available for 273 randomly selected patients. The combination of high intensity statins and ezetimibe was maintained in 87%, although ezetimibe was stopped in 9% and the statin dose was reduced in 15% (mainly reduction from atorvastatin 80 to 40 mg/day). As a result, capacity of the LLT to decrease LDL-c was reduced to 59±11%. Mean LDL-c was 53±33 mg/dL. ESC LDL-c therapeutic goals were reached in 53%: LDL-c<55mg/dL in 62% and >50% decrease in baseline LDL-c in 74%. Regarding the need for PCSK9 inhibitors, the rate was 14% for a threshold for prescription set at a LDL-c≥ 70mg/dL, and 7% for a threshold set at ≥100mg/dL. An LDL-c level <30mg/dL was observed in 19%. Conclusion The SESS strategy before discharge after ACS is feasible in routine practice. At 12 months, LLT intensity was maintained in the majority of cases, yielding an average LDL-c level of 53±33 mg/dL, and 53% of patients at LDL-c goals.