• James Underberg, Peter P Toth, and Fatima Rodriguez.
• Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.
• Postgrad Med. 2022 Nov 1; 134 (8): 752-762.

AbstractAtherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the United States. Elevated low-density lipoprotein cholesterol (LDL-C) is a major causal risk factor for ASCVD. Current evidence overwhelmingly demonstrates that lowering LDL-C reduces the risk of secondary cardiovascular events in patients with previous myocardial infarction or stroke. There is no lower limit for LDL-C: large, randomized studies and meta-analyses have found continuous benefit and no safety concerns in patients achieving LDL-C levels <25 mg/dL. As 'Time is plaque' in patients with ASCVD, early, sustained reductions in LDL-C are critical to slow or halt disease progression. However, despite use of lipid-lowering medications, <30% of patients with ASCVD achieve guideline-recommended reductions in LDL-C, resulting in a substantial societal burden of preventable cardiovascular events and early mortality. LDL-C goals are not met due to several factors: lipid-lowering therapy is not initiated and intensified as directed by clinical guidelines (clinical inertia); most patients do not adhere to prescribed medications; and high-risk patients are frequently denied access to add-on therapies by their insurance providers. Promoting patient and clinician education, multidisciplinary collaboration, and other interventions may help to overcome these barriers. Ultimately, achieving population-level guideline-recommended reductions in LDL-C will require a collaborative effort from patients, clinicians, relevant professional societies, drug manufacturers, and payers.

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