An integrated approach to a multimorbid patient with extreme risk of cardiovascular events. A case report

Abstract

Introduction . Coronary artery disease (CAD) remains one of the leading causes of mortality and disability worldwide. Despite advances in cardiology, a significant proportion of patients with progressive coronary atherosclerosis require multiple surgical and endovascular interventions. Long-term mortality after percutaneous coronary intervention (PCI) remains high. Successful management of these patients requires not only the choice of interventional tactics but also effective secondary prevention, the key element of which is achieving target low-density lipoprotein cholesterol (LDL-C) levels. Brief description . A 73-year-old patient with a long-standing history of CAD, hypertension, multiple risk factors, and multiple episodes of stent restenosis and thrombosis after coronary artery bypass grafting and a series of PCIs in 2013-2018. Due to identified resistance to clopidogrel, antiplatelet therapy was escalated with ticagrelor, which enabled control of thrombotic events. Despite therapy with rosuvastatin 20 mg and ezetimibe 10 mg, LDL-C levels remained elevated (3,02 mmol/L), which did not meet the target value of <1,0 mmol/L for extreme-risk patients. In February 2023, treatment with inclisiran was initiated. After two years (six drug administrations), LDL-C was reduced to 0,83 mmol/L, corresponding to a 72,5% reduction from baseline, with no rehospitalizations for ischemic events. Discussion . This case demonstrates not only the importance of identifying clopidogrel resistance in restenosis but also the efficacy of inclisiran as a long-term lipid management option in patients with CAD, dyslipidemia, and intolerance to high doses of statins.