The Expected Cardiovascular Benefit of Plasma Cholesterol Lowering with or Without LDL-C Targets in Healthy Individuals at Higher Cardiovascular Risk

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 [S(target-100)] or ≤ 70 mg/dL [S(target-70)]) and two strategies based on percent LDL-c reduction (30% [S(30%)] or 50% [S(50%)]). 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 S(30%), 71 ± 16 mg/dL in S(50%), 98 ± 9 mg/dL in S(target-100), and 70 ± 2 mg/dL in S(target-70). Ten-year ASCVD risk would be reduced to 8.8 ± 4.8% in S(50%) and 8.9 ± 5.2 in S(target-70). The number of major cardiovascular events prevented in 10 years per 1,000 individuals would be 32 in S(30%), 31 in S(target-100), 49 in S(50%), and 48 in S(target-70). Compared with S(target-70), S(50%) 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.