Efficacy and Safety of Bempedoic Acid Added to Intensive Lipid-Lowering Therapy in Patients With chronic coronary syndrome: Real-World Clinical Experience

Background and aims: Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in Europe. Many very-high-risk patients with chronic coronary syndrome (CCS) do not achieve guideline-recommended low-density lipoprotein cholesterol (LDL-C) targets despite intensive lipid-lowering therapy. Bempedoic acid, a liver-activated ATP citrate lyase inhibitor, may provide additional benefit. We assessed its effectiveness and safety in a real-world cohort of intensively treated CCS patients. Methods: This was a prospective, single-centre, real-world study including consecutive CCS patients ≥ 18 years with LDL-C ≥ 55 mg/dL despite ≥ 8 weeks of high-intensity statin plus ezetimibe, or PCSK9 inhibitor plus ezetimibe in statin-intolerant individuals. All patients received bempedoic acid 180 mg/day. Lipid profile, uric acid, and renal function were assessed at baseline and ≥ 8 weeks. Primary endpoints were absolute and relative LDL-C changes and attainment of LDL-C < 55 mg/dL. Secondary endpoints included changes in other lipid parameters and safety. Multivariable regression identified predictors of LDL-C reduction and goal achievement. Results: Of 125 patients, 118 completed follow-up (mean age 62.4 ± 10.0 years; 79.2% male). LDL-C decreased from 71.90 ± 18.03 to 55.54 ± 14.23 mg/dL (− 16.36 mg/dL; −22.75%; p < 0.001), and 48.3% achieved LDL-C < 55 mg/dL. Total and non–HDL cholesterol decreased, while triglycerides and glucose remained unchanged. HDL-C showed a modest reduction. Uric acid increased by 0.96 mg/dL but no gout occurred; renal function changes were small. Higher untreated LDL-C and diabetes independently predicted a greater LDL-C reduction, whereas higher untreated LDL-C and baseline uric acid predicted LDL-C target attainment. Conclusions: In CCS patients not meeting LDL-C goals despite intensive therapy, adding bempedoic acid provided an additional ~ 23% LDL-C reduction and enabled nearly half to reach < 55 mg/dL with good tolerability. Bempedoic acid represents an effective real-world intensification strategy.