Goal LDL for a 72-Year-Old with CAD
For a 72-year-old patient with established coronary artery disease, the primary LDL-C goal is <70 mg/dL, with a more aggressive target of <55 mg/dL representing the optimal evidence-based goal for very high-risk patients. 1
Primary Treatment Target
LDL-C <70 mg/dL is the minimum goal for all patients with established CAD, as this threshold has been demonstrated in angiographic and intravascular ultrasound studies to arrest or reverse atherosclerosis progression 1
LDL-C <55 mg/dL is the current gold standard target recommended by the American College of Cardiology for patients with coronary heart disease, representing the most aggressive evidence-based goal 1, 2
The 2011 AHA/ACCF guidelines established that it is reasonable to treat to LDL-C <70 mg/dL in patients at highest risk, with benefits proportional to the degree of LDL-C reduction 3
Age Considerations
Age 72 does not modify these targets—older persons have been confirmed to benefit from therapeutic lowering of LDL-C in multiple clinical trials 3
The evidence supporting aggressive LDL-lowering extends to elderly patients with established atherosclerotic disease 3
Treatment Algorithm to Achieve Goals
Step 1: Initiate high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) to achieve ≥50% LDL-C reduction from baseline 1, 2
Step 2: If LDL-C remains ≥70 mg/dL after maximally tolerated statin dose, add ezetimibe 10 mg daily 1, 2
Step 3: If LDL-C still >55-70 mg/dL on statin plus ezetimibe, add a PCSK9 inhibitor (evolocumab, alirocumab, or inclisiran) 1, 2
Step 4: Consider bempedoic acid as an alternative or addition if statins are not tolerated or targets remain unmet 1
Evidence Supporting Lower Targets
The PROVE-IT trial demonstrated that achieving median LDL-C of 62 mg/dL with high-dose atorvastatin resulted in a 16% reduction in major cardiovascular events compared to achieving 95 mg/dL 3, 1
Clinical trials have shown continuous cardiovascular benefit with no lower threshold—patients achieving LDL-C <25 mg/dL demonstrate ongoing risk reduction without safety concerns 1
When baseline LDL-C is very high and the <70 mg/dL target cannot be achieved, aim for at least a 50% reduction in LDL-C levels 3
Secondary Lipid Targets
If triglycerides ≥200 mg/dL, use non-HDL-C as a secondary target with goal <100 mg/dL (calculated as total cholesterol minus HDL-C) 3, 2
Consider adding a fibrate or nicotinic acid to LDL-lowering therapy when triglycerides are elevated or HDL-C is low (<40 mg/dL) 3
Common Pitfalls to Avoid
Undertreating due to age concerns: The evidence clearly supports aggressive lipid-lowering in older adults with CAD 3
Stopping at the <100 mg/dL goal: This older target has been superseded by more aggressive goals of <70 mg/dL or <55 mg/dL for established CAD 1, 2
Failing to uptitrate or add combination therapy: Studies show only 15-35% of very high-risk patients achieve optimal LDL-C goals, primarily due to suboptimal medication intensification 4, 5, 6
Not monitoring LDL-C levels: Patients with more frequent LDL-C measurements achieve significantly lower levels and higher goal attainment rates 5