Under-treated high-risk patients: identifying patients in high-risk subgroups and treating them to LDL-C targets

Many patients at high risk for coronary heart disease (CHD) are not readily identified by routine risk assessment in clinical practice and are consequently at risk for inadequate management. Peripheral arterial disease is a CHD risk equivalent, requiring intensive low-density lipoprotein cholesterol (LDL-C) lowering to the lowest recommended target levels; however, asymptomatic disease, although still associated with elevated risk, is not likely to be recognized in routine clinical practice. Heterozygous familial hypercholesterolaemia (FH) is associated with early and aggressive atherosclerotic disease, yet individuals with FH may go unrecognized in the absence of family screening. The metabolic syndrome is very common and is also associated with increased CHD risk, but affected individuals may not be identified if attention is not given to the relatively simple clinical criteria currently recommended for use in diagnosis. Although it is widely known that type 2 diabetes is associated with elevated CHD risk, the fact that statin treatment in diabetic patients is warranted even in those with relatively low LDL-C levels may not be widely appreciated. Recent modifications of the National Cholesterol Education Program Adult Treatment Panel III guidelines include optional reductions in both LDL-C goals and thresholds for initiating therapy in light of persuasive clinical trial evidence that patients at high risk and moderately high risk derive protective benefits from statin therapy even when treatment is started at LDL-C levels below prior goal or threshold levels. Increased vigilance for high-risk conditions that may elude routine risk assessment is necessary to ensure that all high-risk patients receive adequate treatment.