By Ahmed El-Medany
Guidelines for the management of dyslipidaemia from the ESC and the EAS were updated in late 2019. With the advent of combination therapy using ezetimibe and/or proprotein convertase subtilisin/kexin type 9 inhibitors in addition to statins, the routine attainment of extremely low LDL-C levels in the clinic has become a reality.
This helpful and thorough review by Packard et al discusses the evidence that led to the most aggressive goals yet for LDL-C lowering, and explores a case-based interpretation of the practicality of intensive LDL-C lowering.
Figure 1. Case 1 is a patient with probable FH on the basis of his high LDL-C and sibling with diagnosed FH. Note, the additional 6% reduction on 40 mg rosuvastatin is based on the untreated LDL-C of 5.1 mmol/L; the 20% drop on ezetimibe is calculated from the LDL-C on 20 mg rosuvastatin. Case 2 is a woman with obesity, type 2 diabetes plus other risk factors (hypertension) with symptomatic ASCVD. Case 3 is a man with hypertension with repeat ASCVD events within a short time period (26 months).
Figure 2. Schematic showing rationale for intensive LDL-C lowering. The outer circle represents patients at ‘high risk’ with an LDL-C goal of below 1.8 mmol/L (70 mg/dL). Evidence of established disease, comorbidities, cardiometabolic disorders and multiple risk factors moves patients into the ‘very high’ risk middle circle, with a more ambitious target of below 1.4 mmol/L (55 mg/dL). The most stringent goal of below 1.0 mmol/L (40 mg/dL) is recommended for those with a particularly aggressive disease
More here: https://heart.bmj.com/content/early/2021/03/31/heartjnl-2020-318760
Packard C, Chapman MJ, Sibartie M, Laufs U, Masana L. Intensive low-density lipoprotein cholesterol lowering in cardiovascular disease prevention: opportunities and challenges. Heart. 2021 Mar 31. (Figures taken from Packard et al, 2021)
