Reassessing the First Step: Lessons From ES-BempedACS and the Era of Multi-Mechanism LDL-C Lowering

he Caribbean proverb, "All fish does swim, but not all in the same water, " captures the essence of contemporary lipid management.In clinical practice, while low-density lipoprotein cholesterol (LDL-C) reduction remains a universal goal, the approach must be individualized to each patient.The risk of recurrent major adverse cardiovascular events is highest soon after acute coronary syndrome (ACS), with nearly 1 in 10 patients experiencing myocardial infarction, stroke, or cardiovascular death within 3 months.1 Despite this risk, optimal lipid management in secondary prevention remains elusive, and both adherence and treatment intensity have declined over time.2,3 In a cohort of >100 000 patients in Northern California (2010-2021), fewer than 60% were prescribed any statin 1 year after an atherosclerotic cardiovascular disease event, fewer than 25% received high-intensity statins, and fewer than 30% achieved LDL-C