From the Guidelines
For patients with coronary artery disease (CAD), the target LDL cholesterol level should be below 55 mg/dL (1.4 mmol/L) for very high-risk patients, as recommended by the most recent guidelines 1. The goal of treatment is to lower LDL-C to <1.4 mmol/L (<55 mg/dL) and to reduce it by at least 50% if the baseline LDL-C level is 1.8-3.5 mmol/L (70-135 mg/dL) 1. When this level cannot be achieved, the addition of ezetimibe has been demonstrated to decrease cholesterol and cardiovascular events in post-ACS patients, and in patients with diabetes 1. Statin treatment must be considered, irrespective of low-density lipoprotein cholesterol (LDL-C) levels, and the goal is to lower LDL-C to <1.4 mmol/L (<55 mg/dL) 1. Some key points to consider when managing LDL levels in CAD patients include:
- Using statins as the primary treatment to reach the LDL-C goal, up to the highest recommended dose or highest tolerable dose to reach the goal 1
- Considering the addition of other lipid-lowering agents, such as ezetimibe, if the target LDL level cannot be achieved with statins alone 1
- Monitoring LDL levels closely, with regular lipid panel testing (every 3-6 months), to ensure that the target levels are being maintained 1
- Never reducing or stopping statin treatment without medical supervision, as this could increase the risk of heart attack or stroke 1. The 2019 ESC/EAS Cholesterol Guidelines recommended lowering LDL-C to <55 mg/dL in very high-risk patients for both primary and secondary prevention (Class I recommendation) and to <40 mg/dL in patients experiencing a second vascular event within 2 years (Class IIb) 1. It's also important to note that the European Society of Cardiology (ESC) guidelines recommend measuring Lipoprotein(a) [Lp(a)] in patients at high risk of cardiovascular disease (CVD) and to target levels below 50 1. Overall, the management of LDL levels in CAD patients requires a comprehensive approach that includes lifestyle modifications, statin therapy, and regular monitoring to ensure that target levels are being maintained.
From the Research
LDL Cholesterol Goals in CAD Patients
The recommended LDL cholesterol goal for patients with coronary artery disease (CAD) varies, but most guidelines suggest a target of less than 70 mg/dl for those at very high risk.
- According to 2, current guidelines recommend serum LDL cholesterol <70 mg/dl for patients at very high risk, in particular for those with CAD or type 2 diabetes.
- A study published in 3 found that the majority of patients (92.4%) who attained a LDL-C goal of less than 70 mg/dl were receiving statin monotherapy or in combination.
- Another study 4 reported that only 35% of patients with CAD achieved the more aggressive goal of <70 mg/dl, while 79% achieved the minimal LDL cholesterol goal of 100 mg/dl.
Factors Associated with Achieving LDL Cholesterol Goals
Several factors are associated with achieving LDL cholesterol goals in CAD patients, including:
- Male gender and presence of diabetes, which were independent predictors for reaching the LDL cholesterol treatment goal of <70 mg/dl, as reported in 2.
- Statin treatment, which was found to be a predictor of LDL-C <70 mg/dl in 5.
- Use of high-intensity statin combined with ezetimibe, which may be necessary to bridge the treatment gap, as suggested in 6.
Prognostic Impact of Reaching LDL Cholesterol Goals
Reaching LDL cholesterol goals has a significant prognostic impact in CAD patients:
- A study published in 5 found that patients who reached their LDL-C goal of <70 mg/dl had the lowest risk of cardiovascular events.
- The adjusted hazard ratio for the composite endpoint (cardiovascular death, myocardial infarction, ischemic stroke or coronary revascularization) was 1.31 for LDL-C ≥70 mg/dl versus <70 mg/dl, as reported in 5.