Low-density lipoprotein-cholesterol lowering in individuals at intermediate cardiovascular risk: Percent reduction or target level?

Abstract

Background: Recommendations for blood cholesterol management differ across different guidelines. Hypothesis: Lipid-lowering strategies based on low-density lipoprotein-cholesterol (LDL-c) percent reduction or target concentration may have different effects on the expected cardiovascular benefit in intermediate-risk individuals. Methods: We selected individuals between 40 and 75 years of age with 10-year risk for atherosclerotic cardiovascular disease (ASCVD) between 5.0% and <7.5% who underwent a routine health screening. For every subject, we simulated a strategy based on a 40% LDL-c reduction (S40%) and another strategy based on achieving LDL-c target ≤100 mg/dL (Starget-100). The cardiovascular benefit was estimated assuming a 22% relative risk reduction in major cardiovascular events for each 39 mg/dL of LDL-c lowered. Results: The study comprised 1756 individuals (94% men, 52 ± 5 years old). LDL-c and predicted 10-year ASCVD risk would be slightly lower in S40% compared to Starget-100. The number needed to treat to prevent 1 major cardiovascular event in 10 years (NNT10) would be 56 with S40% and 66 with Starget-100. S40% would prevent more events in individuals with lower baseline LDL-c, whereas Starget-100 would be more protective in those with higher LDL-c. A dual-target strategy (40% minimum LDL-c reduction and achievement of LDL-c ≤100 mg/dL) would be associated with outcomes similar to those expected with the S40% (NNT10 = 55). Conclusions: In an intermediate-risk population, cardiovascular benefit from LDL-c lowering may be optimized by tailoring the treatment according to the baseline LDL-c or by setting a dual-target strategy (fixed dose statin plus achievement of target LDL-c concentration).