Are we being able to meet current guidelines LDLcholesterol goals in very high risk patients? How many of them could benefit of PSCK9 inhibition by the FOURIER/ODYSSEY and NICE criteria?

BACKGROUND/INTRODUCTION: With increasing evidence of LDLcholesterol (LDLc) lowering and a subsequente reduction in cardiovascular events, guidelines of different parts of the world aim for lower LDLc goals by risk stratification. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition has been able to reduce up to 60% LDLc levels, with further reduction in cardiovascular outcomes. Purpose: Our aim was to evaluate the proportion of very high risk patients in a tertiary cardiology center that met LDLc goal of less than 50mg/dL proposed by the Brazilian Society of Cardiology (BSC) guidelines. Furthermore, we assessed the number of patients that were receiving adequate statin intensity therapy and could benefit from PCSK9 inhibition by the FOURIER/ODYSSEY and by the National Institute for Health and Care Excellence (NICE) criteria. METHODS: We screened 2180 consecutive patients from March, 2018 to February, 2019 for cardiovascular risk factors, cholesterol and glycemic levels, and current medical therapy at use. Patients were stratified by level of risk, and compliance to recommended statin therapy was evaluated. We then analyzed how many of the very high risk patients, that were in use of high intensity statin therapy, met the inclusion LDLc levels of the FOURIER/ODYSSEY trials (= 70mg/dL) and the NICE recommendations (= 140mg/dL) for the introduction of PCSK9 inhibitors. RESULTS: Of the 2180 patients enrolled to our study, 1225 (56.2%) patients were at very high cardiovascular risk level. Of these patients, 136 (11.1%) met LDLc BSC guideline levels. Using the LDLc target of 70mg/dL, an additional 320 (26.1%) patients were below target range. When analyzing statin therapy at use, 913 (74,5%) were receiving adequate statin therapy. Of the very high risk patients in adequate statin treatment, 617 (65.9%) by the FOURIER/ODYSSEY criteria and 88 (9.4%) patients by the NICE criteria would benefit from PCSK9 inhibitors. CONCLUSIONS: With lower LDLc goals, achievement of optimal LDLc levels is now a challenge for current clinical practice. Even though many patients are receiving adequate guidelinebased statin therapy, difficultyb remains in achieving optimal treatment, especially in the higher risk stratum. These patients would benefit from PCSK9 inhibition, being the NICE criteria, a more costeffective strategy, still applicable in a substantial portion of our patients. (AU)