What are the LDL (Low-Density Lipoprotein) targets for treatment?

LDL Targets for Treatment

For patients at very high cardiovascular risk, the recommended LDL-C goal is <1.8 mmol/L (70 mg/dL), or a reduction of at least 50% if the baseline LDL-C is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL). 1

Risk Stratification and LDL-C Goals

Very High-Risk Patients

• LDL-C goal of <1.8 mmol/L (<70 mg/dL) or a reduction of at least 50% if baseline LDL-C is between 1.8 and 3.5 mmol/L (70-135 mg/dL) 1
• For patients with recurrent cardiovascular events despite maximum tolerated statin-based therapy, an even lower LDL-C goal of <1.0 mmol/L (40 mg/dL) may be considered 2
• Very high-risk category includes patients with documented cardiovascular disease (CVD), diabetes with target organ damage, severe chronic kidney disease, or a calculated SCORE risk ≥10% 1

High-Risk Patients

• LDL-C goal of <2.6 mmol/L (<100 mg/dL) or a reduction of at least 50% if baseline LDL-C is between 2.6 and 5.2 mmol/L (100-200 mg/dL) 1
• High-risk category includes patients with markedly elevated single risk factors, diabetes without target organ damage, or a calculated SCORE risk of ≥5% to <10% 1

Moderately High-Risk Patients

• LDL-C goal of <2.6 mmol/L (<100 mg/dL) is a therapeutic option 1
• Traditional recommended goal is <3.0 mmol/L (<130 mg/dL) 1
• This category includes patients with 2+ risk factors and 10-year risk of 10-20% 1

Lower-Risk Categories

• For patients with moderate risk: LDL-C goal of <3.0 mmol/L (<115 mg/dL) 1
• For patients with low risk: LDL-C goal of <3.0 mmol/L (<116 mg/dL) 2

Treatment Approach

First-Line Therapy

• Statins are the first-line treatment to reach LDL-C goals 1
• Use the highest recommended dose or highest tolerable dose to reach the goal 1
• When LDL-lowering drug therapy is employed in high-risk or moderately high-risk persons, intensity should be sufficient to achieve at least a 30-40% reduction in LDL-C levels 1

Additional Therapeutic Considerations

• For patients with high triglycerides or low HDL-C, consider combining a fibrate or nicotinic acid with an LDL-lowering drug 1
• When triglycerides are ≥200 mg/dL, non-HDL-C becomes a secondary target of therapy, with a goal 30 mg/dL higher than the identified LDL-C goal 1
• Triglyceride goal of <150 mg/dL is recommended 3

Clinical Implementation Challenges

Treatment Gaps

• Despite guideline recommendations, many high-risk patients fail to achieve their LDL-C goals 4, 5
• Only 15.1% of very high-risk patients achieve LDL-C levels <70 mg/dL in real-world practice 6
• Suboptimal uptitration of statin dose is a major factor in failure to reach targets 6

Monitoring and Follow-up

• Regular lipid assessments should be performed to monitor treatment efficacy 3
• For patients on lipid-lowering therapy, more frequent monitoring is recommended 3
• For patients with low-risk lipid values, assessments may be repeated every 2 years 3

Special Populations

Patients with Diabetes

• For patients with type 2 diabetes and CVD or chronic kidney disease, the recommended LDL-C goal is <1.8 mmol/L (<70 mg/dL) 1
• Secondary goals include non-HDL-C <2.6 mmol/L (<100 mg/dL) and apoB <80 mg/dL 1
• For all patients with type 1 diabetes and those with microalbuminuria/renal disease, LDL-C lowering of at least 50% is recommended regardless of baseline LDL-C 1

Elderly Patients

• Treatment with statins is recommended for older adults with established CVD in the same way as for younger patients 1
• Clinical trials confirm that older persons benefit from therapeutic lowering of LDL-C 1

Familial Hypercholesterolemia

• Patients with familial hypercholesterolemia (FH) should be treated with intensive-dose statin, often in combination with ezetimibe 1
• FH should be suspected in patients with CHD before age 55 (men) or 60 (women), in subjects with relatives with premature CVD, tendon xanthomas, or severely elevated LDL-C (>5 mmol/L or 190 mg/dL in adults, >4 mmol/L or 150 mg/dL in children) 1

Pitfalls and Caveats

• Focusing solely on LDL-C without addressing other modifiable risk factors may lead to suboptimal outcomes 1
• Therapeutic lifestyle changes remain essential regardless of pharmacological therapy 1
• Combination therapy is underutilized in clinical practice despite potential benefits for patients with mixed dyslipidemia 5
• The vast majority of very high-risk patients do not achieve optional LDL-C goals, resulting in loss of clinical benefits 6, 7