From the Guidelines
For a diabetic patient with three-vessel coronary artery atherosclerosis on CT scan, the LDL cholesterol goal according to the most recent guidelines is less than 55 mg/dL (or less than 1.4 mmol/L). This patient falls into the very high-risk category for cardiovascular disease due to having both diabetes and established atherosclerotic cardiovascular disease. 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. To achieve this target, high-intensity statin therapy should be initiated, such as atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily. If the LDL goal cannot be achieved with maximum tolerated statin therapy alone, adding ezetimibe 10 mg daily should be considered as second-line therapy. For patients still not at goal, a PCSK9 inhibitor (evolocumab or alirocumab) may be added. Regular lipid panel monitoring is recommended every 3-6 months initially, then annually once stable. This aggressive LDL target is justified because diabetic patients with established coronary disease have significantly higher cardiovascular event rates, and lowering LDL cholesterol has been consistently shown to reduce major adverse cardiovascular events in this high-risk population.
Some key points to consider in managing this patient's lipid profile include:
- The importance of lifestyle modification, including reduction of saturated fat and cholesterol intake, weight loss (if indicated), and increases in dietary fiber and physical activity 1
- The use of lipid goals to guide residual risk discussions on follow-up among those with a clearly established risk of ASCVD, while making it explicitly clear that maximizing the statin dose is the first priority 1
- The potential benefits of adding non-statin agents, such as ezetimibe or PCSK9 inhibitors, to further lower LDL-C levels in patients who are not at goal with statin therapy alone 1
From the Research
LDL Goal in ADA Guidelines for Diabetic Patients with Three-Vessel Coronary Artery Atherosclerosis
- The American Diabetes Association (ADA) guidelines recommend an LDL goal of <100mg/dL (2.6mmol/l) for patients with documented cardiovascular disease (CVD) 2.
- For higher-risk patients, such as those with diabetes and three-vessel coronary artery atherosclerosis, the recommended LDL goal is <70mg/dL (1.8mmol/l) 2.
- High-intensity statin treatment is recommended to achieve these LDL goals, as it can halt the progression and induce regression of coronary atheromatous plaques while lowering CVD event rates 2, 3, 4.
- The use of nonstatin drugs, such as ezetimibe, bile acid sequestrants, or proprotein convertase subtilisin/kexin type 9 inhibitors, may also be considered for patients who require further LDL reduction 3.