Lipid management across Europe in the real-world setting: a rapid evidence review

Retrospective real-world analysis of adherence and persistence to lipid-lowering therapy in Germany

BACKGROUND

Cardiovascular disease is the leading cause of mortality in Germany. Cardiovascular risk can be mitigated with long-term lipid-lowering therapies (LLTs) that reduce levels of low-density lipoprotein cholesterol. Although effective, risk mitigation is hindered by poor persistence and adherence.

OBJECTIVE

To investigate real-world persistence and adherence to LLTs through 36 months post-initiation.

METHODS

This retrospective cohort study included patients with dyslipidemia who were newly prescribed LLTs between July and December 2017, using anonymized prescription data from the Insight Health™ Patient Insight Tool, and followed up until March 2021. Persistence and adherence to the therapies were stratified by age and sex. The proportion of days covered (PDC) was used to measure adherence.

RESULTS

Patients with dyslipidemia and newly prescribed statins (n = 865,732), ezetimibe (n = 34,490), or anti-proprotein convertase subtilisin/kexin type 9 monoclonal antibodies (anti-PCSK9 mAbs; n = 1940) were included. Persistence to LLTs declined gradually across all treatment subgroups and was lower in women than men. Adherence, calculated as the mean PDC at the end of the analysis period (July 2017‒March 2021) was 0.84, 0.92, and 0.93 for statins, ezetimibe, and anti-PCSK9 mAbs, respectively. Among patients who discontinued treatment, mean treatment duration was 265, 255, and 387 days for statins, ezetimibe, and anti-PCSK9 mAbs, respectively. Only ~ 10% of patients persisted between 201 and 300 days. By Day 300, 71% of patients on statins had discontinued treatment. At 36 months, overall persistence rates were lowest with statins (20.6%), followed by ezetimibe (22.3%) and anti-PCSK9 mAbs (50.9%).

CONCLUSIONS

High non-persistence rates were observed across all LLT regimens analyzed, with the lowest persistence rates observed with statins.

Real-world data on treatment patterns in at least high cardiovascular risk patients on dual and triple lipid lowering therapy in a Hellenic nationwide e-prescription database

Background

Despite recent guidelines appropriate lipid-lowering treatment (LLT) remains suboptimal in everyday clinical practice.

Aims

We aimed to describe clinical practice of use of LLT for at least high CV risk populations in a Hellenic real-world setting and assess how this relates to the European Society of Cardiology treatment guidelines.

Methods

We analyzed data from a retrospective cohort study of the National Registry of patients with dyslipidemia between 1/7/2017 and 30/6/2019 who were at least of high CV risk and filled a dual or triple lipid-lowering treatment (dLLT, tLLT) prescription. The primary outcomes of interest of this analysis were to report on the patterns of LLT use in at least high CV risk patients.

Results

A total of 994,255 (45.4% of Greeks on LLT) were of at least high CV risk and 120,490 (5.5%) were on dLLT or tLLT. The percentage of patients with reported statin intolerance ranged from 2 to 10%. While persistence was reported to be satisfactory (>85% for both dLLT or tLLT), adherence was low (ranging between 14 and 34% for dLLT). In 6-month intervals, the percentage of patients achieving a low-density lipoprotein cholesterol (LDL-C) target below 100 md/dL ranged from 20% to 23% for dLLT and 34%-37% for tLLT.

Conclusions

The prevalence of at least high CV risk patients among patients receiving LLT in Greece is substantial. Despite the high persistence and probably due to the low adherence to treatment, LDL-C remains above targets in more than two thirds of patients.

Are We Using Ezetimibe As Much As We Should?

Lipid-lowering therapies, particularly non-statin regimens, are underutilized as ~2/3 of patients with atherosclerotic cardiovascular (CV) disease (CVD) are not optimally managed, and do not attain target low-density lipoprotein cholesterol (LDL-C) concentrations, despite statin treatment. Statins have been the mainstay of hypolipidemic therapies; however, they are plagued by adverse effects, which have partly hindered their more widespread use. Ezetimibe is often the first added mode of treatment to attain LDL-C goals as it is efficacious and also allows the use of a smaller dose of statin, while the need for more expensive therapies is obviated. We herein provide a comprehensive review of the effects of ezetimibe in lipid lowering and reducing CV events and improving outcomes. Of the hypolipidemic therapies, oral ezetimibe, in contrast to newer agents, is the most convenient and/or affordable regimen to be utilized as mono- or combined therapy supported by data from CV outcomes studies attesting to its efficacy in reducing CVD risk and events. When combined with a statin, the statin dose could be lower, thus curtailing side-effects, while the hypolipidemic effect is enhanced (by ~20%) as the percentage of patients with target level LDL-C (<70 mg/dL) is higher with combined treatment versus a high-intensity statin. Ezetimibe could also serve as an alternative treatment in cases of statin intolerance. In conclusion, ezetimibe has an excellent safety/tolerability profile; it is the first added treatment to a statin that can attain LDL-C targets. In the combined therapy, the hypolipidemic effect is enhanced while the dose of statin could be lower, thus limiting the occurrence of side-effects. Ezetimibe could also serve as an alternative mode of treatment in cases of statin intolerance.

Statins use amidst the pandemic: prescribing, dispensing, adherence, persistence, and correlation with COVID-19 statistics in nationwide real-world data from Poland

Background

Adherence to medications presents a significant challenge in healthcare. Statins, used in primary and secondary prevention of cardiovascular disease, are of particular importance for public health. The outbreak of the COVID-19 pandemic resulted in additional healthcare system-related barriers impeding the execution of therapies. This study aimed to assess the use of as well as adherence and persistence to statins in a national cohort of 38 million of Polish citizens during pandemic.

Methods

A retrospective analysis of prescription and dispensation data for all statins users from the national payer organization covering the years 2020-2022 was conducted. Medication adherence was assessed using the Medication Possession Ratio, for persistence the 30-day cut-off was accepted. National data on COVID-19 cases and COVID-19 related deaths were obtained from ECDC.

Results

The analysis identified 7,189,716 Polish citizens (approximately 19% of Polish population) who were dispensed at least 1 pack of statins within the study period. Over that time, there was a continuous significant increasing trend in prescribing and dispensing of statins. Despite a total increase of 18.9% in the number of prescribed tablets, the percentage of tablets dispensed remained similar, averaging 86%. Overall percentage of adherent patients was 48.2%. For a random sample of 100,000 patients, the mean period of continuous therapy in 2022 was 6.2+/- 5.3 months. During the lockdown period, the mean number of prescribed and dispensed tablets was lower by 6.8% and 5.9%, respectively (p < 0.05). However, fluctuations in the number of COVID-19 cases or COVID-19-related deaths per week had no major impact on the prescribing and dispensing of statins.

Conclusion

Over the time of pandemic, there was a continuous increase in the number of statin tablets prescribed and dispensed in Poland. This suggests that, despite the potential limitations posed by COVID-19, access to statins remained easy, which may be attributed to the mass-scale implementation of the national e-prescription system. However, it is crucial to realise that approximately 1/7 of prescribed statin doses were never dispensed, and the overall levels of adherence and persistence were low. This underscores the necessity for concerted efforts to change this scenario in Poland.

LOGAN-CV: A Prospective Study of a Multifaceted Intervention Targeting United States Clinicians to Improve Guideline-Based Management of Lipid-Lowering Therapy

INTRODUCTION

The 2018 American Heart Association (AHA)/American College of Cardiology (ACC)/Multisociety blood cholesterol guidelines recommend clinicians consider adding non-statin therapy for patients with very high-risk (VHR) atherosclerotic cardiovascular disease (ASCVD) and low-density lipoprotein cholesterol (LDL-C) ≥ 70 mg/dl while receiving maximally tolerated statins. However, according to a recent study, only 17.1% of patients with established ASCVD received appropriate lipid-lowering therapy (LLT) intensification. Here, we describe the design of a prospective, 12-month study (LOGAN-CV) evaluating a multifaceted site-level intervention to enhance clinicians' adherence to guidelines to improve LDL-C levels for patients with VHR ASCVD.

METHODS

Clinicians from up to ten research sites are eligible if they care for adult patients with ASCVD. Interventions include educational modules, a cloud-based performance platform providing clinicians a tailored summary of their LDL-C management performance, newsletters, periodic peer-to-peer calls, and pre- and post-intervention surveys evaluating knowledge, attitudes, and beliefs around LDL-C management, with additional interventions for clinicians demonstrating a lower readiness to make treatment decisions based on guideline recommendations. Patients with VHR ASCVD, defined as having recent myocardial infarction and LDL-C ≥ 70 mg/dl despite statin treatment, will be included in the study. Patient data will be collected from electronic medical records from baseline (clinician enrollment) through the 12-month intervention. The study started in October 2022, with anticipated completion in March 2024.

PLANNED OUTCOMES

The change in proportion of patients with LDL-C < 70 mg/dl achieved at any time during the 12-month intervention (primary); LLT intensification, changes in guideline-aligned LDL-C testing and LLT titration over 12 months, and change in overall clinicians' knowledge, attitudes, and beliefs are key outcomes of interest. The LOGAN-CV study addresses a critical unmet need in LDL-C control in patients with VHR ASCVD and evaluates the effect of a multifaceted intervention targeting clinicians to improve their adherence to guidelines and consequently improve clinical outcomes for patients.

Patients who suffer a first atherosclerotic cardiovascular event while taking statins are often far off of lipid targets

BACKGROUND AND AIMS

Despite considerable evidence that lipid-lowering therapies (LLTs) afford clinical benefit, the control of low-density lipoprotein cholesterol (LDL-C) is suboptimal, and available LLTs are underused, especially in patients at high and very high cardiovascular (CV) risk. This study assesses the real-world LDL-C target attainment rate in patients on LLT before experiencing a first major acute cardiovascular event (MACE).

METHODS AND RESULTS

The HEARTBEAT was a retrospective, multicentre observational study. From March to June 2021 a total of 334 patients on LLT who had a first MACE while being on statins were included in the study. Of these patients, 83.2 % had a high (40.7 %) or very high CV risk (29.0 %) prior to MACE. Overall, 87.5 % and 89.7 % of the patients at high and very high CV risk, respectively, failed to reach the LDL-C target. Regarding LLTs, only 11.8 % and 19.6 % of the patients at high and very high risk had received high-intensity LLTs prior to MACE. It was estimated that if these patients had reached their recommended LDL-C targets, the risk of MACE may have been reduced by a median of 24.5 % and 23.2 % in patients at high and very high risk respectively.

CONCLUSIONS

Patients who suffer a first MACE while on statin therapy often were at high/very high CV risk. Despite their risk, LDL-levels and being on statins they are undertreated, and too far from lipid targets. A proper use of high-intensity LLTs led to an increase attainment of LDL targets and lower CV events.

STRUGGLE FOR. Italian-Polish-Spanish-Uzbek-Vietnamese Expert Forum Position Paper 2023 for better control of classical modifiable risk factors in clinical practice

The progress in pharmacotherapy that has been made in recent years, including the introduction of very effective and safe lipid-lowering and antihypertensive drugs, has not yet translated into the expected universal control of blood pressure, lipid disorders and diabetes. In the STRUGGLE FOR Italian- -Polish-Spanish-Uzbek-Vietnamese Expert Forum Position Paper 2023, experts from five countries recounted several points about the paradigms of cardiological and cardiometabolic care for better control of classical modifiable risk factors in the year 2023. It is believed herein, that the need to intensify treatment, actively search for patients with cardiovascular risk factors, especially with arterial hypertension, hypercholesterolemia and diabetes, should go hand in hand with the implementation of the latest therapy, based on single pill combinations including proven, effective antihypertensive, lipid-lowering and antidiabetic molecules, many of which are listed in the present document. There is a need to use both new technological concepts, completely new drugs, as well as novel treatment concepts such as metabolic treatment in coronary artery disease, try to intensify the fight against smoking in every way, including the available range of drugs and procedures reducing the harm. This approach will provide substantially better control of the underlying cardiovascular risk factors in countries as varied as Italy, Poland, Spain, Uzbekistan and Vietnam.

Trends in acute myocardial infarction mortality in the European Union, 2012-2020

AIMS

To assess the sex- and age-specific trends in acute myocardial infarction (AMI) mortality in the modern European Union (EU-27) member states between years 2012 and 2020.

METHODS AND RESULTS

Data on cause-specific deaths and population numbers by sex for each country of the EU-27 were retrieved through a publicly available European Statistical Office (EUROSTAT) dataset for the years 2012 to 2020. AMI-related deaths were ascertained when codes for AMI (ICD-10 codes I21.0-I22.0) were listed as the underlying cause of death in the medical death certificate. Deaths occurring before the age of 65 years were defined as premature deaths. To calculate annual trends, we assessed the average annual percent change (AAPC) with relative 95% confidence intervals (CIs) using joinpoint regression. During the study period, 1 793 314 deaths (1 048 044 males and 745 270 females) occurred in the EU-27 due to of AMI. The proportion of AMI-related deaths per 1000 total deaths decline from 5.0% to 3.5% both in the entire population (P for trend < 0.001) and in males or females, separately. Joinpoint regression analysis revealed a continuous linear decrease in age-adjusted AMI-related mortality from 2012 to 2020 among EU-27 members [AAPC: -4.6% (95% CI: -5.1 to -4.0), P < 0.001]. The age-adjusted mortality rate showed a plateau in some Eastern European countries and was more pronounced in EU-27 females and in subjects aged ≥65 years.

CONCLUSION

Over the last decade, the age-adjusted AMI-related mortality has been continuously declining in most of the in EU-27 member states. However, some disparities still exist between western and eastern European countries.

Simulation of bempedoic acid and ezetimibe in the lipid-lowering treatment pathway in Austria using the contemporary SANTORINI cohort of high and very high risk patients

OBJECTIVE

The low-density lipoprotein cholesterol goals in the 2019 European Society of Cardiology/European Atherosclerosis Society dyslipidaemia guidelines necessitate greater use of combination therapies. We describe a real-world cohort of patients in Austria and simulate the addition of oral bempedoic acid and ezetimibe to estimate the proportion of patients reaching goals.

METHODS

Patients at high or very high cardiovascular risk on lipid-lowering treatments (excluding proprotein convertase subtilisin/kexin type 9 inhibitors) from the Austrian cohort of the observational SANTORINI study were included using specific criteria. For patients not at their risk-based goals at baseline, addition of ezetimibe (if not already received) and subsequently bempedoic acid was simulated using a Monte Carlo simulation.

RESULTS

A cohort of patients (N = 144) with a mean low-density lipoprotein cholesterol of 76.4 mg/dL, with 94% (n = 135) on statins and 24% (n = 35) on ezetimibe monotherapy or in combination, were used in the simulation. Only 36% of patients were at goal (n = 52). Sequential simulation of ezetimibe (where applicable) and bempedoic acid increased the proportion of patients at goal to 69% (n = 100), with a decrease in the mean low-density lipoprotein cholesterol from 76.4 mg/dL at baseline to 57.7 mg/dL overall.

CONCLUSIONS

The SANTORINI real-world data in Austria suggest that a proportion of high and very high-risk patients remain below the guideline-recommended low-density lipoprotein cholesterol goals. Optimising use of oral ezetimibe and bempedoic acid after statins in the lipid-lowering pathway could result in substantially more patients attaining low-density lipoprotein cholesterol goals, likely with additional health benefits.

Treatment gaps in the implementation of LDL cholesterol control among high- and very high-risk patients in Europe between 2020 and 2021: the multinational observational SANTORINI study

Background

European data pre-2019 suggest statin monotherapy is the most common approach to lipid management for preventing cardiovascular (CV) events, resulting in only one-fifth of high- and very high-risk patients achieving the 2019 ESC/EAS recommended low-density lipoprotein cholesterol (LDL-C) goals. Whether the treatment landscape has evolved, or gaps persist remains of interest.

Methods

Baseline data are presented from SANTORINI, an observational, prospective study that documents the use of lipid-lowering therapies (LLTs) in patients ≥18 years at high or very high CV risk between 2020 and 2021 across primary and secondary care settings in 14 European countries.

Findings

Of 9602 enrolled patients, 9044 with complete data were included (mean age: 65.3 ± 10.9 years; 72.6% male). Physicians reported using 2019 ESC/EAS guidelines as a basis for CV risk classification in 52.0% (4706/9044) of patients (overall: high risk 29.2%; very high risk 70.8%). However, centrally re-assessed CV risk based on 2019 ESC/EAS guidelines suggested 6.5% (308/4706) and 91.0% (4284/4706) were high- and very high-risk patients, respectively. Overall, 21.8% of patients had no documented LLTs, 54.2% were receiving monotherapy and 24.0% combination LLT. Median (interquartile range [IQR]) LDL-C was 2.1 (1.6, 3.0) mmol/L (82 [60, 117] mg/dL), with 20.1% of patients achieving risk-based LDL-C goals as per the 2019 ESC/EAS guidelines.

Interpretation

At the time of study enrolment, 80% of high- and very high-risk patients failed to achieve 2019 ESC/EAS guidelines LDL-C goals. Contributory factors may include CV risk underestimation and underutilization of combination therapies. Further efforts are needed to achieve current guideline-recommended LDL-C goals.

Trial registration

ClinicalTrials.gov Identifier: NCT04271280.

Funding

This study is funded by Daiichi Sankyo Europe GmbH, Munich, Germany.

Early approach to LDL-related risk after acute coronary syndrome: The OPTA Project

INTRODUCTION

Hyperlipidemia is the main underlying cause of atherosclerotic cardiovascular disease. Reducing low-density lipoprotein (LDL) cholesterol to recommended targets after an acute coronary syndrome (ACS) is of utmost importance as it is associated with a reduction of mortality and further cardiovascular events. Unfortunately, there are considerable gaps between guideline recommendations and clinical practice. In addition, the approach to treatment of this population is very heterogeneous, even in specialized cardiovascular units. Some easy-to-implement strategies may help to optimize the management of these patients.

AREAS COVERED

The OPTA Project was developed to identify these gaps and to provide recommendations to improve and harmonize the management of patients with ACS, with a specific focus on lipids.

EXPERT OPINION

Five areas of interest were defined: 1) evaluation of cardiovascular risk at admission, 2) development of a strategy to effectively and rapidly reduce LDL cholesterol levels, 3) determining LDL cholesterol goals (<55 mg/dL or stricter) and follow-up, 4) data collection during hospitalization, and 5) standardized discharge report. Specific recommendations are given to reduce inequalities, following the targets "the lower, the better" and "the earlier, the better".

Real-World Attainment of Low-Density Lipoprotein Cholesterol Goals in Patients at High Risk of Cardiovascular Disease Treated with High-Intensity Statins: The TERESA Study

Despite steady improvements in cardiovascular disease (CVD) prevention, a scarce proportion of patients achieve the recommended LDL-C goals, even under high-intensity lipid-lowering therapy (LLT). Our study aimed to evaluate the attainment rate of LDL-C targets recommended by the 2019 European guidelines, and to characterize potential factors associated with LDL-C goal achievement and change patterns in LLT. We conducted a retrospective, observational study on patients treated with high-intensity atorvastatin or rosuvastatin ± ezetimibe at cardiology and internal medicine clinics across Spain. It included 1570 evaluable patients (median age: 62 years; established CVD: 77.5% [myocardial infarction: 34.3%]; and 85.8% at very high cardiovascular risk). Rosuvastatin ± ezetimibe was the LLT in 52.2% of patients, and atorvastatin ± ezetimibe in 47.8%. LLT had been modified in 36.8% of patients (side effects: 10%), being the most common switch from atorvastatin- to rosuvastatin-based treatment (77.2%). The risk-based LDL-C goal attainment rate was 31.1%, with 78.2% high-risk and 71.7% very high-risk patients not achieving the recommended LDL-C targets. Established CVD and familial hypercholesterolemia were significantly associated with the non-achievement of LDL-C goals. Although having limitations, this study shows that the guideline-recommended LDL-C goal attainment rate is still suboptimal despite using high-intensity statin therapy in a real-world setting in Spain.

Cardiovascular Risk in Patients with Dyslipidemia and Their Degree of Control as Perceived by Primary Care Physicians in a Survey-TERESA-Opinion Study

OBJECTIVE

The aim of this study was to evaluate, through a survey, the opinion of primary care (PC) physicians on the magnitude of dyslipidemia and its degree of control in their clinical practice.

MATERIALS AND METHODS

An ecological study was carried out, in which the physicians were invited to participate by means of an online letter. Data were collected at a single timepoint and were based only on the experience, knowledge, and routine clinical practice of the participating physician.

RESULTS

A total of 300 physicians answered the questionnaire and estimated the prevalence of dyslipidemia between 2% and 80%. They estimated that 23.5% of their patients were high-risk, 18.2% were very high-risk, and 14.4% had recurrent events in the last 2 years. The PC physicians considered that 61.5% of their patients achieved the targets set. The participants fixed the presence of side-effects to statins at 14%. The statin that was considered safest with regard to side-effects was rosuvastatin (69%).

CONCLUSIONS

PC physicians in Spain perceive that the CVR of their patients is high. This, together with the overestimation of the degree of control of LDL-C, could justify the inertia in the treatment of lipids. Moreover, they perceive that one-sixth of the patients treated with statins have side-effects.

European Physician Survey Characterizing the Clinical Pathway and Treatment Patterns of Patients Post-Myocardial Infarction

INTRODUCTION

The 2019 European Society of Cardiology and European Atherosclerosis Society (2019 ESC/EAS) guidelines stress the importance of managing low-density lipoprotein cholesterol (LDL-C) after myocardial infarction (MI) to reduce the risk of cardiovascular events. Information on guideline implementation is limited. The aim of this survey was to describe current clinical practice regarding LDL-C management in the first year post-MI across Europe, improving understanding of the role of ESC/EAS guidelines on clinical practice.

METHODS

A qualitative web-based cross-sectional physician survey about the patient pathway and LDL-C management post-MI was conducted in 360 physicians from France, Italy, Germany, The Netherlands, Spain, and the UK (n = 60/country) between December 2019 and June 2020. Secondary and primary care physicians (SCPs/PCPs) described their experiences treating patients post-MI over the preceding 2 months.

RESULTS

Physicians reported that on average 90.7% of patients not prescribed lipid-lowering therapy (LLT) before an MI initiated LLT as inpatients; for patients already taking LLT, treatment was intensified for 64.7% of inpatients post-MI. SCPs reported prescribing higher-intensity statins and/or ezetimibe for between 72.3% (Italy) and 88.6% (UK) of patients post-MI. More than 80.0% of SCPs and 51.2% of PCPs stated that they would initiate a change in LLT immediately if patients did not achieve their LDL-C treatment goal by 12 weeks post-MI; 82.0% of SCPs and 55.1% of PCPs reported referring to 2019 ESC/EAS guidelines for management of patients post-MI. Barriers to initiating PCSK9 inhibitors (PCSK9is) included prior prescription of a maximally tolerated dose of statin (49.4%) and/or ezetimibe (38.9%), requirement to reach threshold LDL-C levels (44.9%), and pre-authorization requirements (30.4%).

CONCLUSION

Differences in clinical practice post-MI were reported across the countries surveyed, including divergence between 2019 ESC/EAS and local guidelines. Increased use of innovative medicines to achieve LDL-C goals should reduce risk of subsequent cardiovascular events in very high-risk patients post-MI.

Treatment and low-density lipoprotein cholesterol levels in patients with hypercholesterolaemia or mixed dyslipidaemia at high or very high cardiovascular risk: a population-based cross-sectional study in the Netherlands

OBJECTIVE

To describe treatment patterns, low-density lipoprotein cholesterol (LDL-C) levels and healthcare resource utilization (HCRU) in the Netherlands in 2018 of patients with hypercholesterolaemia or mixed dyslipidaemia at high or very high cardiovascular (CV) risk.

METHODS

From the PHARMO Database Network adult patients with a diagnosis or receiving lipid lowering therapy (LLT) between 2009 and 2018 were selected. Patients at high or very high CV risk according to 2016 ESC/EAS guidelines with recorded LDL-C levels who were treated with LLT or were characterized as statin intolerant in 2018 were included. LLT treatment patterns, LDL-C levels and HCRU (General Practitioner [GP] consultations and hospitalizations) were assessed.

RESULTS

The study population included 54,346 patients, of which 70% were at very high CV risk and 30% at high CV risk. The majority (93%) received statin monotherapy, mostly of moderate (73%) or high (15%) intensity. Only 3% received a combination of statin and ezetimibe. Statin intolerance, based on a treatment algorithm, was estimated at 3%. Average LDL-C decreased with LLT intensity. Overall, 74% reached LDL-C < 2.5 mmol/l and 34% <1.8 mmol/l with their current treatment, and 46% reached their LDL-C goal according to 2016 ESC/EAS guidelines. The highest rates of hospitalizations and GP consultations, including home visits, were recorded in patients with peripheral artery disease or polyvascular disease.

CONCLUSION

The treatment of hypercholesterolaemia and mixed dyslipidaemia in patients at high or very high CV risk in the Netherlands was suboptimal in 2018. To further lower CV risk alternative treatment strategies using add-on therapies are needed.

LDL-C: The Only Causal Risk Factor for ASCVD. Why Is It Still Overlooked and Underestimated?

PURPOSE OF REVIEW

Low-density lipoprotein cholesterol (LDL-C) is the most important causal risk factor for atherosclerotic cardiovascular disease (ASCVD). This article reviews why LDL-C remains overlooked and underestimated despite numerous studies that have proved its role.

RECENT FINDINGS

Recently published EAS/ESC Guidelines for dyslipidemia and EAS Guidelines for prevention set new targets for LDL-C levels in primary and secondary prevention of ASCVD. These guidelines are based on data from large studies and meta-analyzes that have shown that lower LDL-C also means lower cardiovascular event rates. Real-life experience published in registries worldwide has shown us that the guidelines have not been translated to everyday clinical practice, meaning that a significant number of patients are undertreated and have LDL-C levels well above target. Potential reasons for the abovementioned are poor adherence and education of the patient and physician and health care system related factors. Implementation of the latest version of guidelines will require continuous patient and physicians education, as well as a shared decision-making process between physician and patient.