Low-Density Lipoprotein Cholesterol Reduction: The End Is More Important Than the Means

Many epidemiologic studies and clinical trials have demonstrated the linear relation between elevated serum levels of low-density lipoprotein (LDL) cholesterol and the risk for coronary heart disease. Conversely, for each 1% reduction in LDL cholesterol in clinical trials, there is a corresponding 1% reduction in coronary heart disease risk. Although the degree of reduction is more important in affecting risk than the means used to lower LDL, statins are considered the most consistently effective means of lowering LDL. The National Cholesterol Education Program now recommends an optional goal of <70 mg/dl for patients at very high risk for coronary heart disease. In conclusion, on the basis of completed clinical trials, there is no evidence that achieving and maintaining such low levels of LDL cholesterol result in adverse effects. The most potent statins, rosuvastatin and atorvastatin, are capable of getting most patients to their LDL cholesterol goals, but combinations of statins with other drugs may be necessary for patients who require additional lipid lowering.