Recent Developments in Lipid Management

LDL cholesterol is causal for atherosclerotic disease, and lower is better. The question has moved from whether to treat to how quickly we can reach the target.

Targets by risk category

The 2019 ESC/EAS guidelines set LDL cholesterol goals by cardiovascular risk:

• Very high risk: below 55 mg/dL and at least a 50% reduction from baseline
• High risk: below 70 mg/dL
• Moderate risk: below 100 mg/dL
• Low risk: below 116 mg/dL

The Lipid Association of India adds an extreme-risk category with lower targets, reflecting the high burden of premature coronary disease in India.

Combination therapy, earlier

Many patients will not reach very-high-risk targets with a statin alone. A high-intensity statin, followed by ezetimibe and then a PCSK9 inhibitor, is the usual sequence. Starting combination therapy early after an acute coronary syndrome is increasingly common.

Reaching the target matters more than the choice of the first drug.

Newer options

• Inclisiran, a small interfering RNA, lowers LDL cholesterol by around half with twice-yearly injections after the first two doses.
• Bempedoic acid reduced major cardiovascular events in statin-intolerant patients in the CLEAR Outcomes trial.

Lipoprotein(a)

Lipoprotein(a) is largely genetic and is not lowered by statins. Measuring it at least once in a lifetime helps refine risk, particularly in patients with premature disease or a strong family history.