At the KAHN CENTER, we do advanced heart assessments. Unfortunately, many patients do have known or previously unknown coronary artery disease (CAD) and require intensive lifestyle and medical therapy including medications if needed. Many patients still question the role of cholesterol lowering as they are flooded with misleading social media posts. Of note, I do not have CAD and do not take statin medications, just like I would advise to most other patients proven to have no CAD.
Despite guideline recommendations, evidence from randomized trials evaluating the appropriate low-density lipoprotein (LDL-C) cholesterol target for secondary prevention in patients with CAD remains limited.
A new study provides impressive support to lowering the LDL-C <55 mg/dl, whether it is lifestyle or Rx medications to achieve that.
In an open-label superiority trial conducted in South Korea, patients with CAD were randomly assigned in a 1:1 ratio to a target LDL-Clevel of less than 55 mg per deciliter (intensive-targeting group) or less than 70 mg per deciliter (conventional-targeting group). The primary end point was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, any revascularization, or hospitalization for unstable angina at 3 years. Safety was also assessed.
Of 3048 patients who underwent randomization, 1526 were assigned to the intensive-targeting group and 1522 to the conventional-targeting group. The median follow-upwas 3.0 years.
The median LDL-C level during the trial was 56 mg per deciliter in the intensive-targeting group (usually by adding ezetimibe to a statin, or a PCSK9 ihiibitor like Repatha) and 66 mg per deciliter in the conventional-targeting group.
A primary end-point event occurred in 100 patients (6.6%) inthe intensive-targeting group and in 147 patients (9.7%) in the conventional-targeting group or a 33% reduction. Men benefited more than women. The major reduction was in nonfatal myocardial infarctions (heart attacks). Death was lower in the intensive therapy group but was infrequent overall.
The incidence of prespecified safety endpoints was similar in the two trial groups, except for a lower incidence of creatinine elevation in the intensive-targeting group (better kidneys).
Among patients with atherosclerotic cardiovascular disease, targeting an LDL-C of less than 55 mg/dl resulted in a lower risk of cardiovascular events at 3 years than targeting a level of less than 70 mg per deciliter.
At the KAHN CENTER, we have been teaching patients with CAD about a recommended LDL-C of <55 mg/dl since it was recommended in 2019 by the European Society of Cardiology. Many patients with advanced CAD are being treated with LIFESTYLE and medications to much lower LDL-C levels.
Of note, generally, patients without CAD are not treated with Rx medications (like I do for my own health) and are encouraged to follow an optimal lifestyle program.
