From the Guidelines
For patients at high risk, the target LDL cholesterol level is generally less than 100 mg/dL (2.6 mmol/L), or a reduction of at least 50% if the baseline LDL-C is between 2.6 and 5.1 mmol/L (100 and 200 mg/dL), as recommended by the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. High-risk patients typically include those with established cardiovascular disease, diabetes, moderate to severe renal disease, very high levels of individual risk factors, familial hypercholesterolaemia, or a high SCORE risk. To achieve these targets, lifestyle modifications including a heart-healthy diet, regular exercise, weight management, and smoking cessation are foundational. Medication therapy often includes statins, which are the usual first-line treatment to reach the LDL-C goal, and should be used up to the highest recommended dose or highest tolerable dose to reach the goal 1. If statins alone don't achieve the target, additional medications may be considered. Lower LDL targets are recommended for high-risk patients because LDL cholesterol directly contributes to atherosclerotic plaque formation, and research shows that aggressive LDL lowering significantly reduces the risk of cardiovascular events in these vulnerable populations. Some key points to consider in managing high-risk patients include:
- The importance of therapeutic lifestyle changes (TLC) in reducing cardiovascular risk through mechanisms beyond LDL lowering
- The consideration of combining a fibrate or nicotinic acid with an LDL-lowering drug in high-risk patients with high triglycerides or low HDL-C
- The potential benefits of achieving an LDL-C level <70 mg/dL in very high-risk patients, as supported by recent clinical trials 1.
From the FDA Drug Label
The NCEP treatment guidelines are summarized below. Definite Atherosclerotic Disease* Two or More Other Risk Factors† LDL-Cholesterol mg/dL (mmol/L) Initiation Level Goal No No ≥ 190 (4.9) < 160 (< 4. 1) No Yes ≥ 160 (4.1) < 130 (< 3.4) Yes Yes or No ≥ 130 (3.4) ≤ 100 (≤ ‑2. 6)
The target Low-Density Lipoprotein (LDL) level for patients at high risk is ≤ 100 mg/dL for those with definite atherosclerotic disease, and < 130 mg/dL for those with two or more other risk factors but no definite atherosclerotic disease 2.
From the Research
Target Low-Density Lipoprotein (LDL) Level for Patients at High Risk
- The target LDL cholesterol level for patients at high or very high risk is recommended to be 70 mg/dL, as stated in current guidelines 3.
- Epidemiologic studies and clinical trials have shown that achieving very low LDL cholesterol levels (lower than 70 mg/dL) is associated with a very low risk of cardiovascular disease 3.
- Analyses of randomized clinical trials have shown a greater benefit in reducing the risk of cardiovascular disease among those with very low achieved LDL (below 40 mg/dL) 3.
Achievement of Target LDL Levels
- According to a study published in 2015, only 17% of patients with coronary heart disease reached the target level of LDL-C <70 mg/dL 4.
- Another study published in 2011 found that only 15.1% of very high-risk patients with coronary heart disease had LDL-C levels of <70 mg/dL 5.
- A study published in 2018 reported that among patients at extreme cardiovascular risk, only 5.3% had LDL-C <55 mg/dL 6.
Treatment Options
- High-intensity statin therapy is associated with a higher rate of transaminase elevations, but no hepatic failure, a very small risk of myopathy, and an increased risk of developing diabetes 3.
- Switching to rosuvastatin has been shown to be an effective and safe therapeutic option for high-risk patients to achieve their lipid and apolipoprotein targets 7.