Residual Atherothrombotic Risk After Myocardial Infarction: Integrating Lipid, Inflammatory and Thrombotic Pathways

Despite major advances in reperfusion strategies and guideline-directed medical therapy, patients surviving myocardial infarction (MI) remain at substantial risk of recurrent cardiovascular events. Among the multiple determinants of post-MI cardiovascular risk, persistent atherothrombotic vulnerability remains a major therapeutic challenge despite guideline-directed secondary prevention. This review provides an integrated overview of residual atherothrombotic risk after MI, focusing on the complementary roles of lipid, inflammatory, and thrombotic pathways. Current evidence supports the use of biomarkers such as apolipoprotein B, lipoprotein(a), remnant cholesterol, triglyceride-rich lipoproteins, and high-sensitivity C-reactive protein to improve risk stratification beyond LDL-C. Landmark clinical trials have demonstrated that intensive lipid-lowering therapy, selected anti-inflammatory agents, and individualized antithrombotic strategies can further reduce recurrent cardiovascular events in appropriately selected patients. However, these pathogenic pathways rarely occur in isolation and frequently overlap, generating heterogeneous residual risk phenotypes. We propose a pragmatic multi-layered model in which lipid, inflammatory, and thrombotic mechanisms are viewed as interconnected biological processes rather than independent entities. This framework supports a personalized approach to secondary prevention based on comprehensive risk assessment, targeted therapeutic intensification, and longitudinal reassessment. Integrating these complementary domains may provide a framework for more individualized secondary prevention after MI, although its clinical utility requires prospective validation.