Lipid-lowering therapy in patients with a ‘normal’ LDL-C

Letter

Thank you for the valuable article on managing hypercholesterolaemia.¹ Given there is no target lipid concentration for reducing cardiovascular disease risk, in a patient at high cardiovascular disease risk but with a normal low-density lipoprotein cholesterol (LDL-C) concentration, what is the appropriate dosing for lipid-lowering therapy?

John Hackett
General Practitioner, Wonthaggi Medical Group, Victoria

Conflicts of interest: none declared

 

References

1. Nelson AJ, Nicholls SJ. Managing hypercholesterolaemia. Aust Prescr 2024;47:7-14.

 

Authors’ response

Adam Nelson and Stephen Nicholls, the authors of the article, comment:

Thank you for your comment on our article and for the question regarding dosing of lipid-lowering therapy.

The 2023 Australian Guideline for Assessing and Managing Cardiovascular Disease Risk¹ does not provide lipid-lowering treatment targets and thus we defer to the European guidelines for management of dyslipidaemias.² These guidelines recommend achieving an LDL-C concentration target of 1.4 mmol/L and a 50% reduction from baseline in patients considered at high cardiovascular risk. The linear relationship between reduction in LDL-C and prospective risk for atherosclerotic events holds independently of baseline LDL-C;³ thus, for every 1 mmol/L decrease in LDL-C, one would expect an approximately 21% reduction in the relative risk of an event, despite a ‘normal’ baseline LDL-C. In this context, while the 1.4 mmol/L target may be more attainable in a patient with a lower starting concentration (e.g. LDL-C 2.5 mmol/L), a 50% reduction from baseline still remains important, and will likely require high-intensity statin therapy (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily) or a combination of a moderate-intensity statin and ezetimibe.

Addressing other modifiable risk factors in patients at high risk of cardiovascular disease remains critical and includes, but is not limited to, achieving a blood pressure of less than 130/80 mmHg, smoking cessation, exercising more than 150 minutes per week, and reducing glycated haemoglobin (HbA1c) to less than 53 mmol/mol (7%).

 

References 2

1. Commonwealth of Australia. Australian Guideline for assessing and managing cardiovascular disease risk. Department of Health and Aged Care; 2023. [cited 2024 Apr 23]
2. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020;41:111-88.
3. Cholesterol Treatment Trialists C, Mihaylova B, Emberson J, Blackwell L, Keech A, Simes J, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 2012;380:581-90.

 

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