Very high LDL-C, no coronary calcification, low risk?The Danish study

2022-05-25 0 By

At present, for patients with severe hypercholesterolemia with low density lipoprotein cholesterol (LDL-C) ≥4.9 mmol/L, the European and American guidelines for dyslipidemia management strongly recommend the use of statins for treatment.Furthermore, the 2019 Guidelines for dyslipidemia of the European Society of Cardiology (ESC) uniformly classified patients with LDL-C≥4.9 mmol/L as high-risk groups, and recommended ldL-C treatment targets as.To achieve this goal, many patients need to be treated with other lipid-lowering drugs, such as ezetimibe or PCSK9 inhibitors, in addition to the maximum tolerated dose of statin.However, in recent years, some studies have found that even ldL-C ≥4.9 mmol/L, the coronary calcification score of some patients is 0.So, do these patients also belong to the high-risk group?Do you still need lipid-lowering drugs?On February 11, JAMA network open to a Danish study published ZiKan found that in patients with coronary heart disease symptoms, regardless of level of LDL – C high or low, as long as the coronary calcification score of 0, the risk of atherosclerotic cardiovascular disease and death are low, and with the increase of coronary calcification score, the incidence of these events increased.The findings suggest that atherosclerosis is caused by multiple factors, not just LDL-C levels, the researchers note.In patients with LDL-C≥4.9 mmol/L, atherosclerotic load, including coronary calcification score, can be used to identify low-risk patients and thus individually determine treatment intensity.The study also showed that 46.2% of patients with LDL-C≥4.9 mmol/L had a coronary calcification score of 0 on coronary CT, of which 77.2% did not detect coronary plaque.That’s not too different from the percentage of patients with lower LDL-C levels.However, in all patients with coronary calcification score of 0, the proportion of non-calcified plaque and obstructive plaque gradually increased with the increase of LDL-C level: the proportion of non-calcified plaque was 11.4% and 22.8%, and the proportion of obstructive plaque was 4.7% and 9.6%, respectively, in patients with LDL-C and ≥4.9 mmol/L.However, there was no clear correlation between the prevalence of coronary calcified plaque and LDL-C level.Data were collected from the Western Danish Heart Registry, which represents half of Denmark. A total of 23143 patients with symptoms of coronary heart disease, but not previously diagnosed coronary heart disease, were 58 years old, 55.6% were female, and 4.1% of them had LDL-C≥4.9 mmol/L.During a median follow-up of 4.2 years, 1029 atherosclerotic cardiovascular events (mi and stroke) and deaths occurred.Analysis showed that the incidence of atherosclerotic cardiovascular events and death was lower in patients with a coronary calcification score of 0 (6.3 per 1000 years);In patients with LDL-C≥4.9 mmol/L, the incidence of these events was only 6.9 per 1000 years.The incidence increased as coronary calcification scores increased (11.1 per 1000 years and 21.9 per 1000 years for patients with 1-99 and 100 points, respectively).The incidence of these end points was similar in patients with different LDL-C levels;Patients with a coronary calcification score of 0 had a lower incidence of these events regardless of whether there was no coronary plaque or only non-calcified plaque.On the one hand, the absence of coronary plaque, whether ldL-C was high or low, was associated with a lower incidence of atherosclerotic cardiovascular events and mortality;On the other hand, the presence of coronary plaque, the higher the coronary calcification score, the higher the cardiovascular risk.First, a coronary calcification score of 0 or no coronary plaque seems to be a safe signal for patients with severe hypercholesterolemia who may have symptoms of coronary heart disease.Second, coronary CT may be useful in screening symptomatic patients with severe hypercholesterolemia, since 22.8% of patients with severe hypercholesterolemia in this study had non-calcified plaques and 9.8% had non-calcified and obstructive plaques, which are prognostic.Third, a coronary calcification score of 0 or no coronary plaque does not mean that patients with severe hypercholesterolemia do not need statin therapy, especially in younger patients.Imaging studies may help guide the use of PCSK9 inhibitors in patients who still fail to meet LDL-C standards after statin therapy.Source:[1]Association of Coronary Plaque With Low-Density Lipoprotein Cholesterol Levels and Rates of Cardiovascular Disease Events Among Symptomatic Adults. JAMA Netw Open. 2022;5(2):e2148139.[2]Calcified and Noncalcified Coronary Plaques and Atherosclerotic Cardiovascular Events in Patients With Objective to study the Risk Stratification and Therapy of chronic hyperemia and Moving Forward. JAMA Netw Open. 2022;Many difficult and complicated cases are only seen by a doctor once in his lifetime