From the Guidelines
LDL cholesterol targets should be set based on cardiovascular risk categories, with very high-risk patients aiming for <70 mg/dL, high-risk patients for <100 mg/dL, and moderate-risk patients for <130 mg/dL, as recommended by the most recent guidelines 1.
Risk-Based Targets
The following targets are recommended:
- Very high-risk patients: <70 mg/dL or at least a 50% reduction from baseline
- High-risk patients: <100 mg/dL or at least a 50% reduction from baseline
- Moderate-risk patients: <130 mg/dL
Treatment Approach
Treatment typically begins with lifestyle modifications, including a Mediterranean diet, regular exercise, weight management, and smoking cessation. If targets aren't achieved, statins are the first-line medication, starting with moderate-intensity and escalating to high-intensity if needed. For patients not reaching targets on maximum tolerated statins, ezetimibe 10 mg daily can be added, followed by PCSK9 inhibitors (evolocumab or alirocumab) in very high-risk patients, as supported by recent clinical trials 1.
Key Considerations
- LDL-C should be used as the primary lipid analysis for screening, risk estimation, diagnosis, and management 1.
- A statin is the usual first-line treatment to reach the LDL-C goal and should be used up to the highest recommended dose or highest tolerable dose to reach the goal 1.
- High-dose statins should be given early after admission in all acute coronary syndrome patients without contraindication or a history of intolerance, regardless of initial LDL-C values 1.
From the Research
LDL Target According to Risk
The LDL target according to risk can be summarized as follows:
- For very high-risk patients, the target LDL level is <70 mg/dl 2, 3
- For high-risk patients, the target LDL level is <100 mg/dl 2, 4
- Achieving LDL cholesterol target levels <1.81 mmol/L (<70 mg/dl) may provide extra cardiovascular protection in patients at high risk 5
Factors Influencing LDL Target Achievement
The following factors influence the achievement of LDL targets:
- Use of intensive lipid-lowering medication, which is associated with a 12-fold higher possibility of achieving LDL-C levels of <70 mg/dl 2
- Combination therapy with additional LDL-C lowering drugs, such as ezetimibe, bile acid sequestrants, or fibrates, for patients who do not reach the LDL-C target 4
- Use of PCSK9 inhibitors, which can reduce LDL-C by 50-60% above that achieved by statin therapy alone 6
Clinical Benefits of Achieving LDL Targets
The clinical benefits of achieving LDL targets include:
- Reduced risk of cardiovascular events, such as ischemic stroke, myocardial infarction, and death resulting from vascular disease 2, 3, 5
- Improved prognosis for very high-risk stable coronary patients 2
- Reduced risk of subsequent stroke and other major vascular events in patients with and without diabetes 3