Early and intensive LDL-cholesterol (LDL-c) reduction is associated with improved short-term and long-term outcomes. Bempedoic acid is an oral ATP citrate lyase inhibitor that lowers LDL-c upstream of HMG-CoA reductase. When added to maximally tolerated statins, it has demonstrated significant LDL-c reduction and cardiovascular benefit, particularly in statin-intolerant or high-risk patients. However, evidence on early initiation of bempedoic acid during the index ACS hospitalization is currently lacking. The investigators therefore would like to see whether early (pre-discharge) initiation of an oral triple lipid-lowering therapy including bempedoic acid, high-intensity statin (HIS), and ezetimibe is superior to usual care in reducing LDL-c levels at 8 weeks after randomization in patients hospitalized for ACS.

Despite major improvements in the acute management of Acute Coronary Syndromes (ACS), recurrent cardiovascular events remain frequent after hospital discharge. Real-world registries consistently show suboptimal implementation of guideline-recommended lipid-lowering strategies, with more than 60% of patients failing to achieve recommended LDL-cholesterol (LDL-c) targets after ACS. Early and intensive LDL-c reduction is associated with improved short-term and long-term outcomes. While injectable lipid-lowering therapies such as PCSK9 inhibitors have demonstrated rapid LDL-c reduction when initiated early after ACS, their high cost and parenteral administration limit widespread adoption. Bempedoic acid is an oral ATP citrate lyase inhibitor that lowers LDL-c upstream of HMG-CoA reductase. When added to maximally tolerated statins, it has demonstrated significant LDL-c reduction and cardiovascular benefit, particularly in statin-intolerant or high-risk patients. However, evidence on early initiation of bempedoic acid during the index ACS hospitalization is currently lacking.

Inclusion Criteria:

• Age ≥18 years
• Male and females at birth
• Admitted for ACS caused by an atherothrombotic coronary event;
• Calculated LDL-c: 70-140 mg/dL within 24 hours from admission for the ACS index event
• Lipid lowering therapy on admission consisting of a low/moderate intensity statin or a high intensity statin (HIS); or no lipid lowering therapy (naïve patients)
• Lipid-lowering therapy at discharge (at the time of randomization) consisting of HIS or HIS + ezetimibe
• Scheduled home discharge
• Written informed consent provided; patients who are unable to give informed consent for any reason will be excluded from the study.

Exclusion Criteria:

• Patients already treated with HIS+Ezetimibe on admission for the ACS event,
• Patients currently, previously or planned to be treated with PCSK9i or inclisiran,
• Patients treated currently or in the last 3 months with bempedoic acid or in whom this treatment is planned in the following 8 weeks,
• Known allergy, sensitivity or intolerance to bempedoic acid and/or study drugs' formulation ingredients (e.g. lactose intolerance),
• Patients with history of documented intolerance to statins, ezetimibe or bempedoic acid
• Patients with known Familial Hypercholesterolemia (FH; heterozygous or homozygous),
• Patients with plasma triglycerides concentration exceeding 400 mg/dL (4.52 mmol/L),
• Patients with dysbetalipoproteinemia (type III hyperlipoproteinemia),
• Unstable clinical status (hemodynamic or electrical instability),
• Severe renal dysfunction (eGFR <30 ml/min/1.73m2 using the CKD-EPI formula),
• Active liver disease or hepatic dysfunction (AST or ALT levels > 3xUNL),
• Current enrolment in another investigational device or drug study,
• Current pregnancy, lactation or women of childbearing potential, unless using highly effective contraception,
• Patients unlikely to comply with the protocol or unable to understand the nature, scope and possible consequences of the study.