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The Expected Cardiovascular Benefit of Plasma Cholesterol Lowering with or Without LDL-C Targets in Healthy
Fernando Henpin Yue Cesena1, Antonio Gabriele Laurinavicius1, Viviane A Valente1
1Hospital Israelita Albert Einstein, São Paulo, SP - Brazil.
Insights
Aggressive lipid-lowering strategies, whether based on LDL-cholesterol (LDL-c) targets or percentage reduction, may prevent significantly more cardiovascular events. Individual baseline LDL-c levels are key to determining the most appropriate strategy for managing cardiovascular risk.
Area of Science:
- Cardiology
- Preventive Medicine
- Lipid Metabolism
Background:
- Controversy exists regarding whether blood cholesterol management should be based on LDL-cholesterol (LDL-c) target concentrations.
- Assessing the impact of different lipid-lowering strategies is crucial for high-cardiovascular-risk populations.
Purpose of the Study:
- To compare the estimated impact of lipid-lowering strategies, with or without LDL-c targets, on major cardiovascular events.
- To evaluate strategies based on LDL-c targets (≤100 mg/dL or ≤70 mg/dL) versus percentage reduction (30% or 50%).
Main Methods:
- Included 1,897 individuals with a 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥ 7.5%.
- Simulated four lipid-lowering strategies: LDL-c targets (≤100, ≤70 mg/dL) and percentage reductions (30%, 50%).
- Utilized pooled cohort equations (ACC/AHA, 2013) for risk assessment.
Main Results:
- More aggressive strategies (50% reduction or ≤70 mg/dL target) reduced 10-year ASCVD risk to approximately 8.8-8.9%.
- These strategies potentially prevented 48-49 major cardiovascular events per 1,000 individuals over 10 years, compared to 31-32 for less intensive approaches.
- The 50% reduction strategy prevented more events in lower LDL-c tertiles and fewer in higher tertiles compared to the ≤70 mg/dL target.
Conclusions:
- Aggressive lipid-lowering strategies, targeting LDL-c reduction or specific levels, may prevent approximately 50% more cardiovascular events.
- Baseline LDL-c levels are critical in determining the optimal individualized lipid-lowering strategy.
- The choice between target-based or percentage-reduction strategies may depend on individual patient characteristics.
Background::
There is controversy whether management of blood cholesterol should be based or not on LDL-cholesterol (LDL-c) target concentrations.
Objectives::
To compare the estimated impact of different lipid-lowering strategies, based or not on LDL-c targets, on the risk of major cardiovascular events in a population with higher cardiovascular risk.
Methods::
We included consecutive individuals undergoing a routine health screening in a single center who had a 10-year risk for atherosclerotic cardiovascular disease (ASCVD) ≥ 7.5% (pooled cohort equations, ACC/AHA, 2013). For each individual, we simulated two strategies based on LDL-c target (≤ 100 mg/dL [Starget-100] or ≤ 70 mg/dL [Starget-70]) and two strategies based on percent LDL-c reduction (30% [S30%] or 50% [S50%]).
Results::
In 1,897 subjects (57 ± 7 years, 96% men, 10-year ASCVD risk 13.7 ± 7.1%), LDL-c would be lowered from 141 ± 33 mg/dL to 99 ± 23 mg/dL in S30%, 71 ± 16 mg/dL in S50%, 98 ± 9 mg/dL in Starget-100, and 70 ± 2 mg/dL in Starget-70. Ten-year ASCVD risk would be reduced to 8.8 ± 4.8% in S50% and 8.9 ± 5.2 in Starget-70. The number of major cardiovascular events prevented in 10 years per 1,000 individuals would be 32 in S30%, 31 in Starget-100, 49 in S50%, and 48 in Starget-70. Compared with Starget-70, S50% would prevent more events in the lower LDL-c tertile and fewer events in the higher LDL-c tertile.
Conclusions::
The more aggressive lipid-lowering approaches simulated in this study, based on LDL-c target or percent reduction, may potentially prevent approximately 50% more hard cardiovascular events in the population compared with the less intensive treatments. Baseline LDL-c determines which strategy (based or not on LDL-c target) is more appropriate at the individual level.
Fundamentos::
Há controvérsias sobre se o controle do colesterol plasmático deve ou não se basear em metas de concentração de colesterol LDL (LDL-c).
Objetivos::
Comparar o impacto estimado de diferentes estratégias hipolipemiantes, baseadas ou não em metas de LDL-c, sobre o risco de eventos cardiovasculares maiores em uma população de risco cardiovascular mais elevado.
MéTodos::
Foram incluídos indivíduos consecutivamente submetidos a uma avaliação rotineira de saúde em um único centro e que apresentavam um risco em 10 anos de doença cardiovascular aterosclerótica (DCVAS) ≥ 7,5% ("pooled cohort equations", ACC/AHA, 2013). Para cada indivíduo, foram simuladas duas estratégias baseadas em meta de LDL-c (≤ 100 mg/dL [Emeta-100] ou ≤ 70 mg/dL [Emeta-70]) e duas estratégias baseadas em redução percentual do LDL-c (30% [E30%] ou 50% [E50%]).
Resultados::
Em 1.897 indivíduos (57 ± 7 anos, 96% homens, risco em 10 anos de DCVAS 13,7 ± 7,1%), o LDL-c seria reduzido de 141 ± 33 mg/dL para 99 ± 23 mg/dL na E30%, 71 ± 16 mg/dL na E50%, 98 ± 9 mg/dL na Emeta-100 e 70 ± 2 mg/dL na Emeta-70. O risco em 10 anos de DCVAS seria reduzido para 8,8 ± 4,8% na E50% e para 8,9 ± 5,2 na Emeta-70. O número de eventos cardiovasculares maiores prevenidos em 10 anos por 1.000 indivíduos seria de 32 na E30%, 31 na Emeta-100, 49 na E50% e 48 na Emeta-70. Em comparação com a Emeta-70, a E50% evitaria mais eventos no tercil inferior de LDL-c e menos eventos no tercil superior de LDL-c.
ConclusõEs::
As abordagens hipolipemiantes mais agressivas simuladas neste estudo, com base em meta de LDL-c ou redução percentual, podem potencialmente prevenir cerca de 50% mais eventos cardiovasculares graves na população em comparação com os tratamentos menos intensivos. Os níveis basais de LDL-c determinam qual estratégia (baseada ou não em meta de LDL-c) é mais apropriada para cada indivíduo.
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