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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.

Author information

1
Second Department of Cardiology, University General Hospital Attikon, Athens, Greece. Electronic address: lrallidis@gmail.com.
2
Second Department of Cardiology, University General Hospital Attikon, Athens, Greece.
3
251 Air Force General Hospital, Athens, Greece.

Abstract

BACKGROUND AND AIMS:

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.

METHODS:

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.

RESULTS:

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.

CONCLUSIONS:

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.

KEYWORDS:

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

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