From the Guidelines
For a diabetic patient with three-vessel coronary artery atherosclerosis on CT scan, the LDL cholesterol goal should be less than 1.4 mmol/L (<55 mg/dL) and a reduction of at least 50% if the baseline LDL-C level is 1.8-3.5 mmol/L (70-135 mg/dL). This patient has very high cardiovascular risk due to both diabetes and established coronary artery disease. According to the 2020 ESC guidelines for the management of acute coronary syndromes, statin treatment must be considered, irrespective of low-density lipoprotein cholesterol (LDL-C) levels 1. High-intensity statin therapy is recommended as first-line treatment.
- Key considerations for treatment include:
- The goal of treatment is to lower LDL-C to <1.4 mmol/L (<55 mg/dL) and to reduce it by at least 50% if the baseline LDL-C level is 1.8-3.5 mmol/L (70-135 mg/dL) 1
- When this level cannot be achieved, the addition of ezetimibe has been demonstrated to decrease cholesterol and cardiovascular events in post-ACS patients, and in patients with diabetes 1
- Treatment options may include:
- High-intensity statin therapy, such as atorvastatin or rosuvastatin
- Addition of ezetimibe if LDL goal is not achieved with maximum tolerated statin therapy
- Consideration of a PCSK9 inhibitor for patients still not at goal
- Regular lipid panel monitoring is essential to assess the effectiveness of treatment and adjust as needed, typically 4-12 weeks after starting or adjusting therapy, then every 3-12 months once stable. This aggressive LDL lowering approach is crucial because diabetic patients with coronary disease have significantly increased risk of cardiovascular events 1.
From the Research
Three Vessel Coronary Artery Atherosclerosis on a CT Scan for a Diabetic Patient
- The presence of three-vessel coronary artery atherosclerosis on a CT scan for a diabetic patient indicates a high risk of cardiovascular events 2, 3, 4.
- Studies have shown that coronary artery bypass grafting (CABG) may be a more effective treatment option for diabetic patients with multivessel coronary artery disease, including those with three-vessel disease, compared to percutaneous coronary intervention (PCI) or medical therapy alone 2, 4.
- However, the optimal treatment approach for diabetic patients with three-vessel coronary artery disease remains a subject of ongoing discussion and should be determined on a case-by-case basis, taking into account individual patient characteristics and preferences 3, 5.
LDL Goal for Diabetic Patients with Three-Vessel Coronary Artery Atherosclerosis
- Current guidelines recommend statin therapy for all patients with diabetes between the ages of 40 and 75, including those without cardiovascular disease, with the goal of reducing LDL cholesterol levels and preventing cardiovascular events 6.
- However, a more risk-based approach to statin therapy may be warranted, taking into account individual patient characteristics and risk factors, such as coronary artery calcium (CAC) scores 6.
- The use of CAC scores can help risk stratify patients with diabetes and inform decisions about statin therapy, with a CAC score of 0 potentially downgrading the estimated risk of a cardiovascular event 6.