From clinical inertia to therapeutic optimization in patients with atherosclerotic cardiovascular disease: A Monte Carlo simulation within the ITACARE-P registry
Abstract
Background Despite the intensive approach recommended by the 2019 European Society of Cardiology/European Atherosclerosis Society guidelines, low-density lipoprotein cholesterol (LDL-C) target attainment ( Methods We analyzed real-world LLT patterns in the ITACARE-P registry, enrolling 1909 Italian ASCVD patients referred to cardiovascular rehabilitation or secondary prevention programs. Baseline LLT and LDL-C levels were recorded. For patients not at LDL-C target, a Monte Carlo simulation with 10,000 iterations was performed using efficacy data from pivotal randomized trials to model sequential addition of ezetimibe, bempedoic acid, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, and inclisiran to estimate potential LDL-C goal attainment rates. Results Among 1909 patients (mean age 66 ± 10 years, 26% women), 41.3% were at LDL-C target. Most (90%) were on statins, predominantly at moderate or high intensity, whereas only 3% were untreated. Among patients not at LDL-C target, the Monte Carlo simulation predicted a stepwise increase in goal attainment from 43% to 50% after ezetimibe, 63% after bempedoic acid, 95% after PCSK9 inhibitors, and 90% after inclisiran. A baseline percentage distance of 23.66% from the LDL-C target was identified as a threshold beyond which the addition of bempedoic acid alone was rarely sufficient ( Conclusion A structured, guideline-based intensification strategy in secondary prevention could close the treatment gap and enable near-…
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In routine clinical practice, oral agents such as bempedoic acid, which has demonstrated LDL-C-lowering efficacy and cardiovascular outcomes data, may facilitate treatment intensification in patients who remain above recommended LDL-C targets.
“Recent data suggest that oral agents such as bempedoic acid, with demonstrated LDL-C–lowering efficacy and cardiovascular outcomes data, may facilitate treatment intensification in patients who remain above recommended targets [48].”
From Systematic literature review on the real-world effectiveness and safety of bempedoic acid (2026) · cites this paper as [48]
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- Authors
- Faggiano, A., Maloberti, A., Ambrosetti, M., Giallauria, F., Mureddu, G., Venturini, E., Ruzzolini, M., Maranta, F., Vatri, M., Zadre, L., Carugo, S., Ruscica, M., Fattirolli, F., & Faggiano, P.
- Affiliations
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (IT)
- Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda (IT)
- Federico II University Hospital (IT)
- Azienda Ospedaliera San Giovanni Addolorata (IT)
- IRCCS Ospedale San Raffaele (IT)
- Azienda Ospedaliero-Universitaria Careggi (IT)
- University of Brescia (IT)
- University of Milan (IT)
- Fondazione Poliambulanza Istituto Ospedaliero (IT)
- Corresponding author
- Faggiano, Andrea
- Faggiano, Pompilio
- ORCID
- Venue
- Journal of Clinical Lipidology
- Publisher
- Elsevier BV
- Published
- 2026-01
- Volume
- 20
- Issue
- 1
- Pages
- 21-30
- ISSN
- 1876-4789 (ISSN-L)
- 1933-2874
- OpenAlex
- W4416265818
- Cited by
- 10
- References
- 32
- Citations by year
- 2026: 10
- FWCI
- 9.48
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of clinical lipidology (publishedVersion)
- PubMed (publishedVersion)
- BOA (University of Milano-Bicocca) (submittedVersion)
- Funders
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico
- Ministry of Health
- Topics
- Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
- Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
- Keywords
- atherosclerotic cardiovascular disease, LDL-C goal attainment, lipid-lowering therapy, clinical inertia, secondary prevention, cardiac rehabilitation, ezetimibe, bempedoic acid, PCSK9 inhibitors, inclisiran, combination therapy, treatment gap, Monte Carlo simulation
- MeSH terms
- Aged, Cardiovascular Diseases, Female, Humans, Cholesterol, LDL, Male, Middle Aged, Monte Carlo Method, Registries, Atherosclerosis
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