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How low to target LDL?

Nature Clinical Practice Endocrinology & Metabolism volume 2, pages 414–415 (2006)Cite this article

In 2004, on the basis of several trials published after its 2001 recommendations, the National Cholesterol Education Program (NCEP) Adult Treatment Panel III1 suggested consideration of a more reduced LDL goal for those patients at the highest risk of coronary heart disease (CHD). An optional LDL goal of <1.81 mmol/l, rather than <2.58 mmol/l, might now be considered for patients at the very highest risk, including those with a recent acute coronary syndrome, as well as in those with cardiovascular disease plus multiple major risk factors (especially diabetes), severe or poorly controlled risk factors (especially continued cigarette smoking), or multiple risk factors of the metabolic syndrome. In addition, if a patient with CHD but without these risk factors has a baseline LDL level that is already <2.58 mmol/l, an LDL level of <1.81 mmol/l is a therapeutic goal.

Subsequent to the 2004 NCEP report, the Treating to New Targets (TNT)2 trial further confirmed that more-aggressive LDL lowering resulted in additional risk reduction. In the TNT trial, patients in the 80 mg atorvastatin group (mean LDL 1.99 mmol/l) had an additional 22% reduction in cardiovascular risk, compared with the 10 mg atorvastatin group (mean LDL 2.62 mmol/l). Notably, only half of the patients in the 80 mg atorvastatin group achieved an LDL level of <1.81 mmol/l. These results are similar to those seen in the earlier studies considered in the 2004 NCEP report. The Heart Protection Study (HPS)3 found that 3,421 patients with CHD or diabetes and a baseline LDL <2.58 mmol/l had a 22% reduction in risk of cardiovascular events when treated with 40 mg simvastatin daily, which is similar to the reduction seen in patients with higher LDL levels. The Pravastatin or Atorvastatin Evaluation and Infection Therapy Thrombolysis in Myocardial Infarction 22 (PROVE IT–TIMI 22)4 study enrolled patients with acute coronary syndromes (n = 4,162), and demonstrated a 16% reduction in cardiovascular events in patients receiving 80 mg atorvastatin daily, compared with those receiving 40 mg pravastatin daily for 2 years.

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Authors and Affiliations

  1. Departments of Epidemiology and Medicine,

    Jennifer G Robinson

  2. Lipid Research Clinic at the University of Iowa, IA, USA

    Jennifer G Robinson

  3. Rush University Medical Center,

    Michael H Davidson

  4. Radiant Research, Chicago, IL, USA

    Michael H Davidson

Authors
  1. Jennifer G Robinson
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  2. Michael H Davidson
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Corresponding author

Correspondence to Jennifer G Robinson.

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Competing interests

Jennifer G. Robinson, MD, MPH has received grants from Abbott, Andrx Labs, Astra-Zeneca, Atherogenics, Inc., Bristol-Myers Squibb, GlaxoSmithKline, Hoffman La Roche, Merck, Pfizer, Procter & Gamble, Schering-Plough, Sankyo, Takeda, and Wyeth Ayerst. She has received speaker honoraria from Pfizer and has served as a consultant for Pfizer.

Michael Davidson, MD

Speakers' Bureau: Abbott Laboratories, Astra Zeneca Pharmaceuticals, Kos Pharmaceuticals, Merck, Merck/Schering-Plough, Pfizer, Inc., Reliant Pharmaceuticals, Inc., Sankyo Pharma, and Takeda Pharmaceuticals

Consultant: Abbott Laboratories, Astra Zeneca Pharmaceuticals, Kos Pharmaceuticals, Merck, Merck/Schering-Plough, Pfizer, Inc., Novartis, Reliant Pharmaceuticals, Inc., Roche Pharmaceuticals, Sankyo Pharma, Sumitomo Pharmaceuticals, and Takeda Pharmaceuticals

Grant/Research: Abbott Laboratories, Astra Zeneca Pharmaceuticals, Bristol-Myers Squibb, Kos Pharmaceuticals, Merck, Merck/Schering-Plough, Pfizer, Inc., Novartis, Reliant Pharmaceuticals, Inc., Roche Pharmaceuticals, Sankyo Pharma, and Takeda Pharmaceuticals

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Robinson, J., Davidson, M. How low to target LDL?. Nat Rev Endocrinol 2, 414–415 (2006). https://doi.org/10.1038/ncpendmet0261

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