The Cumulative Burden of LDL-C

Summary

The experts emphasize that in addition to "lower is better" for LDL cholesterol, emerging data also shows that "lower faster is better" and "lower for longer is better" in reducing atherosclerotic cardiovascular disease (ASCVD) risk. Similar to the concept of smoking pack-years, there is increasing focus on "cholesterol years" of exposure even to mild elevations, likening LDL to an "endotoxin."

Early, intensive, sustained LDL lowering has the greatest population impact on lifetime ASCVD risk. However, there is often hesitation and inertia in practice rather than urgently treating to target soon after events. Combination lipid lowering therapy initiation is advocated to rapidly reduce LDL, analogous to a football quarterback throwing a long pass when time is running out rather than incrementally running the ball down the field.

Getting to goal faster reinforces behavior change and a sense of urgency. But critical first steps of checking lipids and knowing one's "score" are often lacking post-event. For example, up to 20% of patients with myocardial infraction (MI) may not get LDL checked in the first year. Without assessing LDL, one cannot determine if rapid, intensive treatment is needed.

In summary, the experts stress not only treating to lower LDL targets, but doing so faster and earlier after events, maintaining treatment for the long-term to minimize lifetime cholesterol exposure. However, clinical inertia and knowledge gaps impair delivery of optimally timed, intensive LDL lowering to realize maximum ASCVD risk reduction.

This summary was AI-generated and edited for clarity and readability.