From the Guidelines
The recommended LDL cholesterol level before a myocardial infarction is generally less than 100 mg/dL for individuals at high risk for cardiovascular disease, and after a myocardial infarction, the target LDL level becomes more aggressive, with guidelines recommending levels below 55 mg/dL for very high-risk patients. According to the most recent guidelines, as outlined in the 2024 recommendations on the optimal use of lipid-lowering therapy in established atherosclerotic cardiovascular disease and following acute coronary syndromes 1, the goal is to achieve LDL-C values of < 55 mg/dL (< 1.4 mmol/L) after a myocardial infarction. This can be achieved through high-intensity statin therapy, such as atorvastatin or rosuvastatin, and if necessary, the addition of ezetimibe or a PCSK9 inhibitor. Some key points to consider in managing LDL levels include:
- The use of potent statins, such as atorvastatin or rosuvastatin, as the primary treatment for lowering LDL-C levels 1
- The addition of ezetimibe if LDL-C goals are not achieved with statin therapy alone 1
- The consideration of PCSK9 inhibitors for patients who still do not achieve LDL-C goals despite maximally tolerated statin and ezetimibe therapy 1
- The importance of lifestyle changes, including a healthy diet and regular physical activity, in addition to medication therapy 1 It's also important to note that the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation recommend an LDL-C reduction of at least 50% from baseline and an LDL-C goal <1.4 mmol/L (<55 mg/dL) for patients at very high cardiovascular risk 1. Overall, the management of LDL levels is a critical component of cardiovascular disease prevention and treatment, and should be tailored to the individual patient's risk factors and medical history.
From the FDA Drug Label
The median [Q1, Q3] LDL-C at baseline was 92 80, 109 mg/dL; the mean (SD) was 98 (28) mg/dL. At Week 48, the median [Q1, Q3] LDL-C was 26 15, 46 mg/dL in the REPATHA group, with 47% of patients having LDL-C < 25 mg/dL.
The guideline-recommended LDL level before a myocardial infarction is not explicitly stated in the provided text. However, the baseline LDL-C level in the study was 92 80, 109 mg/dL. After a myocardial infarction, the study aimed to reduce LDL-C levels, achieving a median of 26 15, 46 mg/dL at Week 48, with 47% of patients having LDL-C < 25 mg/dL 2.
- Key points:
From the Research
Guideline-Recommended LDL Levels
- Before a myocardial infarction, the recommended LDL level is less than 2.5 mmol/L (97 mg/dl) or less than 1.81 mmol/L (70 mg/dl) for high-risk patients 3.
- After a myocardial infarction, the recommended LDL level is less than 1.8 mmol/L 4.
- For patients with acute coronary syndrome (ACS) or recent myocardial infarction, the recommended LDL level is less than 1.81 mmol/L (70 mg/dl) 3, 4.
LDL Level Reduction
- Statins can reduce LDL levels by 50-60% above that achieved by statin therapy alone 5.
- PCSK9 inhibitors can reduce LDL levels by 50-60% above that achieved by statin therapy alone 5.
- Rosuvastatin 10 mg can lower mean cholesterol more effectively than simvastatin 40 mg and achieve better results for the latest, more stringent, ESC target 3.
Cardiovascular Risk
- High-risk patients with ASCVD and above-threshold LDL-C levels have a substantial incidence of recurrent CV events 4.
- Elevated LDL cholesterol is associated with increased risk of myocardial infarction and atherosclerotic cardiovascular disease in individuals aged 70-100 years 6.
- The risk of myocardial infarction and atherosclerotic cardiovascular disease is amplified for all age groups, particularly those aged 70-100 years, per 1.0 mmol/L increase in LDL cholesterol 6.