yes , believer that the lower the LDL the better and use all prooducts available

goals of 70 are strict and have been known to lower risk known therapies are generally good to get that effect to try lower goals is difficult and will cause more failures for patients more pharmaceutical rx more side effects more cost more testing and f/u and i dont think the lower goals are more effective

Getting LDL in these patients to < 55requires adherence to strict low saturated fat diet and usually a combination of multiple medications that are often either too expensive or not approved( PCSK9 i) and in addition there is also the tolerability factor ( injectables in case of PCSK9i)

yes- add zetia for an inexpensive option. if still not at goal of LDL below 55, add bempadoic acid or PSK9

Yes; I add Repatha to maximally tolerated statin to achieve LDL cholesterol to less than 55 mg %

REACH LDL UNDER 55 INSTEAD 100

WITH MAX TOLERATED STATIN AND PCSK-9 INH WITH ADDITION OF ZETIA AND IF NEEDED NEXLETOL IT IS EASY TO REACH A GOAL OF LDL LESS THAN 100

new guidelines to prevent 2nd CV event is LDL of 55, so I add PCSK9 inhibitor if needed

I usually defer these patients to cardiology, but will question the specialist if the therapy doesn't fit with the gudielines. It is usually a patient specific reason.

The answer is yes. I push patients' LDLs under 55 mg/dL in those who have had an ASCVD event such as an MI, unstable angina needing a stent, ischemic stroke, symptomatic limb ischemia, to name a few. Additionally, those who have not had an event but I see have polyvascular disease and DM with CKD will absolutely be treated as if they have had an event. My goal is to use the highest statin dose possible of either rosuvastatin or atorvastatin and I will supplement their usage with either evolocumab or bempedoic acid/ezetimibe.

i use maxium statin with pcsk9 toget ldl under 55

I lower the LDL certainly under 55, but I believe risk can be lowered still to about 40

I am doing my best to target my patients to reach LDL goals close to 55-60 and see the benefits firsthand.

Yes guideline indicate goal
Of 55 or less so its to goal
We shoot for

No, and I have not come across any specialists doing so. I may now.

I have been following this standard of care for years before this recommendation with a target < 50.

i have been using 70 as a goal, but with the new info will try to go lower using the newer drugs.

An LDL of 55 Request the use of PSK nine inhibitors however, as of late insurance carriers are proving to be very uncooperative

Try to achieve LDL goals <55 with addition of injectables or other nonstatins as allowed per insurance carrier. Would opt for aggressive LDL lowering in those with recent ACS or revascularization, diabetics with CKD or PAD in multiple sites

Certainly agree with aggressive LDL reduction in these hi risk patients.
Presumably max tolerated dose of a potent statin is first. If target is close I add Zetia since it cheap and easily accessible. If target is not close I use a PCSK9. Only a rare patient will still have an LDL greater than 55 at this point.
Use of statin, Zetia and PCSK9 is next.
Vascepa is not appropriate to use for LDL reduction; its indication is elevated triglycerides in a hi risk patients.
Lp(a) is also not relevant at this point in time.
Nexlitol would be the next choice as there is now some outcome data available, but for sure by now the insurance company is denying everything and the patient is squalking.

In the past, I have aimed for LDL less than 70. Now with the new guidelines which mimic the European guidelines I will aim for LDL less than 55. PSK9 will be added to more patients who cannot achieve that goal on a statin and zetia

Absolutely agree with the above recommendations for these high risk characteristics. I am trying to get most of my patients with established CAD/ PAD to an LDL of 50 mg/dl, for primary prevention, tolerate a little higher. Statin +/- zetia first, then consider PCSK9

Aim for less than 55 mg/dl in patients that have had events with all a combination of appropriate non statins as add on.

Absolutely agree with the above recommendations for these high risk characteristics. I am trying to get most of my patients with established CAD/ PAD to an LDL of 50 mg/dl, for primary prevention I allow a little higher. Statin +/- zetia first, then PCSK9 or if not allowed sometimes bempedoic acid

Yes, as an Endocrinologist I agree with above statements to bring the LDL as close as possible to 55 mg/dl. Diabetes is always considered high risk and diabetics with added PVD by above definition as well as ASCVD risk factors like high LaP or high Creactive protein are highest risk. Not all patients get to goal with statin-ezetimibe combo and PCSK9i are needed in that authorization process for PCSK9i has eased.

Yes, I agree with an aggressive lipid reduction with a goal LDL of less than 55 in all my
high risk patients.

- and most of my ASCVD patients fall into that category.

Thankfully, treatment options are becoming better.
However, insurance coverage and costs remain an issue.

I use combination of multiple medication,if tolerable with insurance coverage to get LDL cholesterol under 55 in any arterial vascular disease;max statins,PCsk inibitors,also Nexlizet and vascepa if needed

I agree with aggressive lipid reduction, specifically below LDL of 55, in all patients with a previous history of ASCVD events. However, it can be difficult if they are starting out a high LDL and are either intolerant or resistant to statins. Getting the next line of non-statin therapies like PCSK-9 inhibitors and bempedoic acid covered by insurance can be difficult. The most likely covered non-statin is Zetia which tends to be ineffective.

Yes. Most of my patients with ASCVD fit into this high risk profile as they have multiple other medical conditions. Statin may not be enough. I am using more zetia benpenoic acid and PCSK 9 inhibitors to get patients to goal

The 20-25% reduction in LDL cholesterol reported for bempedoic acid is less than the 40-50% reductions typically achieved with statins.
The use of a PCSK9i will achieve 50-60% LDL reduction

Issues of insurance coverage limits use of PCSK9 in certain patients but agree w LDL less than 55

I would recommend the use of PCSK9 inhibitors to achieve LDL of less than 55

Yes I aggressively lower the risk of MACE in patients who are not at goal. There are non statins available to combine with statins that was well tolerated and are the standard of care.

For individuals with established ASCVD and in those at particularly high-risk, including those with elevated lipoprotein(a) levels, LDL goal is less than 55 mg/dl. This goal is achieved through potent statin drug therapy, additional agents, as indicated, and lifestyle modification/behavioral/and exercise management.

Yes I push to lower the ldl-c < 55 mg/dl, using high dose statin, ezetimibe, when necessary pcsk-9 inhibitors, vascepa, nexletol if approved.

Yes. I identify the patients at high risk and aggressively try to achieve LDL below 55. Usually this requires several medicines and the challenge is more with patients tolerating the medicines or insurance coverage and affordability

Yes, I aim for an LDL-cholesterol goal in any of my patients who have suffered a cardiac event. That means dietary instruction in a whole food plant based diet (or Mediterranean diet if the patient declines whole food plant based diet), high dose statin therapy and consider addition of ezetimide or PCSK9 inhibitor if needed to approach LDL-cholesterol goal. Unfortunately, some such patients have an elevated LP(a) level, which doesn't respond to statin, and LP(a) declines by only 20-25% with PCSK9 inhibitor therapy, and no strong LP(a) lowering drugs are approved at this time

Yes, of course. Aiming for an LDL-C level below 55 mg/dL in patients who have experienced a major ASCVD event is recommended, especially for those at very high risk. This target is supported by current guidelines which suggest intensive lipid-lowering therapy to achieve substantial reduction in LDL-C levels to minimize the risk of recurrent ASCVD events

Agree with aggressive LDL lowering (likely without a lower limit) which is now easier with the addition of non-statin meds, although sometimes coverage (and patient reluctance!) can be obstacles.

PCSK 9 INHIBITOR ALONG WITH BEMPOBIC ACID ALONOG WITH EZETIMBIE WILL ACHEIVE 70-80 PERCENT LDL REDUCTION

It is a great time to practice Lipidology as we have much better insight in the pathogenesis of atheromatous plaque ! There is much more awareness of the managing lipids in primary prevention than ever and the most in secondary prevention ! We have been focussed on LDL for long time then came along REDUCE IT trial for Vascepa and highlighted the imporatnce of the Trig reduction in secondary prevention but Lpa is the latest buzz in lipid management as has been idendtified as marker for increased CV risk and has been the focus in HORIZON trial for its reduction in secodary prevention ! Now the question is how much LDL reduction is enough in secondary prevention as per Steve Nissen of Cleveland Clinics you can not have too much of three things " can not be too rich , can not be too thin , and can not have too much of lower LDL " LDL hypothesis still remains the cornerstone of CAD prevention and is not how high it is what is more important is how long it has been high in circulation ! How you can reduce further in secondary prevention in statin tolerated pts it is important to maximize the dose of statins , and how much you reduce it depends upon what was the LDL at the time of the event and if pt has an event at a suitable dose of statin then it is imperative to add Ezetemibe bases on IMPROVE IT trial for easily afforable and well tolerated option it is generally believed that LDL needs to be reduced by 30-40 % from the level where the event occured If any issue with the statin tolerance then PCSK-9 inhibitors are great choice in particular where Lpa is also elevated otherwise Nexletol is also an option where affordibiity of PCSK-9 becomes an issue ! By and large agree LDL less than 55 is the target but individual attributes of Lipid profile need to be taken in to account as above for every pt !

Yes, lower is better and there is no such thing as too low of An LDL cholesterol while on treatment for CAD. The lowest risk of events in one of the PCSK9 trials was when the LDL was less than 10 mg/dL. Lower LDL is better and safe

to get there using multiple meds as necessary - but cannot always get to that target, but try to reduce the risk as much as possible.

Yes. I treat LDL aggressively, especially if they are at high risk for a future event

Yes. That is the goal. Sometimes need to use multiple agents. Cost can be an issue but worth the battle. I like PCSK9 inhibitors. Hopefully we will have more clinical events data.

Yes, LDL-c < 55 is where CAD progression becomes least likely and all meds should be used, along with targeted approaches to reduce inflammation such as lifestyle (exercise, plant-based diet) and also colchicine LoDoCo.

use whatever meds necessary

Patients with atherosclerotic cardiovascular disease (ASCVD) who are considered at very high risk for future events typically meet certain criteria based on their clinical history and comorbid conditions. The American College of Cardiology (ACC) and the American Heart Association (AHA) have outlined specific groups of patients who fall into this category. These criteria include:

Recent Acute Coronary Syndrome (ACS):

Patients who have had an acute coronary syndrome (such as myocardial infarction or unstable angina) within the past 12 months.
History of Multiple Major ASCVD Events:

This includes patients with a history of multiple myocardial infarctions or ischemic strokes.
Single Major ASCVD Event with Multiple High-Risk Conditions:

Patients with a single major ASCVD event (such as a myocardial infarction or ischemic stroke) who also have multiple high-risk conditions. High-risk conditions include:
Age 65 years or older
Heterozygous familial hypercholesterolemia
History of prior coronary revascularization (PCI or CABG) outside of the major ASCVD event
History of prior non-coronary revascularization (such as carotid artery or peripheral artery revascularization)
Diabetes mellitus
Hypertension
Chronic kidney disease (CKD) (eGFR 15–59 mL/min/ m²)
Current smoking
Persistent high LDL-C levels (≥100 mg/dL) despite maximally tolerated statin therapy and ezetimibe
History of congestive heart failure
Significant Multivessel Coronary Artery Disease:

Patients with severe coronary artery disease involving multiple major vessels.
Patients who meet these criteria are at an elevated risk for recurrent cardiovascular events and generally require more aggressive lipid-lowering strategies and overall cardiovascular risk management. This often includes high-intensity statin therapy, and if LDL-C goals are not achieved, additional therapies such as ezetimibe or PCSK9 inhibitors may be recommended. Managing other comorbid conditions (like diabetes and hypertension), lifestyle modification, and addressing other risk factors are also crucial parts of the treatment plan for these high-risk individuals.

In general I say the lower the LDL the better. I aim for LDL<55 in these patients who have had any revascularization. It is clear that the lower the LDL the incidence of recurrent ASCVD decreases. The biggest problem is convincing patients that they need another medication if there LDL is already below 70. There is also a problem with getting additional medications covered by insurance.

The guidelines are very clear, need to get LDL to 55 or less in those patients who have had an event and those who are high risk. My go to method if not at goal on maximally tolerated statin treatment and those intolerant to statins is PCSK-9 inhibitors. Insurance approval is always a hurdle but with proper documentation may be able to overcome

One way or another I will get them to goal!

At this point, I am now trying to target an LDL less than 55 in anybody who has had revascularization or an event (even if no revasc needed). Insurance has been a hurdle at times, but I think it is the best thing to do for patients. An LDL of 70 is now my goal for a patient with asymptomatic PAD or CAD or carotid stenosis/intracranial atherosclerosis in order to prevent events. Once people have an event or need revascularization of some kind, I will push them as low as insurance will allow.

Yes, absolutely. Use whatever medicines the patient can tolerate and are available with their insurance coverage to get the LDL at goal.