Efficacy and Safety of an Early Aggressive Lipid-Lowering Strategy Using Triple Therapy After Mechanical Thrombectomy

초록

Background Current guidelines recommend initial high-intensity statin monotherapy and "the wait and watch paradigm," even in patients with acute ischemic stroke (AIS). However, newer lipid-lowering therapies allow aggressive low-density lipoprotein cholesterol (LDL-C) reduction without drug class restriction. The effectiveness of triple therapy (early aggressive strategy) comprising a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, ezetimibe, and a high-intensity statin after endovascular thrombectomy (EVT) for emergent large vessel occlusion (ELVO) remains uncertain.Methods We retrospectively analyzed patients with AIS due to ELVO who underwent successful EVT at four comprehensive stroke centers between January 2021 and December 2024. Patients were classified into triple therapy or high-intensity statin monotherapy (standard therapy) and followed up for 90 days. Multivariable regression and propensity score matching were used.Results Among 197 patients (mean age, 70.8 +/- 12.1; 36.0% male), 55 received triple therapy. Baseline total cholesterol (TC) and LDL-C levels were comparable between groups. At both 4 and 12 weeks, the triple therapy group demonstrated significantly lower mean TC and LDL-C levels compared with the standard therapy group. Triple therapy was independently associated with a reduced risk of early neurological deterioration (adjusted odds ratio [aOR], 0.14; 95% confidence interval [CI], 0.03-0.81). In the subgroup of patients with ELVO due to large-artery atherosclerosis (LAA), triple therapy was further associated with a higher likelihood of functional independence at 90 days (aOR 9.30; 95% CI 1.86-46.56).Conclusions Triple therapy achieved faster and greater LDL-C reduction and improved clinical outcomes following EVT, particularly among patients with AIS due to ELVO from LAA.

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