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Implementing LDL-C Lowering Therapy
Call to Action: The Importance of ASCVD Risk Assessment and Achieving Targets Through Personalized LDL-C–Lowering Treatment Plans

Released: April 05, 2024

Expiration: April 04, 2025

Ty J. Gluckman
Ty J. Gluckman, MD, MHA, FACC, FAHA, FASPC
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Key Takeaways

  • Many patients with or at risk for ASCVD are not (1) receiving guideline-recommended LDL-cholesterol–lowering therapy and (2) undergoing regular assessment of their lipids. As such, there is significant opportunity to help patients achieve their LDL-cholesterol goals to further reduce their cardiovascular risk. 

  • Although statins are the cornerstone of dyslipidemia management, many patients require nonstatin therapies to achieve treatment targets (percentage reduction in LDL-cholesterol and LDL-cholesterol goal).

  • Join us live in Boston on April 19 or via simulcast or go online for more coverage of hyperlipidemia from CCO.


Importance of Achieving LDL-C Targets to Reduce ASCVD Risk 
Research has consistently recognized hypercholesterolemia (elevated low-density lipoprotein cholesterol [LDL-C] in particular), as a significant contributor to atherosclerotic cardiovascular disease (ASCVD), which in turn, contributes to increased cardiovascular risk. Clinical ASCVD includes myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease, including aortic aneurysm.  

Lowering LDL-C to evidence-based targets remains a key goal in the primary and secondary prevention of ASCVD. Statins represent the cornerstone of LDL-C–lowering therapy, based on their reliable efficacy and general tolerability. On average, high-intensity statins, like atorvastatin 40-80 mg and rosuvastatin 20-40 mg, lower LDL-C by ≥50%, which can help many patients meet their goals. Despite consistent associated reduction in morbidity and mortality related to ASCVD, statins remain underutilized in all at-risk populations for whom they are recommended.  

Nonadherence to statin therapy is also associated with poor health outcomes, reduced quality of life, and increased healthcare costs. Unfortunately, this occurs frequently.  

More broadly, nonadherence to LDL-C–lowering therapy involves multiple factors, including issues related to access to care, having multiple healthcare professionals (HCPs), increased drug costs, and less than optimal counseling about the importance of lowering LDL-C levels. From a patient perspective, medication nonadherence can be because of fear of adverse effects, lack of education and motivation, treatment preferences, polypharmacy, conflicting comorbidities, caregiver participation, and healthcare disparities. To overcome these challenges, it is imperative that HCPs engage patients in shared decision-making to discuss the risks and benefits of LDL-C–lowering therapy. 

Other Lipid and Biomarker Considerations in Assessing ASCVD Risk 
While lowering LDL-C remains the primary lipid target, other lipids and cardiovascular risk factors may warrant consideration by HCPs. These include elevated levels of triglycerides (≥175 mg/dL), high-sensitivity C-reactive protein (≥2.0 mg/L), lipoprotein (a) (Lp[a]) (≥50 mg/dL), and apolipoprotein B (≥130 mg/dL), as well as a reduced ankle-brachial index (<0.9).  

Lp(a), in particular, has been identified as an important cardiovascular risk factor, independent of LDL-C levels. Even in patients able to achieve desirable LDL-C levels on statin therapy, elevated Lp(a) levels have been associated with residual cardiovascular risk.  

Current US guidance considers elevated Lp(a) concentrations (≥50 mg/dL) a risk-enhancing factor, favoring more aggressive risk factor management. Although there are currently no FDA-approved therapies targeting Lp(a) specifically, multiple therapies are under investigation.  

Guideline Recommendations for Hypercholesterolemia 
According to the 2018 AHA/ACC Blood Cholesterol guidelines, there are 4 key groups of patients with indications for LDL-C–lowering therapy, including:   

  • Patients with clinical ASCVD

  • Patients with severe primary hypercholesterolemia, defined by an LDL-C ≥190 mg/dL

  • Patients with type 2 diabetes, aged 40-75 years

  • Patients without ASCVD in those aged 40-75 years with certain risk factors (eg, cigarette smoking, hypertension) and an elevated calculated 10-year risk of ASCVD

In all of these patients, statin therapy should be offered at an intensity appropriate for their risk level and necessary to achieve their dual LDL-C goals (percentage reduction and level below the recommended treatment threshold). For patients unable to achieve their dual LDL-C goals, nonstatin agents are available, including ezetimibe, PCSK9 inhibitors (alirocumab, evolocumab, inclisiran), and bempedoic acid. These agents have varying mechanisms of action, pharmacologic characteristics, delivery methods and frequency of dosing, and effects on the lipid profile. 

Join Us for More on Hyperlipidemia! 

Get up to date and gain new insights on current guidelines and clinical trial results to provide the highest quality of personalized and evidence-based care to your patients with hypercholesterolemia by registering and joining us live in Boston or via simulcast on Friday, April 19. This exciting symposium titled “Staying on Target: Reducing CV Risk by Achieving LDL-C Targets With Statin and Nonstatin Therapies” will explore the latest evidence on the comprehensive management of hypercholesterolemia, including the importance of achieving LDL-C targets, understanding the importance of elevated Lp(a), optimally positioning all agents in the lipid armamentarium, and partnering with patients to reduce ASCVD risk. And of course, we will give you ample opportunity to ask us questions. We are looking forward to seeing you there or online!

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Poll

1.

What are the most common barriers to achieving LDL-C targets in your patients? (Choose all that apply)

2.

Which of the following nonstatin therapies do you prescribe to help patients meet their lipid-lowering goals? (Choose all that apply) 

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