What statistical measure should determine whether a patient with a low-density lipoprotein (LDL) level of 130 mg/dL should continue taking a lipid-lowering medication, considering the benefits and side effects after nearing the target value?

From the Guidelines

The correct option for determining whether a patient should continue taking a lipid-lowering medication when their LDL is around 130 mg/dL is the Number Needed to Treat (NNT) or Hazard Ratio, as these measures provide information about the relative risk reduction of cardiovascular events that can be achieved by continuing the medication compared to discontinuing it. When deciding whether to continue statin therapy or other lipid-lowering medications, clinicians should consider the hazard ratio or NNT to weigh the potential benefits (reduced cardiovascular events) against possible side effects, as seen in studies such as 1 and 1. Even when a patient is approaching but hasn't fully reached their target LDL level, the hazard ratio or NNT helps quantify the incremental benefit of continuing therapy. This is particularly important in primary and secondary prevention of cardiovascular disease, where the decision to continue medication should be based on the patient's overall risk profile rather than solely on whether they've reached an arbitrary LDL target.

Key Considerations

• The patient's overall risk profile, including the presence of other risk factors such as diabetes, hypertension, or family history of cardiovascular disease, should be taken into account when making decisions about continuing lipid-lowering therapy, as noted in 1 and 1.
• The potential benefits of continuing therapy, including reduced risk of cardiovascular events, should be weighed against the potential risks and side effects of the medication, as discussed in 1 and 1.
• The use of hazard ratio or NNT can help clinicians make informed decisions about continuing therapy, as these measures provide a quantitative estimate of the potential benefits and risks of treatment.

Relevant Guidelines

• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend that clinicians consider the patient's overall risk profile and the potential benefits and risks of therapy when making decisions about continuing lipid-lowering medication, as seen in 1 and 1.
• The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines recommend that clinicians consider the patient's LDL level, as well as other risk factors, when making decisions about continuing lipid-lowering therapy, as noted in 1 and 1.

From the Research

Determining Continuation of Lipid-Lowering Medication

To determine whether a patient with a low-density lipoprotein (LDL) level of 130 mg/dL should continue taking a lipid-lowering medication, several factors should be considered, including the benefits and side effects of the treatment.

• The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) recommendations suggest that patients at very high risk for coronary artery disease (CAD) benefit from treatment that lowers LDL cholesterol plasma levels to ≤70 mg/dL 2.
• A study published in the Journal of the American Heart Association found that many patients with atherosclerotic cardiovascular disease are unaware of their underlying disease risk, reasons for taking lipid-lowering medications, current LDL-C levels, or treatment goals 3.
• Research suggests that there may be an optimal LDL-C level, below which the incidence of cardiovascular events is no longer reduced. A subanalysis of the REAL-CAD study found that the risk of cardiovascular events decreased monotonically until the LDL-C level was lowered to 70 mg/dL, but when the level was further reduced, the risk was independent of LDL-C 4.
• A systematic review and individual patient data meta-analysis published in JAMA Cardiology found that an alternative LDL cholesterol-lowering strategy demonstrated comparable efficacy regarding 3-year death or cardiovascular events in patients with atherosclerotic cardiovascular disease, with an associated reduction in LDL cholesterol levels and risk for new-onset diabetes and intolerance 5.
• A review published in High Blood Pressure & Cardiovascular Prevention discusses the potential risks and benefits of reducing LDL-C to very low levels, highlighting the importance of considering individual patient factors and monitoring for potential adverse effects 6.

Statistical Measures for Decision-Making

The decision to continue lipid-lowering medication should be based on individual patient factors, including their LDL-C level, cardiovascular risk, and potential benefits and side effects of treatment.

• The LDL-C level of 130 mg/dL is above the recommended target of ≤70 mg/dL for patients at very high risk for CAD 2.
• The patient's cardiovascular risk profile and potential benefits of continued treatment should be considered in the decision-making process.
• Statistical measures such as the hazard ratio and confidence interval can be used to assess the efficacy and safety of lipid-lowering treatment 4, 5.