This article is part of our special report Cardiovascular health.
SPECIAL REPORT / Researchers have called for lowering the official recommended threshold for bad cholesterol, arguing new drugs now make it possible to go below the currently accepted limit.
When it comes to bad cholesterol, also known as LDL, lower is always better, according to researchers working on cardiovascular diseases.
This was one of the main messages at the European Society of Cardiology (ESC) congress, which took place in London last week (29 August – 5 September).
In 2011, the European Atherosclerosis Society (EAS) and the ESC recommended that patients at very high risk of cardiovascular disease should lower their levels of Low-density lipoprotein (LDL) below 70 mg/dl (miligrams per deciliter).
For patients at high risk of cardiovascular disease, the target goal is less than 100 mg/dl. If this target cannot be achieved, physicians are advised to aim for halving LDL levels at the very least.
But in late 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) presented new guidelines which eliminated numerical targets for LDL cholesterol.
Now, researchers speaking at the ESC congress in London want to reinstate them, saying specific LDL targets for high risk patients are not only needed but should be lower than the current ones.
John Kastelein, a professor of medicine from the University of Amsterdam and Kausik Ray, a professor of cardiovascular disease prevention, said they strongly disagree with the ACC and AHA guidelines, which lack any explicit goals for LDL.
Ray said that despite the recommendation from the EAS and the ESC, he would always recommend doctors to get the LDL level as low as possible.
“That is what is going to do the most good for the patient,” he told the ESC congress in London.
Kastelein said that despite the European guidelines, many high-risk patients who receive LDL-lowering drugs – also known as statins – are unable to reach their targets in more than 33% of cases.
The proportion is even worse for patients who suffer from Familial Hypercholesterolemia (FH), a genetic disorder characterised by high cholesterol levels, which is transmitted from generation to generation, Kastelein said.
While it was previously thought that 1 in 500 people have FH, researchers now believe the proportion to be double (1 in 250), making FH one of the most common heritable diseases across the globe.
Kastelein mentioned two reasons why patients are unable to reach their cholesterol targets. First of all, statins are not always powerful enough to lower LDL to targets to the desired level.
Secondly, not all patients can tolerate statins. “In my clinic, 20 years ago the main reason for referral was very high LDL cholesterol. Now one of the main reasons for referral is statin intolerance,” Kastelein said.
New drugs could potentially address the issue and sharply lower LDL for patients who are intolerant to statins. Praluent, a new powerful cholesterol drug from Sanofi and Reneron was given market approval in Europe last February, two months behind Repatha, a rival product from Amgen.
But Ray also underlined that the new drugs have to he handled with care, saying doctors need to consider different doses for individual patients.
“Tailored treatment to different starting points for the levels of LDL cholesterol should be the way forward,” Ray said. “For an individual, I think we need to think of a way to integrate absolute risk and then determine the absolute risk reduction when you make targets for this particular individual,” he continued.
Robert Eckel, a professor of medicine from the University of Colorado in the US, also called for the use of new drugs as some have proven to lower the levels of bad cholesterol by up to 70%.
“They appear relevant when additional lowering of cholesterol is needed such as for FH, for high risk patients and for people who are statin intolerant,” Eckel said.