News & Perspective

Unmet LDL-C goals common in atherosclerotic cardiovascular disease

4 months ago, OP Editor

Hyperlipidemia is a condition associated with high morbidity and mortality.1 It has both a high incidence and prevalence rate in Hong Kong.1 Low-density lipoprotein cholesterol (LDL-C) has been implicated in the pathogenesis of atherosclerotic plaques, and their clinical sequelae including coronary heart disease.2 Lipid-lowering therapies (LLTs), such as statins, have led to major reductions in the risks of having an atherosclerotic cardiovascular disease (ASCVD) event.3 However, recent studies have demonstrated that lipid lowering for the secondary prevention of cardiovascular disease (CVD) events in patients with ASCVD needs improvement, with gaps in the achievement of guideline-recommended LDL-C goals.4,5 The study results were published in the Journal of the American College of Cardiology and presented at the American Heart Association Scientific Sessions 2019.4,5

CVD is responsible for over 4 million deaths in Europe each year.6 The prevalence of high cholesterol for those aged 15 to 84 was 49.5% in a population health survey conducted in Hong Kong in 2014/15.1 The 2019 European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) recommend a LDL-C goal of <55mg/dL in patients at very high risk of a cardiovascular event.6 For those at high risk, a LDL-C goal of <70mg/dL is recommended.6 Two recent studies analyzing the PINNACLE registry and National Health and Nutrition Examination Survey (NHANES) data have concluded that despite LLT, large gaps still exist in guideline recommended LDL-C goal achievement in ASCVD patients.4,5

Allen et al. examined patients enrolled in the PINNACLE national outpatient registry during 2017-2018 for patterns of LDL-C goal achievement and LLT treatment in adults.5 Of all the ASCVD patients in the registry (n=2,585,931), 52.7% had no history of LLT use, with 71.9% not meeting the LDL-goal.5 Among the subgroup receiving only statins, 68.1% did not achieve their LDL-C goal of <70mg/dL.5 Only 41.7% of patients receiving statin monotherapy achieved a LDL-C level between 70 and 100mg/dL. The study found that younger patients (18-64 years old), females, and African Americans were likely to achieve LDL-C <70mg/dL while on statin therapy.5

Patel et al. analysed the trends in lipid and lipoprotein levels amongst U.S. adults from NHANES between 2005 and 2006, and 2015 and 2016.4 A total of 32,278 participants aged ≥20 years were assessed in the two survey cycles. The age-adjusted mean total cholesterol, triglycerides, and LDL-C levels were found to have declined among U.S. adults from 2005-2006 through 2015-2016.4 Among adults taking LLT, the age-adjusted mean LDL-C decreased from 122mg/dL in 2005-2006, to 107mg/dL in 2013-2014.4 It declined further to 101mg/dL in 2015-2016.4 The proportion of statin use within patients with ASCVD risk ≥7.5% was approximately ~30%.4

From these two analyses, it is clear that majority of those receiving LLT do not reach LDL-C goals of <70mg/dL or <100mg/dL.4,5 Allen et. al concluded that future studies should examine barriers and activators for change, and factors associated with achieving standards-based care goals.5 The 2019 ESC/EAS guidelines recommend ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors to be added to the treatment regimen if patients do not achieve their LDL-C goals.6 It also stresses that the highest-risk patients should achieve the largest LDL-C reductions as possible, and that to date, there are no known adverse effects of very low LDL-C concentrations.6

1. Cheung DC. Outcomes of a clinical audit of hyperlipidaemia in a Hong Kong general outpatient clinic. HK Pract. 2018;40(4):101-108.

2. Soran H et al. Evidence-based goals in LDL-C reduction. Clinical Research in Cardiology. 2017;106(4):237.

3. Barter PJ, Rye K-A. New Era of Lipid-Lowering Drugs. Pharmacological Reviews. 2016;68(2):458.

4. Patel N et al. Trends in Lipid, Lipoproteins, and Statin Use Among U.S. Adults: Impact of 2013 Cholesterol Guidelines. J Am Coll Cardiol. 2019;74(20):2525-2528.

5. Allen Joseph M et al. Abstract 12904: Assessing Low-Density Lipoprotein Cholesterol Risk in Secondary Prevention Patients Within The PINNACLE National Outpatient Registry. Circulation. 2019;140(Suppl_1):A12904-A12904.

6. Mach F et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular riskThe Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). Eur Heart J. 0(0):1-78.


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