CLINICAL QUESTION

In patients with established atherosclerotic cardiovascular disease (ASCVD), should oral cholesterol medications be dosed to achieve a specific low-density lipoprotein cholesterol (LDLC) level or given as a fixed dose according to the patient's risk profile?

EVIDENCE-BASED ANSWER

In patients with established ASCVD, evidence supports dosing oral cholesterol-lowering medications to achieve a specific LDL-C target, ideally less than 70 mg/dL (1.81 mmol/L), rather than treatment based solely on risk profile. (Strength of Recommendation [SOR]: A, meta-analysis and randomized controlled trials [RCTs].) A recent consensus guideline recommends fixed-dose statin therapy based on the patient's risk profile. (SOR: C, expert opinion.)

EVIDENCE SUMMARY

ASCVD

A 2010 meta-analysis of 26 RCTs (N = 169,138) examined the effectiveness of LDL-C lowering with statins. Patients were primarily from high-income regions, male, 50 to 70 years of age, and with or without ASCVD. Interventions included various high-intensity statins. Primary outcomes were cause-specific mortality, major coronary event (death or nonfatal myocardial infarction), coronary revascularization (angioplasty or bypass grafting), stroke, and new cancer diagnosis. A major vascular event was defined as the first occurrence of any major coronary event, coronary revascularization, or stroke.¹