Individuals With Very High Cardiovascular Risk Struggle to Attain LDL-C Goals

Patients with very high cardiovascular risk (CVR) face suboptimal rates of achieving low-density lipoprotein cholesterol (LDL-C) goals despite the widespread use of lipid-lowering therapies (LLTs), highlighting the need for more thorough patient counseling and increased follow-up and shedding light on the importance of novel combination therapies. The data was gathered from a retrospective, multicenter study of Colombian patients (EDHIPO MARCA) with very high CVR due to coronary artery disease (CAD) and was published in Lipids in Health and Disease.¹

Using lipid-lowering therapies to lower low-density lipoprotein cholesterol is critical to improving cardiovascular risk. | Image Credit: © RFBSIP - stock.adobe.com

Patients With Very High Cardiovascular Risk Need Significant LDL-C Reductions

Though there are countless factors that play into cardiovascular risk, dyslipidemia is of paramount importance, known as a significant contributor towards the development of atherosclerotic cardiovascular disease (ASCVD). LDL-C has a large presence in this process, as arterial lipoprotein retention promotes atherosclerosis. In patients with prior cardiovascular events, elevated LDL-C is of major concern because of their heightened risk of recurrent events, morbidity, and mortality. Fortunately, dyslipidemia is a modifiable risk factor, and LLTs can aid in preventing CVD and controlling LDL-C.^2,3

Despite the countless LLT options—including both standard of care statins and newer drug classes such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors—and their proven effectiveness in reducing cardiovascular events, uptake of these therapies remains lacking. Accordingly, achievement rates for LDL-C goals are lackluster and concerning, especially in middle- and low-income countries. Even with updates to cardiovascular guidelines that have relaxed target goals for patients at very high CVR, research continues to estimate that only a small portion of this at-risk population achieved such goals.^1,4

In Colombia, the EDHIPO MARCA Registry is a national initiative that investigates the achievement of LDL-C goals in patients deemed as very high CVR due to CAD undergoing LLT, according to the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines. For this study, the authors conducted a retrospective, descriptive, multicenter analysis of LDL-C goal attainment in patients at very high CVR.¹

LDL-C Goal Attainment Remains Poor for Those at Very High Risk

Coronary angiogram reports and medical records were garnered across multiple institutions in Colombia, and the investigators assessed LDL-C goal achievement across the periods of 2011 to 2012, 2016 to 2017, and 2021 to 2022, with each period corresponding to an update of the ESC/EAS guidelines. Includes patients who had clinically or image-confirmed CAD, with at least 1 follow-up record reporting LDL-C levels. In total, 1788 patients from 11 medical institutions across Columbia were examined.¹

LLTs prescribed at discharge following a coronary angiogram distinctly varied across the differing guideline periods. Overall, statins were the most prescribed LLT, with overall usage of 84.1% and a peak of 89.3% in the 2016 guideline group. In 91% of cases, high-intensity statins were prescribed, peaking at 96.9% in the 2019 guideline period. Interestingly, PCSK9 inhibitors were not often used, and 4.7% of patients were discharged without being prescribed any LLT.¹

At their last follow-up visit, only 36.6% of patients (95% CI, 34.3–38.8%) had achieved LDL-C goals, with the highest proportion in the ESC/EAS 2016 group, followed by the 2019 group. For patients with at least 1 follow-up, 32.9% achieved LDL-C goals; with 2 follow-ups, 41% achieved LDL-C goals; and with 3 and 4 follow-ups, LDL-C goal achievement rates were 45.5% and 44%, respectively, according to the investigators. As patients attended more follow-up visits, there was a more pronounced relative change in LDL-C.¹

Changes in LDL-C were also evaluated. The mean LDL-C in the total population at the end of follow-up was about 73.5 mg/dL. There were significant differences observed between guideline groups, with the highest level in the 2011 guideline group (95.8 mg/dL) and the lowest in the 2019 group (69.5 mg/dL). For patients who achieved LDL-C goals, the mean LDL-C level was 44.4 mg/dL. Notably, statins remained the most prescribed medication across each of the guideline groups.¹

These study results provide a wealth of insight for pharmacists and health care providers on which patients may require more extensive counseling and follow-up to promote cardiovascular risk reduction. Guideline adherence, especially to the most updated version of the ESC/EAS guidelines, will be paramount in this context. Furthermore, the data indicates that novel therapies—including combination therapies—are necessary for more extensive LDL-C lowering and more widespread goal attainment. With dyslipidemia being a key, modifiable factor contributing towards the development of ASCVD, pharmacists play a key role in patient counseling and LLT adherence.¹

REFERENCES

1. Cordoba-Melo BD, Seni-Molina S, Arango-Ibanez JP, et al. From guidelines to practice: LDL-C achievement in very high cardiovascular risk patients – analysis of the EDHIPO MARCA registry. Lipid Health Dis. 2025;24:275. doi:10.1186/s12944-025-02657-9

2. Du Z, Qin Y. Dyslipidemia and Cardiovascular Disease: Current Knowledge, Existing Challenges, and New Opportunities for Management Strategies. J Clin Med. 2023;12(1):363. doi:10.3390/jcm12010363

3. Mackinnon ES, Leiter LA, Wani RJ, et al. Real-World Risk of Recurrent Cardiovascular Events in Atherosclerotic Cardiovascular Disease Patients with LDL-C Above Guideline-Recommended Threshold: A Retrospective Observational Study. Cardiol Ther. 2024;13(1):205-220. doi:10.1007/s40119-024-00349-6

4. Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials. Lancet. 2010;376(9753):1670-1681. doi:10.1016/S0140-6736(10)61350-5