As a cardiovascular pharmacist, there is an ongoing debate regarding the necessity of aiming for a specific LDL goal. For over a decade, the focus has been on using target DOSES of statins shown to reduce CV risk, rather than titrating to an LDL goal. But there’s been a shift toward a blended approach in recent years. Data comparing specific LDL targets are limited. But statins reduce CV risk even with a baseline LDL under 70 mg/dL. Plus adding ezetimibe or a PCSK9 inhibitor (Praluent, Repatha) for statin patients at very high CV risk, while lowering LDL to about 55 mg/dL or less, can further reduce CV risk.
Continue to start a statin at target intensity, then recheck an LDL 4 to 12 weeks later and at least once a year. Generally, think of the mantra “lower is better”, especially for patients at very high CV risk, such as with multiple CV events. Consider the framework below, and use shared decision-making based on CV risk, patient preferences, etc.
| Table (1). Shared decision-making based on CV risk, patient preferences | ||
|---|---|---|
| Cardiovascular Risk | Selected Examples | Target LDL Reduction |
| Very High | Multiple CV events OR Prior CV event + multiple risks (diabetes, smoking, etc) |
≥ 50% AND < 55 mg/dL |
| High | Prior CV event, but not very high risk OR 10-year CV risk ≥ 20% |
≥ 50% AND < 70 mg/dL |
| Intermediate | 10-year CV risk 7.5% to < 20% | ≥ 30% AND < 100 mg/dL |
If LDL stays above these targets, evaluate adherence to lifestyle changes and the statin, and address any statin concerns. Weigh adding a non-statin if that’s not enough, especially for patients at very high CV risk. But don’t add a non-statin in most lower-risk patients, those withOUT CV disease and 10-year CV risk less than 20%. Usually lean toward adding ezetimibe (Choletimb, etc) first. It reduces CV events in some high-risk patients also on a statin, lowers LDL another 20% or so when added to a statin.
Or consider adding an injectable PCSK9 inhibitor. These reduce CV events in high-risk patients on a statin, and lower LDL another 50% or so. But they cost about (15600 L.E/month ~ $550/month). Avoid jumping to other non-statins (fibrates, etc), these aren’t shown to improve CV outcomes with an optimized statin. Don’t worry about “too low” LDL. Long-term PCSK9 inhibitor data link LDL under 40 mg/dL with lower CV risk, without safety concerns.
REFERENCES
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Medication pricing by DrugEye Mobile app, accessed June 2023