Lowering LDL-C for the high-risk patient is well-established, especially for secondary prevention. In these patients, the absolute risk of cardiovascular event is high and trial after trial with various different LDL-C lowering strategies have consistenly shown risk reduction elicited by LDL-C lowering. In high risk patients, many clinicians are adopting the viewpoint that LDL-C is a poison and no level of LDL-C reduction is too low. We're not just talking about statins (HMG-CoA reductase inhibitors), but other LDL-C lowering drugs as well including ezetimibe (NPC1L1 inhibitor), PCSK9 antibodies, and soon to be approved and added to the toolbox inclisiran (PCSK9 RNAi) and bempedoic acid (ATP-citrate lyase inhibitor). 

There are many risk factors to consider in evaluating whether LDL-C lowering is right for the patient. For an otherwise healthy patient with LDL-C under 150 mg/dL, the absolute risk for cardio event is low and most docs wouldn't even consider an LDL-C lowering drug. Would a LDL-C lowering drug lower the low-risk patient's absolute risk? Probably. But, one needs to balance the pros and cons of treating vs. not treating the low risk patient. LDL-C recommendations are always in flux. Some docs are more caught up on them than others. Some docs are more aggressive at primary prevention than others. But the final call is a decision between patient and doc to consider the cost/benefit.

However, as LDL-C creeps up towards 200 and above, or when other risk factors set in (diabetes, insulin resistance, obesity, hypertension, elevated triglycerides, age, etc), then many docs will have a lower threshhold for prescribing an LDL-C lowering strategy for primary prevention. In these cases, it is extremely wise to take the docs advice and get that LDL-C under control. LDL-C as a risk factor has been proven time and time again.

An excellent review came out yesterday. 

Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel

https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz962/5735221

BDAZ