CONGRESS ABSTRACT

Patients with Peripheral Artery Disease are at increased risk of atherosclerotic cardiovascular (CV) events with high rate of recurrence. Bempedoic acid is a therapeutical option for the management of patients with hypercholesterolemia approved by EMA in 2020 and available in Italy since 2023.   We report the case of a 59-year old man who was referred to the vascular surgeon for claudication. Color doppler ultrasound (CDU) revealed occlusion of the right common iliac artery and stenosis of the left common iliac and femoral arteries. At the preoperatory cardiologic visit, the patient reported claudication while running, ECG was normal and blood test showed an untreated hypercholesterolemia (LDL-C 159mg/dL). The patient was started on atorvastatin 40mg+ezetimibe 10mg aiming at a LDL-C target of 55mg/dL and underwent to revascularization a few weeks later.   During a routine follow-up, ECG and echocardiogram revealed a silent myocardial ischemia and coronary angiography showed a chronic occlusion of the first diagonal with an indication to continue medical therapy (ASA100+rivaroxaban 2,5mg BID +bisoprolol 1,25mg). According to the 2019 ESC/EAS guidelines, patients with ASCV and a vascular event within 2 years have an extreme risk of developing a CV event and should reach a more stringent LDL-C target of 40gm/dL. Despite treatment with the maximum tolerated dose of atorvastatin 40mg+ezetimibe 10mg, LDL-C was 91mg/dL, the cardiologist decided to switch to rosuvastatin 20mg+ezetimibe 10mg. At the 6 months follow-up, the patient reported mild claudication but CDU confirmed patency of iliac stents. LDL-C levels (65mg/dL) were reduced by more than 50% but still not at target (40mg/dL) and a step-up in therapy was needed. According to Italian prescription criteria, the use of PCSK9 inhibitors is allowed only in patients with LDL-C ≤70mg/dL. Bempedoic acid was, at the time a newly available therapeutic option. The patient switched then to a triple oral combination therapy of rosuvastatin 20mg+ezetimibe 10mg+bempedoic acid 180mg. At the 6-month follow-up, the patient showed a good clinical, hemodynamic and metabolic balance. CDU confirmed stent patency and blood test showed LDL-C of 46mg/dL. This clinical experience confirms the efficacy of a triple oral combination of rosuvastatin, ezetimibe and bempedoic acid and highlights the importance of combination therapies to effectively lower LDL-C in patient at very high/extreme risk.