Dr Pam Taub Emphasizes Lower Is Better for LDL Cholesterol Levels

There is some confusion about the differences between the European and American guidelines on lowering low-density lipoprotein (LDL) cholesterol, but it’s clear that lower is better, said Pam Taub, MD, FACC, professor of medicine, Division of Cardiovascular Medicine, UC San Diego School of Medicine.


Both European and US multisociety dyslipidemia guidelines stress the importance of lowering low-density lipoprotein cholesterol. What needs to be adjusted in clinical practice to meet these guidelines and the goal levels?

So, I think there’s a lot of confusion about what our ideal LDL should be. And I think the guidelines, unfortunately, contribute to some of this confusion. So, for instance, the American guidelines really endorse an LDL threshold less than 70 [mg/dL]. And what that means is that’s the minimum that patients who’ve had prior events such as a heart attack or stroke should achieve. The European guidelines have a lower threshold of less than 55 [mg/dL].

And so, there some time is confusion among clinicians on what LDL levels should they be aiming for. And I think the message needs to come across: the lower the better. And I think it needs to be very clear that that 70 number that are in the AHA/ACC [American Heart Association/American College of Cardiology] guidelines is not a target, but it’s a minimum threshold.

The other point I always like to emphasize is if someone has a myocardial infarction, let’s say at an LDL of 100 [mg/dL], you don’t really want to be getting them to an LDL of 70 [mg/dL]; you want to aim for a 50% reduction from that 100 [mg/dL], and to get them to an LDL goal of 50 [mg/dL]. So, there just needs to be more clarity, and that term threshold is kind of the minimum standard, and that if you have an LDL of 70 [mg/dL] for a secondary prevention patient, that’s not enough, you need to get lower.

What we’ve also seen with a lot of studies, especially with the PCSK9 [roprotein convertase subtilisin/kexin type 9] inhibitors is the lower, the better. In some of the studies, we’ve seen that the LDL go as low as 20 [mg/dL]. And it’s safe, and it’s associated with improved outcomes. So, we need to be comfortable getting our LDLs even lower.

What I really do hope is both the European guidelines and the American guidelines will align so that there’s one number that we can all remember, so there’s less confusion.

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