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Supplementary data online, Table S17 summarizes the characteristics of a healthy diet that should be adhered to. For further details on nutrition, please refer to the 2021 ESC Guidelines on cardiovascular disease prevention.646 With regard to alcohol consumption, recent data suggest that alcohol abstainers have the lowest risk of CVD outcomes, that any amount of alcohol uniformly increases blood pressure and body mass index, and that a weekly consumption of >100 g of alcohol is associated with decreased life expectancy.773–775 Accordingly, it is recommended to restrict alcohol consumption to a maximum of 100 g per week (same limit for men and women).646

13.2.3 Physical activity and exercise

Based on extensive data from the general population, sedentary behaviour, defined as time spent sitting or lying with low energy expenditure, while awake, is an independent risk factor for all-cause mortality.776,777 According to recommendations from the World Health Organization, adults with chronic conditions should limit their amount of sedentary time, replacing it with physical activity of any intensity (including light intensity).646,778 General physical activity recommendations include a combination of regular aerobic physical activity and resistance exercise throughout the week, which also forms the basis of recommendations for patients post-ACS.646,778 However, it is important to recognize that daily physical activity does not replace participation in exercise-based CR. With support from multiple randomized trials, exercise training is a pivotal part of comprehensive CR and participation in exercisebased CR should be offered to all patients after ACS.779 Cardiorespiratory fitness is a strong predictor of future prognosis both in the general population and in post-ACS patients.780

13.2.4 Psychological considerations

There is a two-fold risk of anxiety and mood disorders in patients with heart disease. Depression, anxiety, and psychological stress are associated with worse outcomes. Psychological and pharmacological interventions can have a beneficial effect and should be considered for ACS patients with depression, anxiety, and stress.781 It is recommended that all patients have their mental well-being assessed using validated tools before discharge, with consideration of onward psychological referral when appropriate.782 For further details, please refer to the 2021 ESC Guidelines on cardiovascular disease prevention.646

13.2.5 Resumption of activities

Information on the resumption of activities, sexual activity, and environmental factors is presented in the Supplementary data online, Section 13.1.2.

13.3 Pharmacological treatment

13.3.1. Antithrombotic therapy Recommendations for antithrombotic therapy are included in Section 6.

13.3.2 Lipid-lowering therapy

Dyslipidaemia should be managed according to the current dyslipidaemia guidelines, with a combination of lifestyle and pharmacological interventions.783 Trials have consistently demonstrated that lower lowdensity lipoprotein-cholesterol (LDL-C) levels after ACS are associated with lower CV event rates.784 The current treatment goal for secondary prevention is to lower LDL-C to <1.4 mmol/L (<55 mg/dL) and to achieve a ≥50% LDL-C reduction from baseline. For patients who experience a second CV event within 2 years (not necessarily of the same type as the first event), an LDL-C goal of <1.0 mmol/L (<40 mg/dL) appears to confer additional benefit.783,785,786

After an ACS event, lipid-lowering treatment should be initiated as early as possible, both for prognostic benefit and to increase patient adherence after discharge. It is recommended that a high-intensity statin (e.g. atorvastatin or rosuvastatin) is initiated as early as possible after hospital admission, preferably before planned PCI, and prescribed up to the highest tolerated dose in order to reach the LDL-C goals.783,787 The intensity of statin therapy should be increased in patients who were receiving low- or moderate-intensity statin treatment before the ACS event. In IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial), ezetimibe treatment early after ACS (within 10 days) was added on top of prior statin therapy or initiated concomitantly in statin-naïve patients (two-thirds of patients) and compared with statin monotherapy.788 Treatment with ezetimibe was shown to be safe and provided long-term benefits for CV outcomes. As such, if patients are on a maximally tolerated statin dose, or have no prior statin treatment, and have LDL-C levels which indicate it is unlikely that targets will be reached with statin therapy alone, initiating ezetimibe in addition to a statin (or statin plus ezetimibe combination treatment) may be considered during the ACS hospitalization.783,788 In the ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) trial, treatment with the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor alirocumab was initiated as early as 1 month after ACS.786 Treatment with PCSK9 inhibitors has been shown to be safe and effective in lowering LDL-C in patients hospitalized with ACS.789–791 Recent data have also shown improvements in plaque phenotype and plaque regression in ACS patients treated with PCSK9 inhibitors.792,793 Combined with the data from trials on the long-term benefits of PCSK9 inhibitors and observational data on the importance of lowering LDL-C early after ACS, PCSK9 inhibitor treatment should be initiated during ACS hospitalization in patients who were not at their LDL-C goal despite being on statin and ezetimibe treatment before admission.785,786,794–796 In all cases, lipid levels should be re-evaluated 4–6 weeks after each treatment or dose adjustment to determine whether treatment goals have been achieved and to check for any safety issues; the therapeutic regimen can then be adapted accordingly. If the LDL-C goals are not achieved with the maximum tolerated dose of a statin alone after 4– 6 weeks following ACS, adding ezetimibe is recommended.783,788 Initiation of PCSK9 inhibitor treatment is recommended in patients who do not reach their LDL-C goal despite maximum tolerated statin and ezetimibe therapy.783,785,786 Finally, icosapent ethyl, at a dose of 2 g b.i.d., can be used in combination with a statin in patients with ACS and triglyceride levels of 1.5–5.6 mmol/L (135–499 mg/dL) despite statin treatment.783,797 An algorithm for lipid-lowering management in ACS patients is outlined in Figure 18. For a detailed description of the different lipid-lowering drug classes and respective trial data, please refer to the Supplementary data online. Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026