Should an LDL-Cholesterol Target–Based Approach Be Readopted?

Abstract

To review clinical trials driving the evolution of hyperlipidemic guidelines, discuss whether low-density lipoprotein (LDL) targets and adjunctive therapy on top of statins should be used, and summarize the pharmacist's role in helping achieve LDL goals. MEDLINE search (1/1980-5/2017) using terms including LDL, lipid, and statin, with forward and backward citation tracking. English-language studies and guidelines assessing LDL-lowering therapy were included. In 2013, the American Heart Association and American College of Cardiology (AHA/ACC) hyperlipidemic guideline stepped back from LDL goals opting for statin monotherapy with an intensity of dosing predicated on baseline risk. This was driven by abundant clinical trial evidence for the statins, with adjunctive therapy on top of statins failing to show substantial benefit. However, recent evidence suggests that returning to LDL goals is warranted and adjuvant ezetimibe or PCSK9 inhibitor therapy may further reduce cardiovascular events. This is reflected in some society guidelines but not from the AHA/ACC. Pharmacists are well positioned to help achieve LDL goals, as they have positively affected LDL goal attainment across a multitude of settings. Statins are the mainstay of therapy but patients should have LDL targets, and if patients on maximally tolerated statin doses are not at goal, adjunctive therapy with ezetimibe and PCSK9 inhibitors may improve outcomes. In the emerging LDL goal paradigm, the pharmacist has a critical role to play.