From the Guidelines
The current guidelines for LDL management in patients with both coronary artery disease (CAD) and diabetes mellitus (DM) recommend lowering LDL-C to <1.4 mmol/L (<55 mg/dL) and reducing 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 goal, statin treatment must be considered, irrespective of low-density lipoprotein cholesterol (LDL-C) levels, as patients with established CAD are regarded as being at very high risk for cardiovascular events. Some key points to consider in the management of LDL in patients with CAD and DM include:
- Dyslipidaemia should be managed with pharmacological and lifestyle intervention, according to lipid guidelines 1.
- When the target LDL-C level cannot be achieved with statin therapy alone, the addition of ezetimibe has been demonstrated to decrease cholesterol and cardiovascular events in post-ACS patients, and in patients with diabetes 1.
- The goal of treatment is to reduce the risk of cardiovascular events, and a more aggressive approach to lipid lowering is justified in patients with CAD and DM due to their high-risk status.
- Regular lipid monitoring every 3-6 months is essential until targets are reached, then annually thereafter.
- High-intensity statins, such as atorvastatin or rosuvastatin, are the first-line therapy, and PCSK9 inhibitors, such as evolocumab or alirocumab, can be added if LDL goals are not achieved with maximum tolerated statin therapy and ezetimibe. The management of LDL in patients with CAD and DM requires a comprehensive approach that takes into account the patient's individual risk factors and medical history, with the goal of reducing the risk of cardiovascular events and improving overall outcomes.
From the Research
New Low-Density Lipoprotein (LDL) Guidelines for Coronary Artery Disease (CAD) in Patients with Diabetes Mellitus (DM)
- The current guidelines recommend a serum LDL cholesterol <70 mg/dl for patients at very high risk, including those with coronary arterial disease (CAD) or type 2 diabetes (T2DM) 2.
- For patients with acute coronary syndrome (ACS) and diabetes mellitus, a lower target of <55 mg/dL is recommended 3.
- The treatment goal of LDL-C is < 70 mg/dL for patients with ACS or stable CAD, with a secondary target of non-high-density lipoprotein cholesterol (non-HDL-C) < 100 mg/dL for patients with a triglyceride level > 200 mg/dL 3.
- Statins are usually the first-line therapy, with moderate or high intensity statins preferred, and up-titration to the highest recommended and tolerable dose to reach the target is necessary 3.
- Combination therapy with statins and other lipid-lowering drugs, such as ezetimibe, can also be considered to achieve the target LDL-C level 4.
- The presence of diabetes is an independent predictor for reaching the LDL cholesterol treatment goal, and intense insulin therapy might be needed for glycemic control, and high-dose statin therapy might be needed for lipid control 2, 5.