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Atherosclerosis. 2018 Aug;275:262-264. doi: 10.1016/j.atherosclerosis.2018.06.821. Epub 2018 Jun 18.

Extreme-risk category: High prevalence among stable coronary patients and an emerging widening treatment gap in achieving LDL-cholesterol less than 55 mg/dL.

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Second Department of Cardiology, University General Hospital Attikon, Athens, Greece. Electronic address:
Second Department of Cardiology, University General Hospital Attikon, Athens, Greece.
251 Air Force General Hospital, Athens, Greece.



The latest guidelines from the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) proposed a new "extreme-risk" category of patients, for whom a low-density lipoprotein cholesterol (LDL-C) level <55 mg/dL (1.4 mmol/L) is advised. We aimed to identify the proportion of patients with stable coronary artery disease (CAD), who are at extreme cardiovascular (CV) risk, and explore how achievable is the new LDL-C goal.


We enrolled 1629 consecutive patients ≤80 years with stable CAD. Fasting lipids were determined and patients having probable or definite heterozygous familial hypercholesterolaemia (HeFH) were identified using the Dutch Lipid Clinic Network algorithm.


The prevalence of risk factors/characteristics suggesting an extreme CV risk were as follows: 32% diabetes mellitus, 33% premature CAD and 9.2% HeFH. In total, 895 (55%) patients had at least one of those risk factors/characteristics and formed the extreme CV risk category. Among patients at extreme risk, 87% were on lipid-lowering therapy, of whom 20.3% had LDL-C <70 mg/dL (1.8 mmol/L) and only 5.3% had LDL-C <55 mg/dL.


More than half of all patients with stable CAD are at extreme CV risk and very few (∼5%) achieve LDL-C levels <55 mg/dL. Using maximally-tolerated high-intensity statin combined with ezetimibe, if necessary, is imperative to bridge the treatment gap, while in selected cases the addition of PCSK9 inhibitors will be required.


Coronary artery disease; Extreme risk category; LDL cholesterol target; PCSK9-Inhibitor; Statins

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