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3yr
Cardiovascular Disease Risk Assessment & LDL-C Goal

Very high-risk patients with ASCVD are defined as having multiple major ASCVD events or one major ASCVD event and multiple other risk factors such as smoking, hypertension, diabetes, or persistent elevated LDL-C to name a few.1 While unclear exactly how many patients are considered very high-risk, separate studies show a range of 26-58% of ASCVD patients may be classified as very high-risk.2-3 The most recent ACC/AHA guideline recommends optimizing LDL-C management in very high-risk ASCVD patients with high-intensity statin therapy or maximally tolerated statin therapy.1 The guidelines further recommend using an LDL-C threshold of 70 mg/dL (1.8 mmol/L) in very high-risk ASCVD patients when considering the addition of nonstatins to statin therapy.1


  • What percentage of your own secondary prevention patients would you classify as being very high-risk?
  • Of those very high-risk patients, what percentage would you estimate are at goal utilizing statins alone?
  • Do you feel that 70 mg/dL LDL-C is low enough to prevent additional ASCVD events or do you target even lower? Should ACC/AHA LDL-C guidelines be adjusted to provide an LDL-C goal ≤55 mg/dL, similar to ESC4?

 

References:

  1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 73(24):3168-3209
  2. Sajja A, Li HF, Spinelli KJ, et al. A simplified approach to identification of risk status in patients with atherosclerotic cardiovascular disease. American Journal of Preventive Cardiology 2021; (7): 100187
  3. Colantonio LD, Shannon ED, Orroth KK, et al. Ischemic Event Rates in Very-High-Risk Adults. Journal of the American College of Cardiology, 2019; 74(20): 2496-2507
  4. Mach F, Baigent C, Catapano A, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). 2020; 41(1): 111–188
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  • 3yr
    approximately 50% of my pts are considered high risk, LDL goal for my pts with diabetes is <50, approximately 50% of my pts will reach the goal with statin monotherapy, i currently add zetia first, then PCSK9 inhibitor if LDLC is still not at goal
  • 3yr
    There are only a few patients who have their first ASCVD event in the absence of multiple risk factors -- I think perhaps only about 20%; meaning that virtually all (>80%) of patients who have had even a single ASCVD event are high risk by definition. A target of <70 is reasonable (I remember when that target was "just" 100) and achieved in perhaps half of high risk patients with full dose statins. Beyond that, the other half will need PCSK9's to reach that goal. I would tend to reach for PCSK9 after full dose statin without trying "marginal" therapies such as Zetia, etc. In terms of whether the goal should be <55, <35 or even 0 is a matter of risk/benefit/cost and my personal opinion is that the cost might start becoming unreasonable on a population basis as we start looking for numbers much less than 50, and I do worry (a little) about potential other side effects of pushing too hard.
  • 3yr
    About 60% are high-risk. Of those, 20% are meeting LDL goal. LDL goal of <70 is difficult to attain. I believe that prevention, living a healthy lifestyle and everything in moderation are keys to lowering CV risk factors.
  • 3yr
    Thanks, All, for your wonderful comments! What insight/advice could you provide to other clinicians on how to help your patients attain goal LDL-C levels?
  • 3yr
    ~ 35% probably are very high risk. Of those I think have seen ~40-50% at goal with statin alone (max tolerated); LDL<70 attainable and has lowered event rate well. Zetia, PCSK9I, and more recently Nexletol/Nexlizet added.
  • 3yr
    virtually 90% of americans are high risk hard to get pts to buy into prevention cost side effects road blocks from insurance to get pts to goal now that it is so low
  • 3yr
    I estimate 30% of my patients are at high risk and that 70mg/dl is good target to aim for reducing this high risk . In my practice 70% have achieved this hoal out of the patients with high rosk either through statin and ezetumibe combo( 70%) or psk9i plus statins 30%)
  • 3yr
    50 percent would be very high risk…about 40 percent can get to goal with statins alone
    I believe lower is better and try to get patients ldl below 55 utilizing zetia, PCSK9, and nexlitol/ nexlizet
  • 3yr
    a good 40-45% of our diabetic patients are at high risk for cardiovascular disease and events and many of our patients that see both cardiology and primary care are not maximized on their medication despite tolerability.
  • 3yr
    30-40 % pts can be considered high risk . LDL of 70 can be achieved with medication and life style modifications
  • 3yr
    In my practice, 60% of patients would meet the definition of high risk. It is surprising how frequently they are under treated by primary care doctors and how often patients feel that dietary and lifestyle modification along will get their lipids to goal.
    About 50% of my high risk patients are at goal. Of these, many either are intolerant of high dose statin or unable to afford the addition of PCSK9 meds.
    The PCSK9 trials have taught us that there is no such thing as an LDL that is too low. Those with an LDL of 30 fared better than those with an LDL of 70. I would recommend that US guidelines adopt a target of <50 for high risk patients.
  • 3yr
    about 60-65% are considered high CV risk
    about 35-40% will achieve goal with statin alnoe
    add 10% to that , with adding Zetia
    about 70-80% will get to goal with adding PCSK9 inhibitor
    having difficulty getting to goal of 70 mg/Dl with current treatment options ,
    So i'm ok with current guidelines, even though I believe lower LDL is better
  • 3yr
    about 60-65 % of my patient are considerd high risk
    about only 40% of statin patients are reaching goal
    adding zetia , will add 10%
    adding PCSK9 will bring 70-80 % of patients below 70 mg LDL
    having difficlty achieving 70 mg goal , but I do believe that lower is better
  • 3yr
    Probably 40% would be very high risk; of these, 70% got to goal of less than 70. I would think that patients who have an LDL < 70 but have another event on good medications should be treated to LDL < 70 (hopefully we have some ability in the future to treat Lp(a) or ApoB, etc, as well.
  • 3yr
    i would consider 30 % to be considered high risk . I do believe LDL of 70 or lower is difficult to achieve and need more than a statin alone. I would say of those at risk 20 % are at goal. I find it is difficult to get many at goal and need other modalities to get to that goal .
  • 3yr
    over 50% of my patient population are very high goal and only approximately 30% are at goal with their therapy. I agree that a lower than 70 LDL goal should be a target, but wonder if achieving that target is possible given the limitations of patient adherence with management recommendations.
  • 3yr
    55-65% are high risk.
    I would say we omly get about 30% to goal on a statin alone and it usually Atorvastatin 80 or Rosuvastatin 40 .
    Have to use multiple drugs to get < 70. Frequently use th P C K S 9 inhibitors .we now know that lower is better



  • 3yr
    Approximately 50-60% of our population would be considered high risk. Only a small portion of them can maintain an LDL around 70 with just statins alone. Similar to European guidelines, targets below an LDL of 70 and closer to 50 may be a better goal in these high risk populations
  • 3yr
    At least 25% of my patients are at very risk for CAD. I usually add zetia, welchol or repatha if LDLC>75, I try to keep LDL<50 in this group of patients
  • 3yr
    teher are about 50% of all [patients may be considered high risk and out of them only 40% gets to goal. I believe strongly, lower is better and goal of less than 55 mg/dl for LDLC is more reasonable like in European guidelines.
  • 3yr
    Recognizing LDL below 70 mg/dl as the target in this country for high risk individuals, I would estimate maybe only 40% of these patients reach the target of <70 on high intensity statin therapy alone. Addition of ezetimibe can be helpful as adjunctive therapy, but targeting the PCSK9 protein has been highly effective (albeit expensive and a bit inconvenient for some) at driving LDL levels down below the 70 level.
  • 3yr
    What percentage of your own secondary prevention patients would you classify as being very high-risk?
    I would estimate that about 65% of my patients are very high risk.
    Of those very high-risk patients, what percentage would you estimate are at goal utilizing statins alone?
    I estimate about 85% of my very high risk patients are at goal. Cost and intolerance can lessen the number getting to goal
    Do you feel that 70 mg/dL LDL-C is low enough to prevent additional ASCVD events or do you target even lower? The lowest LDL is best and aiming <70 mg/dl is a reasonable goal.
    Should ACC/AHA LDL-C guidelines be adjusted to provide an LDL-C goal ≤55 mg/dL, similar to ESC4? If the guidelines in US were for LDL goal <55 mg/dl, then additional lipid lowering would be recommended in US also and one would aim for this target.
  • 3yr
    Consistent with the comments from other colleagues I would have to say anywhere from 40-50% of my patients are very high risk. All things considered it would behoove the clinician to target LDL less than 70 as mounting evidence seems to favor this approach. Certainly having PCSk9 inhibitors in the armamentarium makes this goal quite likely. Really at all because we need to prevent any additional events.
  • 3yr
    1. 50% of my patients are very high risk
    2. 80% of my patients are taking high intensity statins. A reason for them not to take sometimes is intolerance or allergies
    3. I believe target of 70 is low enough.
  • 3yr
    About 70% of my patients are very high risk. About 75% of my patients acheive a goal of 70 LDL on statin alone. I go to zetia next and PSK9 as my third drug. I aim for LDL less than 70. If the ACC/AHA guidelines are updated and lowered to 55 I would aim for that reduction
  • 4yr
    I believe that 45% of my patients belong to the high risk category
    At least 65% are on high intensity statin therapy and 60% are at goal of LDL of 70 or less. If not at goal we add Zetia 10 mg daily.
    May be we will be able to achieve more patients to reach the goal with PCSK( inhibitors but still very difficult to obtain insurance authorization
    With the new drug Inclisiran which is billed under part B Medicare more senior citizens will be able afford this and reach target LDL goal.
    We should aim for LDL of 55 or less in very high risk patients
  • 4yr
    I would suggest about 50% of my patient are very high risk.
    I think about 70% are using high intensity statins alone.
    LDL of 55 or less should be better with these folks, or lower, along with checking of Lp(a). LDL of 55 or less is where disease progression becomes more unlikely. Yes, guidelines should push for more aggressive prevention tactics.
  • 4yr
    By the definitions above, I would regard approximately 70% of my secondary prevention patients to be at very high risk. But from a practical patient-management standpoint, virtually all patients who sustain a major ASCVD event have preexistent significant risks, and there are other less-well-documented risks such as elevated Lp(a), and other yet to be elucidated risks. Recognizing LDL below 70 mg/dl as the target in this country for high risk individuals, I would estimate maybe only 40% of these patients reach the target of <70 on high intensity statin therapy alone. Addition of ezetimibe can be helpful as adjunctive therapy, but targeting the PCSK9 protein has been highly effective (albeit expensive and a bit inconvenient for some) at driving LDL levels down below the 70 level. And there is every suggestion that the ESC has it right: the lower the better. And we should continue the hunt for heretofore unrecognized risky genotypes needing intervention, and targeting such risks as elevated Lp(a) when able.
  • 4yr
    I believe about 70per cent of my secondary prevention patients are at very high risk
    I feel goal of Leland 70 leaves too much residual risk
    In our practice our goal is 50
    With high dose statin alone about 75 percent achieve goal with good compliance
    I currently add zetia if not at goal
    Would use more psk9 inhibitors if it was easier to prescribe
  • 4yr
    1) Fully 60% of secondary prevention pts I’m considering high risk. This is likely to be an underestimation at that.
    2) We just looked at that. Approximately 35% of patients are at goal using 70 mg/deciliter by statins alone. It is only with pcsk9’s that we can drive LDL’s reliably to <70…or in my practice, ideally to Fourier numbers.
    3) As intimated above, NLA supports <55. What is the ESC approximately one year ago suggested was< 40 mg/dL. Yes, you’re correct, the ACC/AHA are woefully behind the PCSK9 data as we continue to drive towards LDL’s sub 30 to do derive the maximum benefit. And especially, now that the PCSK-9 trials have demonstrated that there is no lower limit for LDL supported by the Ebbinghuas trial, aiming for zero should be the “optimal” goal!

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