What is the target low-density lipoprotein (LDL) level for an elderly patient with hypertension (HTN) and multiple risk factors for cardiovascular disease?

Target LDL for Elderly Patient with Hypertension and Multiple Risk Factors

For an elderly patient with hypertension and multiple cardiovascular risk factors, the target LDL should be less than 1.4 mmol/L (55 mg/dL), which corresponds to "Less than 2" in the options provided, assuming the units are mmol/L.

Risk Stratification Determines LDL Target

The most critical step is determining whether this patient qualifies as "very high cardiovascular risk" based on their risk profile 1:

• Very high risk criteria include: established atherosclerotic cardiovascular disease, diabetes with target organ damage or multiple risk factors, hypertension with multiple cardiovascular risk factors, or calculated 10-year cardiovascular disease risk >20% 1
• For patients with Type 2 diabetes at very high cardiovascular risk, an LDL-C target of <1.4 mmol/L (<55 mg/dL) and LDL-C reduction of at least 50% is recommended 1
• A secondary goal of non-HDL-C <2.2 mmol/L (<85 mg/dL) should also be targeted in very high-risk patients 1

Age Does Not Diminish the Importance of LDL Control

Contrary to historical assumptions, elderly patients aged 70-100 years with elevated LDL cholesterol have the highest absolute risk of myocardial infarction and atherosclerotic cardiovascular disease 2:

• Risk of myocardial infarction per 1.0 mmol/L increase in LDL cholesterol was particularly amplified in those aged 70-100 years 2
• The number needed to treat in 5 years to prevent one cardiovascular event was lowest for individuals aged 70-100 years, meaning elderly patients derive the greatest absolute benefit from LDL reduction 2
• Myocardial infarction and atherosclerotic cardiovascular disease events per 1000 person-years were highest in individuals aged 70-100 years 2

Treatment Approach to Achieve Target

Statins are recommended as first-choice lipid-lowering treatment, with intensity defined by the patient's cardiovascular risk profile and target LDL-C levels 1:

• If target LDL-C is not reached with maximal tolerated statin dose, combination therapy with ezetimibe is recommended 1
• In patients at very high cardiovascular risk with persistent high LDL-C despite maximal tolerated statin plus ezetimibe, or in patients with statin intolerance, a PCSK9 inhibitor is recommended 1

Important Caveats for Elderly Patients

While aggressive LDL lowering is beneficial, treatment must be individualized based on tolerability 1:

• Blood pressure management should target systolic BP of 130-139 mmHg in older patients (aged ≥65 years), with 140-150 mmHg acceptable if lower targets are not tolerated 1
• Diastolic BP should be targeted to <80 mmHg but not <70 mmHg to avoid compromising coronary perfusion 1
• The combination of hypertension and dyslipidemia requires aggressive management of both risk factors, as they often coexist and synergistically increase cardiovascular risk 3

Real-World Achievement Gap

Current data show that approximately 75% of patients at very high cardiovascular risk fail to reach their risk-based LDL-C targets in real-world practice 3:

• Only 25.1% of very high-risk patients achieved their LDL-C goals in a recent Spanish cohort 3
• Simultaneous control of LDL-C and blood pressure was achieved in only 8.8% of patients with both conditions 3
• This highlights the need for more intensive treatment strategies in clinical practice 3