[LDL-c and residual cardiovascular risk in patients with coronary artery disease]

In secondary prevention, current therapeutic management of dyslipidemia primarily aims to reduce low-density lipoprotein cholesterol (LDL-c) levels, as LDL-c is a major driver of atherosclerosis. Elevated LDL-c levels are also one of the main modifiable cardiovascular risk factors. LDL-c lowering is directly, proportionally, and linearly associated with a reduction in cardiovascular events, with no apparent threshold effect. However, patients with chronic coronary syndrome or those who have recently experienced an acute coronary event are still generally undertreated and achieve guideline-recommended targets in only one out of four cases. This article aims to explore the underlying causes of and potential solutions to this therapeutic gap, which is associated with an increased risk of cardiovascular morbidity and mortality. Treatment adherence varies considerably across studies (randomized controlled trials or real-life studies), as well as across geographical settings, and appears to be approximately 60%. However, non-adherence to treatment alone does not explain the low proportion of patients achieving LDL-c treatment targets, which remains at approximately 25%. The underlying reasons are complex and multifactorial. Paradoxically, although the expanding therapeutic armamentarium allows for increased substantial LDL-c reductions, this has not translated into a corresponding improvement in target attainment. Therapeutic inertia may arise at the patient, physician, and healthcare system levels. Furthermore, patient education and the therapeutic alliance should remain central to patient management and should be regularly reinforced and individualized.