From the Guidelines
The American College of Cardiology (ACC) and European Society of Cardiology (ESC) recommend LDL-cholesterol targets based on cardiovascular risk categories, with the most aggressive goal being LDL-C <55 mg/dL for very high-risk patients, as stated in the 2019 ESC/EAS Cholesterol Guidelines 1. The guidelines emphasize the importance of individualized treatment approaches, considering the patient's cardiovascular risk profile.
- For very high-risk patients, the goal is LDL-C <55 mg/dL and at least a 50% reduction from baseline, as recommended by the 2019 ESC/EAS Cholesterol Guidelines 1.
- For high-risk patients, the target is LDL-C <70 mg/dL and at least a 50% reduction, according to the 2016 European Society of Cardiology (ESC) CVD prevention guidelines, as mentioned in 1. The treatment strategies typically involve the use of statins, ezetimibe, and PCSK9 inhibitors to achieve the recommended LDL-C targets.
- High-intensity statins, such as atorvastatin or rosuvastatin, are usually the first line of treatment for very high and high-risk patients.
- If targets are not achieved with maximum tolerated statin therapy, adding ezetimibe or a PCSK9 inhibitor may be necessary, as suggested by the 2018 AHA/ACC/Multi-society guidelines, referenced in 1. These recommendations are based on evidence that lower LDL-C levels correlate with reduced cardiovascular events, as LDL particles contribute directly to atherosclerotic plaque formation through endothelial damage and inflammatory processes, as discussed in the context of the 2019 ESC/EAS Cholesterol Guidelines 1.
From the Research
LDL Cholesterol Goals
The American College of Cardiology (ACC) and European Society of Cardiology (ESC) guidelines recommend the following LDL cholesterol goals:
- For patients at high or very high cardiovascular risk, the goal is to achieve an LDL cholesterol level of less than 70 mg/dL 2
- For patients at extreme cardiovascular risk, the goal is to achieve an LDL cholesterol level of less than 55 mg/dL 3
- Some studies suggest that achieving an LDL cholesterol level of less than 55 mg/dL may be beneficial for patients with a very high cardiovascular risk, as it is associated with a lower risk of cardiovascular events and mortality 4
Achieving LDL Cholesterol Goals
The achievement of LDL cholesterol goals can be challenging, especially for patients with diabetes or those who are at high or very high cardiovascular risk:
- Only a small percentage of patients with a very high cardiovascular risk are able to achieve an LDL cholesterol level of less than 55 mg/dL, even with high-dose statin therapy 4
- Many patients with diabetes and cardiovascular disease may require more than two lipid-lowering drugs to achieve an LDL cholesterol level of less than 70 mg/dL 5
- The use of combination therapy, including statins, ezetimibe, and PCSK9 inhibitors, may be necessary to achieve LDL cholesterol goals in patients at extreme cardiovascular risk 3