LDL-C target attainment in secondary prevention of ASCVD in the United States: barriers, consequences of nonachievement, and strategies to reach goals

Figures & data

Figure 1. Effects of lifetime exposure to LDL-C on ASCVD risk. ACS, acute coronary syndrome; ASCVD, atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction. [Figure reproduced with permission from Ference BA et al. J Am Coll Cardiol 2018;72:2980–2995 [8] Copyright © 2018, Elsevier].

Figure 2. Effects of statin versus control therapy and more versus less statin on major vascular events. CABG, coronary artery bypass graft; CHD, coronary heart disease; CI, confidence interval; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; PTCA, percutaneous transluminal coronary angioplasty; RR, rate ratio. [Figure reproduced with permission from Baigent C et al. Lancet. 2010;376(9753):1670–1681 [18] Copyright © 2010, Elsevier].

Table 1. Clinical consensus for maximum, sustained reductions in LDL-C.

Clinical guideline(s)	Recommendation
ACC/AHA multi-specialty guideline on the management of blood cholesterol [10]	Target ≥50% reduction in LDL-C for high-risk patients [62,63]
ACC/AHA guideline on the primary prevention of CVD [38]
ESC guidelines on the management of dyslipidemias [62], ACS [39], and diabetes, pre-diabetes, and CVD [63]
AACE/ACE consensus statement on the management of dyslipidemia and prevention of CVD [40]
ESC/EAS guidelines [62]	Target <40 mg/dL if a patient sustains a recurrent CV event within 2 years of the previous one

AACE, American Association of Clinical Endocrinologists; ACC, American College of Cardiology; ACE, American College of Endocrinology; ACS, acute coronary syndrome, AHA, American Heart Association; CV, cardiovascular; CVD, cardiovascular disease; EAS, European Atherosclerosis Society; ESC, European Society of Cardiology; LDL-C, low-density lipoprotein cholesterol.

Table 2. Barriers and strategies to achieving target, sustained LDL-C reductions.

Barrier	Strategies
Clinical inertia	Routine monitoring of LDL-C Renewed commitment from clinicians
Low medication adherence	Identify demographic, structural, and socioeconomic risk factors Understand motivations Provide patient and clinician education Utilize health information technology
Limited access	Multidisciplinary and cross-sector collaboration

LDL-C, low-density lipoprotein cholesterol.

Figure 3. The barriers to achieving LDL-C goals and strategies to overcome them. ASCVD, atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; LLT, lipid-lowering therapy; PCSK9; proprotein convertase subtilisin kexin 9.

Table

AE	Adverse events
ASCVD	Atherosclerotic cardiovascular disease
CV	Cardiovascular
CVD	Cardiovascular disease
EMR	Electronic medical records
LDL	Low-density lipoprotein
LDL-C	Low-density lipoprotein cholesterol
LLT	Lipid-lowering therapy
MI	Myocardial infarction
MPR	Medication possession ratio
PALM	Provider Assessment of Lipid Management
PCSK9i	Proprotein convertase subtilisin kexin 9 inhibitor
PDC	Proportion of days covered

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