Dr Steven Nissen Argues for Aggressively Lowering LDL Cholesterol

There is an ongoing debate about how aggressively to lower low-density lipoprotein (LDL) cholesterol, but Steven Nissen, MD, of Cleveland Clinic, argues that studies have shown an aggressive approach to lowering LDL always shows benefits.

Transcript (slightly modified)

What is the argument for aggressively lowering low-density lipoprotein cholesterol?

We’ve been studying LDL now for 30 years. There are studies involving hundreds of thousands of patients, large randomized controlled trials, and the one thing that’s been constant is whenever we’ve driven LDL to lower levels, we have seen benefits in an adequately designed, adequately sized trial. This goes back even before statins—we had that kind of data. In fact, recently we have seen benefits of lowering LDL to as low as 30 milligrams per deciliter. So, I think it’s a compelling case that lower LDL equals less cardiovascular events.

Are there concerns with aggressively lowering LDL cholesterol for patients who might not be good candidates?

It turns out that the evidence looks pretty much across the board. Now, it all depends on the drugs you are going to use. We know that higher dose statins have a somewhat higher risk of adverse effects than low dose statins, but these are very safe drugs. Similarly, adding ezetimibe is another very safe drug, PCSK9 inhibitors—very safe. We have pretty good data from multiple trials, including some that we have run, that show that there are no real safety issues with low LDLs. There may be drug specific safety issues, but we used to say you can’t be too rich or too thin, we now say you can’t be too rich, too thin, or have too low an LDL.