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© JUAN GÄRTNER/STOCK.ADOBE.COM. LDL-cholesterol in blood.
More intensive LDL-C lowering benefits higher baseline LDL-C levels

By Bianca Nogrady
The mortality benefits of more intensive LDL-cholesterol (LDL-C) lowering are only evident in individuals with a higher baseline LDL-C level, new research suggests.

Researchers sought to clarify the magnitude of reductions in all-cause and cardiovascular (CV) mortality from intensive LDL-C lowering therapy in a systematic review and meta-analysis of 34 randomised clinical trials involving 270,288 participants, published in JAMA. They found an 8% reduction in all-cause mortality with more intensive LDL-C lowering, but this was only evident in trials with a baseline LDL-C greater than 100mg/dL (2.59mmol/L).

Among patients with a baseline LDL-C of 160 mg/dL (4.14mmol/L) or greater, more intensive LDL-C lowering therapy was associated with a 28% reduction in the risk of all-cause mortality.

Similarly, more intensive LDL-C lowering was associated with a significant 16% reduction in CV mortality, but only in trials with the higher baseline LDL-C. In subgroups with the baseline LDL-C of 160mg/dL or more, there was a 35% reduction in CV mortality with more intensive LDL-C lowering therapy.

The analysis also showed progressively greater reductions in the risk of myocardial infarction, revascularisation and major adverse cardiac events with more intensive LDL-C lowering, but no significant difference between more or less intensive LDL-C lowering therapy in cerebrovascular event risk, regardless of baseline LDL-C levels.

‘This analysis further supports individualising estimates of the potential for a cardiovascular risk reduction benefit from LDL-C lowering therapy based on consideration of not only a patient’s absolute risk and current LDL-C level but also an individualised estimate of the risk reduction based on current LDL-C level and the outcomes desired,’ the researchers wrote.

‘If additional LDL-C lowering therapies are considered in statin-treated patients, nonstatin LDL-C lowering therapies shown to reduce cardiovascular disease events are recommended.’

Associate Professor Julie Redfern, from Westmead Clinical School at The University of Sydney, said the paper’s large, well-conducted analysis confirmed that the worse a patient’s baseline LDL-C levels, the greater room there was for improvement and greater reductions in the risk of death and CV events. ‘It reinforces the importance of everyone having their LDL-C managed and reduced as low as possible, but remembering, this is really for people with existing CV,’ she told Cardiology Today.
JAMA 2018; 319: 1566-1579.