Quel objectif de LDL en prévention secondaire ?

M. John Chapman, Endocrinology-Metabolism Service, Pitie-Salpetriere University Hospital, Sorbonne University, Paris.

An extensive data base derived from randomised, placebo-controlled intervention trials in dyslipidemic subjects has established that targeted lowering of LDL-cholesterol reduces the incidence of cardiovascular events, including ischemic stroke, in secondary prevention. Recent findings from the FOURIER and ODYSSEY OUTCOMES trials in secondary prevention patients involving use of PCSK9 inhibitors as add-on therapy to statin treatment have demonstrated a continuum of clinical benefit to LDL-C levels well below 50mg/dL (1.3mmol/L). As a consequence, the 2019 ESC/EAS guidelines for cholesterol management in secondary prevention propose an LDL-C goal of <55mg/dL (1,4mmol/L), together with a 50 % reduction from baseline levels. This proposal is entirely consistent with the recent “Treat stroke to target” trial in post-stroke patients with atherosclerotic disease after a median follow-up of 3,5 years (Amarenco et al, NEJM, 2019), in which the lowest risk of ischemic stroke was observed in subjects whose target LDL-C level was <70mg/dL (1,8mmol/L). Considered together, no increase in intracranial hemorrhagic relative to the placebo groups was observed in these studies. Future studies are now required to evaluate the effectiveness of LDL-C targets of 55mg/dL or lower in further reducing stroke incidence in clinically-defined cohorts of stroke patients.