Low-density lipoprotein cholesterol lowering therapy for the secondary prevention of atherosclerotic cardiovascular disease

Abstract

Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent and a major contributor to morbidity and mortality worldwide. Elevated blood cholesterol is a key driver of risk for atherosclerotic events, and patients with established ASCVD comprise a specific high-risk population in which low-density lipoprotein cholesterol (LDL-C) lowering therapy is strongly endorsed by multiple guidelines. An increasing number of medications across several pharmacologic classes are available today in clinical practice. Therefore, guidance on the appropriate use of these interventions is necessary for cost-effective solutions to managing residual atherothrombotic risk. In this review we summarize the key evidence supporting LDL-C lowering as described in the most recent 2018 multi-society Blood Cholesterol Guidelines, and provide a framework for optimizing LDL-C lowering therapy in secondary prevention populations.

Pharmacotherapeutics for dyslipidemia management

“…PCSK9 inhibitors are thought to be more effective than second-line treatment in combination with statin therapy; however, because of their high cost, administration via injection, and lack of long-term safety data, NPs might wish to consider a trial of ezetimibe with statins prior to introducing PCSK9 inhibitors. 1,42,43 It is important to note as well that PCSK9 inhibitors may not be covered by insurance or may not be approved by insurance unless an ezetimibe trial has been completed. 1,44 In such cases, if the patient has still not reached the target LDL-C level with combination ezetimibe and statin therapy, then PCSK9 inhibitors may be used.…”

“…PCSK9 inhibitors may also be used as third-line treatment for some individuals for whom traditional first- and second-line therapies were insufficiently effective. PCSK9 inhibitors are thought to be more effective than second-line treatment in combination with statin therapy; however, because of their high cost, administration via injection, and lack of long-term safety data, NPs might wish to consider a trial of ezetimibe with statins prior to introducing PCSK9 inhibitors 1,42,43. It is important to note as well that PCSK9 inhibitors may not be covered by insurance or may not be approved by insurance unless an ezetimibe trial has been completed 1,44.…”

Statins for Patients Undergoing Thoracic Aortic Aneurysm Repair Surgery: What to Do?

“…9 The authors also do not support their statement that "Nonetheless, there is widespread prophylactic use of statins in patients with thoracic aorta disease in the absence of wellestablished cardiovascular indications" with any references and we do not really know what proportion of the use of statins is prophylactic for preventing aneurysm-related complications and what proportion is guideline-directed medical therapy for preventions of cardiovascular disease. This is further complicated by the fact that over time the serum cholesterol targets have decreased 10 and thus the time of the aortic surgery may influence the classification of statin therapy, with a patient treated in 2005 having a different low-density lipoprotein cholesterol target than a patient treated in 2011. The inference that patients who did not have cardiovascular indications were receiving statins for their thoracic aneurysm is not confirmed.…”