From the Research
The 2018 ACC/AHA cholesterol guideline does not specify numerical lipid targets or goals, instead adopting a risk-based approach focusing on percentage LDL-C reduction rather than achieving specific target numbers. This approach is based on the latest evidence from studies such as 1, which highlights the importance of individualized risk assessment and consideration of risk-enhancing factors in making treatment decisions.
Key Points
- For very high-risk ASCVD patients, the guideline recommends an initial LDL-C reduction of ≥50% using high-intensity statin therapy, as supported by studies such as 2.
- If LDL-C remains ≥70 mg/dL despite maximum statin therapy, adding ezetimibe is recommended, followed by PCSK9 inhibitors if needed, as outlined in studies such as 3 and 4.
- For primary prevention in patients with elevated risk, moderate to high-intensity statins are recommended to achieve 30-50% LDL-C reduction, as emphasized in studies such as 5.
Treatment Approach
The guideline's risk-based approach recognizes that the magnitude of LDL-C reduction correlates with cardiovascular risk reduction, and emphasizes the use of tools like the Pooled Cohort Equations to guide treatment decisions.
Considerations
- The use of PCSK9 inhibitors, such as alirocumab and evolocumab, has been shown to significantly reduce LDL-C levels and cardiovascular risk in high-risk patients, as demonstrated in studies such as 2 and 4.
- Ezetimibe, a cholesterol absorption inhibitor, can also be used to achieve additional LDL-C reduction, as outlined in studies such as 3 and 1.