Lipid-lowering therapy and ESC guideline treatment goals in a German population-based cohort study

Abstract Background Hypercholesterolemia is a major risk factor of cardiovascular disease (CVD) leading to premature death. The European Society of Cardiology (ESC) guideline on dyslipidemia recommends LDL cholesterol (LDL-C) targets based on individual risk of fatal CVD. This study aims to determine the proportion of individuals in a German population-based cohort with LDL-C levels above the ESC target level, with and without lipid-lowering medication. Methods The ‘Study of Health in Pomerania’ was conducted between 2008-2012 in Western Pomerania, Germany. We performed a descriptive analysis of CVD risk and lipid levels in 4,215 individuals aged 40-69 years. Individuals were classified into ESC risk categories (low, moderate, high, very high) based on comorbidities and cardiovascular history, with LDL-C targets of < 3.0, <2.6, and <1.8 mmol/L, respectively. Results Males (n = 1,997) had a mean LDL-C level of 3.45 mmol/L (CI 3.41-3.49 mmol/L), while females (n = 2,211) had a slightly higher mean level of 3.52 mmol/L (CI 3.48-3.56 mmol/L). Individuals not on lipid-lowering therapy (n = 3,634) had a mean LDL-C level of 3.59 mmol/L (CI 3.56-3.62), compared to 2.86 mmol/L (CI 2.79-2.92) for those on treatment (n = 574). Overall, 73% of the individuals missed their ESC LDL-C targets, and 58% of those already on treatment also missed their targets. Notably, over 90% of high and very high-risk individuals exceeded their targets. Conclusions The majority of individuals have LDL-C levels above the targets recommended by the ESC guidelines. An attempt to reach target values would necessitate a massive expansion and intensification in drug therapy. Given its uncertain benefits in primary prevention, it is crucial to reevaluate these thresholds. Key messages • There is a discrepancy between the ESC targets and actual population levels. • These targets need to be critically assessed in terms of their benefits, harms, feasibility and the implications of medicalizing the population.