LDL-C Treatment Goals: Clinical Guidelines

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Updated AHA/ACC LDL-C treatment guidelines may present a challenge for you and your patients^1,2

• • The ATP III Update set an LDL-C goal of <130 mg/dL for patients with 2+ risk factors (10-year risk
  10%-20%) and an optional goal of <100 mg/dL.¹
• • The AHA/ACC 2006 Update does not modify recommendations of the ATP III 2004 Update for patients with atherosclerotic disease who have diabetes or multiple risk factors and a 10-year risk level for CHD >20% or for individuals with other types of lower-risk factors who do not have CHD or other forms of atherosclerotic disease.²

^aFactors that place a patient at very high risk: established cardiovascular disease (CVD) plus: multiple major risk factors (especially diabetes); severe and poorly controlled risk factors (eg, cigarette smoking); multiple risk factors of the metabolic syndrome; and acute coronary syndromes.¹

^bAnd other forms of atherosclerotic disease.²

LDL-C remains the primary target of lipid-lowering therapy.¹

If it is not possible to attain LDL-C <70 mg/dL because of a high baseline LDL-C, it is generally possible to achieve LDL-C reductions of >50% with more intensive LDL-C–lowering therapy, including drug combinations.²

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As observed in the NHANES survey of 1,907 patients

In very high-risk patients, providing the LDL-C reduction needed to achieve
<70 mg/dL LDL-C may be a challenge^3,c

^cPatients were classified as very high risk (n=209) if they had coronary heart disease and >2 risk factors.

^dMean reduction needed is based on the weighted averages of individual distance to goal + percent reduction needed to reach goal.

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Many treated and untreated high-risk patients did not reach NCEP ATP III 2004 Update target LDL-C levels^1,5

Based on an analysis from a large managed care database of treated and untreated high-risk US patients (CHD or CHD risk-equivalent)⁵

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Is statin titration enough?

In a clinical trial in patients with hypercholesterolemia, titrating atorvastatin provided limited additional LDL-C reduction.⁶

• • Mean untreated baseline LDL-C was 180.6 mg/dL for the atorvastatin 10-mg group.
• • Primary end point: percent change in LDL-C from baseline to week 6.
• • Atorvastatin 10 mg provided initial LDL-C reduction from untreated baseline of 37%.

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Rosuvastatin titration – Stein 2003⁷

In a clinical trial in patients with hypercholesterolemia, titrating rosuvastatin provided limited additional LDL-C reduction.

• • Mean untreated baseline LDL-C was 292 mg/dL for the rosuvastatin group.
• • Primary end point: percent change in LDL-C from baseline to week 18.
• • Rosuvastatin 20 mg provided initial LDL-C reduction from untreated baseline of 47%.

References: 1. Grundy SM, Cleeman Jl, Merz CNB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227–239. 2. Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation. 2006;113:2363–2372. 3. Data available on request from Merck, Professional Services-DAP, WP1-27, PO Box 4, West Point, PA 19486-0004. Please specify information package 21050988(1)-MSP. 4. NCEP Expert Panel. Final Report of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, MD: National Heart, Lung, and Blood Institute, National Institutes of Health; 2002. NIH publication 02-5215. 5. Data available on request from Merck, Professional Services-DAP, WP1-27, PO Box 4, West Point, PA 19486-0004. Please specify information package CARD-1012394-0000. 6. Ballantyne CM, Blazing MA, King TR, et al. Efficacy and safety of ezetimibe co-administered with simvastatin compared with atorvastatin in adults with hypercholesterolemia. Am J Cardiol. 2004;93:1487–1494. 7. Stein EA, Strutt K, Southworth H, et al. Comparison of rosuvastatin versus atorvastatin in patients with heterozygous familial hypercholesterolemia. Am J Cardiol. 2003;92:1287–1293.