From the Guidelines
Patients with established atherosclerotic cardiovascular disease (ASCVD), diabetes with multiple risk factors or target organ damage, familial hypercholesterolemia, and those at very high cardiovascular risk should have an LDL goal less than 70 mg/dL. This includes individuals with a history of heart attack, stroke, coronary artery disease, peripheral arterial disease, or those who have undergone coronary revascularization procedures. Additionally, patients with diabetes plus other risk factors such as hypertension, smoking, or family history of premature heart disease should target this lower LDL level 1. To achieve this goal, high-intensity statins like atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily are typically first-line therapy. If statins alone are insufficient, additional medications such as ezetimibe 10 mg daily or PCSK9 inhibitors (evolocumab or alirocumab) may be added 1. This aggressive LDL target is recommended because these patient populations have demonstrated significant reduction in cardiovascular events and mortality when LDL is maintained below this threshold, as lower LDL levels correlate with decreased plaque formation and progression in the arterial walls. Some key points to consider when managing these patients include:
- Using the SCORE calculator to assess risk and guide treatment decisions 1
- Considering the use of CAC scores to guide statin therapy in intermediate- or select borderline-risk individuals 1
- Using LDL-C targets or thresholds to guide treatment decisions, with a goal of <55 mg/dL for very high-risk patients and <70 mg/dL for high-risk patients 1
- Adding non-statin therapy, such as ezetimibe or PCSK9 inhibitors, to maximally tolerated statin therapy if LDL-C goals are not achieved 1.
From the Research
Patients Requiring LDL Goal Less Than 70
The following patients should have an LDL goal less than 70:
- Patients with very high cardiovascular risk, such as those with diabetes or peripheral artery disease 2
- Patients who have had a previous cardiovascular event, such as a heart attack or stroke 3
- Patients with highly elevated low-density lipoprotein (LDL) cholesterol levels 4
- Patients who are at extreme risk of cardiovascular events, and may benefit from an aggressive LDL-C-lowering approach 2
Specific LDL Targets
- For very high CV risk patients, the most recent European guidelines recommend an LDL-C reduction of at least 50% and a goal of <55 mg/dL or even <40 mg/dL 2
- Physiologically normal levels of low-density lipoprotein cholesterol (LDL-C) are in the 30- to 70-mg/dl range 3
- Current guidelines for cholesterol management recommend achieving an LDL-C level of about 30 to 50 mg/dl 3
Treatment Options
- Statins are the first-line therapy for reducing LDL-C levels, but may not be sufficient for all patients 4
- Ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors can be used in addition to statins to further reduce LDL-C levels 4, 5, 6
- PCSK9 inhibitors may be particularly useful for patients who are statin intolerant or have very high cardiovascular risk 5, 6