High risk dyslipidemia: can we predict early coronary disease?

Type of funding sources: None.

The AHA/ACC guidelines on the management of blood cholesterol (2013 and 2018) classified the LDL-c >190 mg/dL as high-risk patients, with the indication of high-intensity statins (c-LDL reduction greater than 50%). Recently the 2019 ESC guidelines(1) also classify these patients as high cardiovascular (CV) risk.

Determine factors associated with the development of early coronary disease (ECD) in patients with high-risk dyslipidemia (HRD).

Observational retrospective cohort of 160 patients with historical maximum LDL-c ≥190 mg/dL without secondary cause. We compared the clinical characteristics, the baseline blood test with maximum LDL-c (BT1), and the effects of lipid-lowering treatment on the last blood test (BT2), between patients with ECD (53 patients Group A) and patients without cardiovascular events (107 patients Group B).

Group A, presented maximum LDL-c at a younger age, had dyslipidemia of longer evolution time, had a higher proportion of men, smokers, diabetics, and had a higher number of associated risk factor's (Table 1).

In the BT1 they presented greater proportion of HDL-c values below 45 mg/dL (35.3% vs 12.3%, p=0.001), and a higher proportion of remnant cholesterol (Non HDLc - LDLc = >30 mg/dL, 51% vs 33.3%, p=0.037). Patients with ECD received high-intensity lipid-lowering treatment, statin + ezetimibe (73.6% vs 29.8%, p<0.0001), IPCSK9 (7.5% vs 2.9%, p=0.18), and achieving LDL-c goals (32.1% vs 13.6%, p=0.006) and Non HDL-c (47.2% vs 14.6%, p<0.0001) according to cardiovascular risk. There were no variation between BT1 and BT2 in HDL-c levels in both groups.

In the Cox regression model, male sex (HR 2.8 (1.4-5.7), p=0.003), tobacco (HR 2.5 (1.3-4.7), p=0.005), and the relation between Non HDL-c/HDLc (>4.5 male, >4 female, in primary prevention) in BT1 (HR 1.65, (1.15-1.86) p=0.02) increase independently the risk of ECD in patients with HRD.

In patients with HRD the presence of male sex, tobacco, increase relation between Non HDLc/HDLc, diabetes, a greater number of cardiovascular risk factors, most atherogenic blood test (HDLc <45 mg/dL and remnant cholesterol) have been associated with the development of ECD. We have had some apreciated 5.45 (± 4) years since the BT1 to prevent ECD.