Are LDL-Cholesterol Targets Back?

Two endocrinology groups – the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) – recently issued new lipid management guidelines that bring back LDL-cholesterol (LDL-C) “targets”. They divide patients into 5 risk categories including a new “extreme-risk” category of patients for whom an LDL -cholesterol level of less than 55 mg/dL is recommended. Those in the extreme risk group include:

  • those with progressive atherosclerotic cardiovascular disease (ASCVD), including unstable angina, despite achieving an LDL-C < 70 mg/dL
  • those with established clinical cardiovascular disease in patients with diabetes, stage 3/4 chronic kidney disease or heterozygous familial hypercholesterolemia
  • those with a history of premature ASCVD (men < 55 years of age and women < 65).   

These guidelines are a departure from the 2013 American Heart Association/American College of Cardiology (AHA/ACC) Blood Cholesterol Guideline that was endorsed by PCNA. The AHA/ACC guideline did away with LDL-C treatment targets and focused instead on intensity of statin therapy according to level of risk. Look for an update to the AHA/ACC Cholesterol Guideline next year; until then, clinicians should be familiar with the various lipid treatment guidelines, and the evidence behind the recommendations, as they make treatment decisions together with their patients. Some feel giving a patient a goal or target provides the necessary motivation for patients to adhere to treatment recommendations. Others feel that having targets is not the point, it is how you get there – with evidenced-based therapies that have demonstrated positive outcomes including the reduction of major CVD events including death.

There may not be one answer for every clinician and every patient. Guidelines, after all, are just that: guidelines. Ultimately, it is up to you to make the best possible recommendation based on your knowledge of the science and how to best apply it to an individual patient at a given time.

The ACE/AACE guideline was published in the April 2017 issue of Endocrine Practice and can be accessed here.

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