ACS.Symptoms can include cardiogenic shock, chest pain, and pulmonary edema. For free wall rupture, patients may also have cardiac arrest and develop cardiac tamponade [4, 29]. Free wall rupture is managed through urgent surgical repair. Pre­and perioperative mechanical circulatory support may be needed to reduce left ven­tricular end diastolic pressure. Management of ventricular septal or papillary muscle rupture involved a combination of pharmacotherapy to maintain blood pressure and cardiac output (e.g., vasopressors and inotropes) as well as surgical repair, ideally 7days or more from the event [29, 35, 36]. Mechanical circulatory support may be required for both complications. It is also recommended to incorporate palliative care due to the nature and severity of the complications [29, 35].

For patients who underwent ischemia-guided therapy without intervention, the aspirin can be combined with either clopidogrel or ticagrelor. TRITON-TIMI did not include patients who received medical management for acute coronary syndrome [39]. TRIOLOGY ACS evaluated patients receiving medical management with pra- sugrel in comparison to clopidogrel in patients with unstable angina or NSTEMI.There was not a statistically signicant difference in the occurrence of the primary end point of myocardial infarction, death from cardiovascular causes, or nonfatal stroke or the safety end point of major bleeding events in patients receiving prasugrel. Therefore, prasugrel is not recommended as part of DAPT in patients with acute coronary syndrome receiving medical/ischemia-guided management [4, 29, 38, 39].

In the 2018 ACC/AHA multidisciplinary guideline for management of choles­terol, the addition of non-statin therapy with ezetimibe for LDL cholesterol reduc­tion can be considered for patients who are considered to have a very-high-risk ASCVD [43]. Very-high-risk ASCVD includes patients with multiple major ASCVD events or ASCVD in combination with multiple high-risk conditions (e.g., diabetes, hypertension, current smoking, persistent LDL elevation of 70mg/dL or greater despite high-intensity statin therapy) [43, 45]. Ezetimibe inhibits the absorp­tion of cholesterol at the brush border of the small intestine [43–45]. Addition of ezetimibe to statin therapy further improves cardiovascular outcomes and reduces LDL cholesterol. Ezetimibe has a low risk for side effects and can lower LDL-C by 15–30% [4, 43–46]. Furthermore, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor therapy could be considered for very-high-risk ASCVD patients who are already receiving statin therapy at the maximum tolerated dose in combina­tion with ezetimibe and when LDL remains 70mg/dL or greater [4, 43–45]. PCSK9 binds to LDL receptors and promotes degradation within the liver. Circulating LDL is primarily cleared when bound to the LDLR; therefore, lower levels of LDLR result in increased levels of LDL-C.There are three agents available in the United States that reduce PCSK9 activity, which include alirocumab, evolocumab, and inclisiran. These agents have been observed to reduce LDL-C by 45–70%. Adverse effects observed are typically mild and include injection-site reactions and naso­pharyngitis. These are not usually therapies that are initiated during hospitalization due to cost and require insurance review and approval to conrm that patients will be able to obtain and afford them [4, 47].