Europe to US: Re-establish specific low density lipoprotein cholesterol targets because we all need them

Vasilios G. Athyros, Konstantinos Tziomalos, Asterios Karagiannis



The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines do not recommend specific low density lipoprotein cholesterol (LDL-C) targets in contrast to all other previous guidelines for the management of dyslipidemia. Instead, they recommend a ≥ 50% reduction in LDL-C in high risk patients and a 30-50% reduction in moderate risk patients with the administration of either high- or moderate-intensity statin therapy depending on the cardiovascular risk. These guidelines had several practical problems but the most important was the lack of specific LDL-C targets. The dogma “shoot and forget” is not applicable to everyone. In several cases of high risk patients, we need to know if LDL-C during treatment has reached a specific and desired level, so that we can add ezetimibe and/or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors if they have not reached that level. In patients with heterozygous familial hypercholesterolaemia (HeFH), who have very high baseline LDL-C levels, the 50% reduction is not enough to reach an acceptable level. In addition, in statin intolerant patients and in those high risk patients who do not adequately respond to combined treatment (statin plus ezetimibe) we need to add PCSK9 inhibitors that can further reduce LDL-C by 50-60% with a different mechanism of action than statins. Thus, there is a pressing need for a change in 2013 ACC/AHA guidelines towards adopting specific LDL-C goals so that rules are established for the administration of the expensive PCSK9 inhibitors only in those who need them. Otherwise, healthcare systems will not approve the use of PCSK9 inhibitors and that will cost a lot of lives.

Keywords: Dyslipidemia, LDL-C targets, statins, PCSK9 inhibitors