LDL-C is the cardinal modifiable predictor of atherosclerosis in the absence of risk factors
A study by researchers at Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC) found that, even at levels currently considered normal, low-density lipoprotein cholesterol (LDL-C) is a prime predictor of the presence of atherosclerotic plaques in arteries. [J Am Coll Cardiol 2017;70:2979–2991] These findings provide a basis to the occurrence of myocardial infarction in healthy individuals with no cardiovascular (CV) risk factors, ie, hypertension, smoking, obesity, dyslipidaemia and diabetes.
Fortunately, this new-found independent risk factor can be modified to prevent the development of atherosclerotic plaques, thus emphasizing the need for aggressive LDL-C reduction strategies, even in individuals with no CV risk factors. The research team noted the importance of defining new CV risk factors in addition to those currently known, as a measure towards early detection and prevention of CV events. “Although the absence of classical CV risk factors is linked to low risk of CV events, people in this situation still have heart attacks and strokes. We therefore need to define new markers of early atherosclerosis in these apparently healthy individuals,” said the study’s first author, Dr Leticia Fernández-Friera.
Atherosclerotic CV diseases are the leading cause of morbidity and mortality, worldwide. Though associated with multiple risk factors, LDL-C (ie, ‘bad’ cholesterol) is directly implicated in the development of atherosclerotic CV diseases. [Eur Heart J 2017;38:2459–2472] The evaluation of a subgroup of participants with no classical CV risk factors, from the Progression of Early Subclinical Atherosclerosis (PESA) study, reported that apart from age and the male sex, LDL-C is prominently associated with the presence of atherosclerotic plaques. [J Am Coll Cardiol 2017;70:2979–2991] According to Dr Javier Sanz, who was part of the research team, “even in people with optimal blood pressure, blood sugar, and total cholesterol, we detected an independent association between the level of circulating LDL-C and the presence and extent of subclinical atherosclerosis”. With the aid of the latest noninvasive vascular imaging technology, the researchers demonstrated the presence of atherosclerotic plaques in 49.7% of middle-aged individuals without CV risk factors.
The findings of this study could pave the way towards defining new normal levels of LDL-C, one that is much lower than those stated in current guidelines. “We should be more restrictive, and consider lowering the threshold values stipulated in the guidelines,” stressed the researchers. The findings of this study serve to guide primordial prevention and better understand the pathology underlying early atherosclerosis. The ability to identify patients with the disease prior to the appearance of symptoms could help avoid or reduce disease-related complications, translating into enormous societal and economic benefits.