Opinion
Video
Guideline Recommendations for LDL-C Management
Author(s):
Panelists discuss how evolving clinical guidelines for intensive low-density lipoprotein cholesterol (LDL-C)–lowering therapies have shaped personalized treatment approaches through risk stratification, with different targets for primary vs secondary prevention and consideration of genetic factors when determining appropriate statin intensity.
Video content above is prompted by the following:
Clinical Update: LDL-C–Lowering Therapies and Prescribing Guidelines
Recent Guideline Evolution
Recent years have witnessed significant shifts in LDL-C management guidelines, moving from specific numerical targets toward a risk-based approach. The 2018/2019 American College of Cardiology/American Heart Association guidelines and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines emphasize percentage reductions in LDL-C levels based on patient risk categories rather than fixed targets alone. This risk-stratified approach has led to more aggressive LDL-C level lowering in high-risk patients, with a greater use of combination therapies and nonstatin options such as PCSK9 inhibitors in appropriate cases.
Determining Individual LDL-C Level Goals
Individual LDL-C level goals are determined through:
- Comprehensive CV risk assessment (using tools such as the ASCVD [Atherosclerotic Cardiovascular Disease] Risk Estimator)
- Clinical ASCVD status
- Age and comorbidities
- Baseline LDL-C levels
- Response/tolerance to initial therapy
Primary vs Secondary Prevention Targets
Secondary Prevention (established ASCVD):
- Very high risk: greater than or equal to 50% LDL-C level reduction AND target of less than 55 mg/dL (less than 1.4 mmol/L)
- High risk: greater than or equal to 50% LDL-C level reduction AND target of less than 70 mg/dL (less than 1.8 mmol/L)
Primary Prevention:
- Low/moderate risk: less than 100 mg/dL (less than 2.6 mmol/L)
- High risk: less than 70 mg/dL (less than 1.8 mmol/L) or 30% to 50% reduction from baseline
- Family history of premature ASCVD may warrant more aggressive targets
Genetic Factors Impact
Family history of premature ASCVD or genetic disorders (such as familial hypercholesterolemia [FH]) significantly modify treatment targets:
- FH patients typically require more aggressive therapy regardless of calculated risk
- Cascade screening recommended for first-degree relatives
- Earlier initiation of therapy often warranted
- May necessitate combination therapy approach from treatment outset
Determining Statin Intensity
Selection between moderate- and high-intensity statin therapy is based on:
- Absolute ASCVD risk (greater than or equal to 7.5% prompts consideration as high intensity)
- Clinical ASCVD status (generally warrants high intensity)
- Baseline LDL-C level (higher levels may necessitate high intensity)
- Patient age (younger patients with longer life expectancy benefit more from aggressive therapy)
- Comorbidities (diabetes with target organ damage qualifies as higher intensity)
- Prior statin tolerance/response
- Potential drug-drug interactions
Current guidelines generally recommend high-intensity statins for most secondary prevention cases and high-risk primary prevention, with moderate-intensity statins appropriate for moderate-risk patients and those with contraindications to high-intensity therapy.
