How close to European guidelines are the actually achieved LDL cholesterol values in clinical practice?

Lipid-lowering therapy (LLT), primarily with statins, has been strongly recommended by joint guidelines of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) for the Management of Dyslipidaemias to reduce cardiovascular risk. According to the calculated cardiovascular risk, recommendations for LDL-C goals are getting lower, comparing 2016¹ with 2019² guidelines, both for primary and secondary prevention. On the other hand, adherence to those targets, proposed by solid evidence, looks too challenging when is applied to daily practice.

In the EU-Wide Cross-Sectional Observational Study of Lipid-Modifying Therapy Use in Secondary and Primary CARE (DA VINCI study) the aim was to investigate the degree of LDL-C goal achievement for adult patients in different cardiovascular risk categories, being prescribed LLT, from 18 European countries between June 2017 and November 2018. ³ All the relevant data (demographics, medical history, most recent LDL-C measurement in the previous 14 months, comorbidity etc.) were extracted from the patients’ medical records. SCORE and REACH were used to assess cardiovascular risk profiles in primary and secondary prevention respectively. Apart from the attainment of treatment targets recommended by ESC/EAS 2016 guidelines, a post hoc analysis of the proportion of patients achieving the ESC/EAS 2019 was also performed for comparison.

Of the 5,888 patients enrolled in the study 3,000 of them were registered in primary care, whereas from the rest 2,888, 97% of them had a diagnosis of established atherosclerotic cardiovascular disease. Overall, 54% of the study population had attained their risk-based 2016 LDL-C treatment goal. Goal attainment was higher in moderate-risk patients in primary prevention using low-intensity statin monotherapy (67%). In the group of patients with established ASCVD, only 39% of them achieved the very high-risk goal of LDL-C <1.8mmol/L, treated mainly with high-intensity statin monotherapy and much less in combination with ezetimibe or PCSK9 inhibitor. When ESC/EAS 2019 guidelines were used, only 60% in the primary prevention group and only 18% in the ASCVD established group achieved the LDL-C stratified risk goals.

Despite the minor methodological bias, the present study managed to highlight the gaps, commonly observed in clinical practice, between theories and practice i.e. guidelines recommendations and guidelines actual implementation. The acceptance of ESC/EAS guidelines by both the medical community and the patients and the degree of their endorsement by different health care systems, probably affect the clinical outcome, which is the failure to achieve the recommended treatment goals for LDL-C. This discrepancy was even greater with the lower treatment goals according to the updated 2019 guidelines, indicating the need for intensive and targeted policy interventions.