Lower LDL Target For People with Stable Coronary Disease

I have followed the present recommendations for treating low density lipoprotein (LDL) cholesterol. Targets in the current guidelines are as follows:

  • LDL cholesterol less than 100 mg/dL for those with stable coronary heart disease (CHD)
  • LDL cholesterol less than 70 mg/dL for patients at high risk

A new study suggests that LDL cholesterol should be lowered to less than 70 mg/dL in all patients with known CHD. This study treated 10,000 patients with stable CHD and a starting LDL cholesterol level less than 130 mg/dL with either a low or high dose of the statin atorvastatin. Patients treated with the low dose had average LDL cholesterol levels of 101 mg/dL; in those on the high dose the average LDL cholesterol was 77 mg/dL. During a follow-up period of 4.9 years, patients on the high dose had significantly fewer coronary events and strokes, but no lower death rate, than those taking the low dose of atorvastatin. The high dose was not associated with any greater incidence of serious adverse events.

The results of this and other studies tempt me to aim for an LDL cholesterol below 70 mg/dL in patients with CHD, but I'm still not sure that the target should apply to all patients with CHD. Several drugs may be required to achieve this goal in some patients, and it's not clear whether the benefits in the study were entirely due to the low LDL cholesterol rather than to some other protective effect of the statin. Furthermore, the decrease in cardiovascular events was not matched by a decline in overall mortality.

These studies also raise questions about what to do with the millions of people who have slightly high LDL cholesterol levels but no recognized CHD despite the presence of substantial amounts of narrowing in their arteries due to atherosclerosis. These people will be the next targets, and soon a statin drug will be recommended for almost everybody.