I think the answer is that you can’t be too low.
VERY LOW LDL CHOLESTEROL RANGE TRIAL
In the present analysis, researchers included a subset of patients from the FOURIER trial in which the median baseline LDL cholesterol level was 66 mg/dL. The median LDL cholesterol levels in the control arms of IMPROVE-IT and REVEAL were 70 mg/dL and 63 mg/dL, respectively. All three studies were secondary prevention trials and tested ezetimibe, evolocumab (Repatha Amgen), and the commercially abandoned anacetrapib, respectively. Researchers also included three randomized, double-blind, placebo-controlled trials ( IMPROVE-IT, FOURIER, and REVEAL ) of LDL-cholesterol lowering with nonstatin therapy.
The new analysis, published online August 1, 2018, ahead of print in JAMA Cardiology, includes a subset of patients in the CTTC starting with LDL cholesterol levels of less than 70 mg/dL (mean 65.7 mg/dL). The most recent European Society of Cardiology guidelines for the treatment of dyslipidemias retain treatment targets and recommend a goal of less than 70 mg/dL in very high-risk patients, consistent with recommendations from the National Lipid Association (NLA). However, prior to the 2013 guidelines, the National Cholesterol Education Program recommended intensifying therapy in very high-risk patients if LDL cholesterol levels exceeded 70 mg/dL. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the treatment of cholesterol do not currently recommend a treatment target for LDL cholesterol, instead advising physicians to use moderate- or high-intensity statins based on patient risk. That has begged the question of how low should we go in terms of LDL cholesterol? And I think the answer is that you can’t be too low.” “We and others have done trials studying patients with average LDL cholesterol and also showed a benefit.
“If we think back, the initial statin trials studied patients with elevated LDL cholesterol, patients in the 160 or 170 mg/dL range, and showed a benefit of lowering,” senior investigator Marc Sabatine, MD (Brigham and Women’s Hospital, Boston, MA), told TCTMD. Importantly, taking LDL cholesterol down further in these patients was not associated with increased risks of myalgia/myopathy, new-onset diabetes, hemorrhagic stroke, or cancer. Further lowering LDL cholesterol in patients who have levels once considered ideal reduces the risk of major vascular events and does not appear to be associated with excess risk, according to results of a new meta-analysis.įor individuals with baseline LDL cholesterol levels of 70 mg/dL or less, lowering LDL cholesterol another 38.7 mg/dL, or approximately 1 mmol/L, results in a 21% reduction in major cardiovascular events, a relative reduction in line with that observed in the Cholesterol Treatment Trialists’ Collaboration (CTTC), where baseline LDL cholesterol levels were roughly twice as high.
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