From the Guidelines
LDL (Low-Density Lipoprotein) is a type of cholesterol that, when elevated, increases the risk of heart disease and stroke, and its levels should be managed through lifestyle changes and, if necessary, medications to achieve a goal of below 100 mg/dL, as recommended by the most recent guidelines 1.
Definition and Risks of LDL
LDL transports cholesterol from the liver to cells throughout the body, but when present in excessive amounts, it can deposit cholesterol on artery walls, forming plaques that narrow blood vessels. High levels of LDL cholesterol are a major risk factor for coronary heart disease (CHD) and stroke, as documented in numerous studies, including those referenced in the National Cholesterol Education Program Adult Treatment Panel III guidelines 1.
Management of LDL Levels
Healthy LDL levels are generally considered to be below 100 mg/dL, with levels above 160 mg/dL considered high. Management of LDL levels can be achieved through lifestyle changes such as:
- Eating a diet low in saturated fats and trans fats
- Regular exercise
- Maintaining a healthy weight
- Avoiding smoking When lifestyle changes are not sufficient, medications like statins may be prescribed to lower LDL levels, as supported by evidence from clinical trials 1.
Importance of Cholesterol Screening
Regular cholesterol screening is important for identifying individuals with high LDL levels and for monitoring the effectiveness of lifestyle changes and medication therapy. Screening is typically recommended every 4-6 years for adults, with more frequent testing for those with risk factors or existing heart disease, as emphasized in the guidelines 1 and supported by more recent research on the benefits of early intervention in reducing cardiovascular risk 1.
From the Research
Definition of LDL
- Low-density lipoprotein cholesterol (LDL-C) is an important modifiable risk factor for atherosclerotic cardiovascular disease 2.
- LDL cholesterol is a major cardiovascular risk factor, and statins have been proven to effectively reduce the risk of atherosclerotic cardiovascular disease (ASCVD) and are recommended as a first-line therapy for the primary and secondary prevention of ASCVD 3.
Role of LDL in Cardiovascular Disease
- Dyslipidemia, highly elevated low-density lipoprotein (LDL) cholesterol, is a major cardiovascular risk factor 3.
- The percentage LDL-C reduction with statins, ezetimibe, and PCSK9 inhibition is not attenuated in patients starting with lower baseline LDL-C levels and is 6.6% greater for PCSK9 inhibition 2.
Treatment of High LDL Levels
- Statin therapy reduces low-density lipoprotein (LDL) cholesterol levels and the risk of cardiovascular events, but whether the addition of ezetimibe, a nonstatin drug that reduces intestinal cholesterol absorption, can reduce the rate of cardiovascular events further is not known 4.
- The combination of simvastatin and ezetimibe resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes 4.
- Adding ezetimibe to statin consistently reduced the risk for cardiovascular events in post-acute coronary syndrome patients irrespective of baseline LDL-C values, supporting the use of intensive lipid-lowering therapy with ezetimibe even in patients with baseline LDL-C <70 mg/dL 5.
Alternatives to Statins for Lowering LDL
- The main alternatives to statins are ezetimibe, the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, evolocumab, alirocumab, and inclisiran, and the recently approved bempedoic acid 6.
- These alternatives have all shown an excellent safety profile and have not been associated with skeletal muscle symptoms or with increased risk of new onset diabetes and they have no major drug interactions 6.