Achievement of low-density lipoprotein cholesterol thresholds in very high-risk atherosclerotic cardiovascular disease

BACKGROUND

The 2022 American College of Cardiology Expert Consensus Decision Pathway on the Role of Nonstatin Therapies recommended more aggressive management of low-density lipoprotein cholesterol (LDL-C) compared to the 2018 American Heart Association/American College of Cardiology/Multisociety Guideline. In congruence with European guidelines, a target LDL-C threshold of 55 mg/dL is recommended for patients with very high-risk atherosclerotic cardiovascular disease (ASCVD). Real-world status of the early implementation of this recommendation remains uncertain.

OBJECTIVE

To determine the proportion of patients with very high-risk ASCVD achieving an LDL-C <55 mg/dL and characterize differences between patients who did and did not achieve this LDL-C value.

METHODS

This retrospective cohort study evaluated patients between January 1, 2023, and December 31, 2023, who were ≥ 18 years old with very high-risk ASCVD from the University of Colorado Health system primary care practices. Very high-risk ASCVD was defined as a history of a major ASCVD event with at least 2 high-risk conditions.

RESULTS

A total of 8974 patients met inclusion criteria for very high-risk ASCVD. Of these, only 21.0% achieved an LDL-C <55 mg/dL, while 39.5% of patients achieved the previously recommended LDL-C threshold of <70 mg/dL. More than half of patients were prescribed a high-intensity statin-based regimen.

CONCLUSION

Within a large, academic health-system, achievement of LDL-C threshold among patients with very high-risk ASCVD was low. Recommendations from the 2022 ACC Expert Consensus Decision Pathway that endorse more aggressive LDL-C lowering and emphasize nonstatin therapies as an adjunct to statins are not fully implemented in real-world clinical practice.