Dual PCSK9 Inhibition With Inclisiran and Alirocumab in Secondary Prevention

Inclusion Criteria: * Adults aged ≥18 years * Established atherosclerotic cardiovascular disease (secondary prevention), defined as prior cardiovascular events or imaging-confirmed atherosclerosis (e.g., coronary artery disease on angiography or CT, carotid plaque on ultrasound, or peripheral arterial disease). * Eligible for PCSK9 inhibitor therapy according to national clinical criteria * Fasting LDL cholesterol ≥2.5 mmol/L and ≤5.0 mmol/L at screening * Documented statin intolerance or contraindication to statin therapy * On stable background lipid-lowering therapy (including ezetimibe if applicable) for at least 4 weeks prior to enrollment * Able and willing to provide written informed consent Exclusion Criteria: * Eligibility for PCSK9 inhibitor therapy solely based on elevated lipoprotein(a) \>1000 mg/L with LDL-C below inclusion threshold * Prior use of any PCSK9 inhibitor (alirocumab, evolocumab or inclisiran) before enrollment * Planned initiation or modification of lipid-lowering therapy during the study period * Known homozygous familial hypercholesterolemia * Active liver disease or alanine aminotransferase (ALT) or aspartate aminotransferase (AST) \>3× upper limit of normal * Severe renal impairment (eGFR \<30 mL/min/1.73 m²) * Active malignancy or life expectancy \<1 year * Pregnancy, breastfeeding, or women of childbearing potential not using effective contraception * Known hypersensitivity to inclisiran, alirocumab, or any of their excipients * Participation in another interventional clinical trial within 30 days prior to enrollment * Any condition that, in the opinion of the investigator, would interfere with study participation or interpretation of results