Review Article

Safety and Efficacy of Extremely Low LDL-Cholesterol Levels and Its Prospects in Hyperlipidemia Management

Table 1

Summary of the trials that attained lower-than-recommended LDL level.

Trial, year of publicationComparisonLDL reductionCV event reductionAdverse eventsComment

Cannon et al., 20044162PVS versus AVS-26.3% versus 22.4%21.4% versus 22.8%Median LDL level - 62 mg/dl

TNT, 200518,003AVS 10 mg versus 80 mg-20–30% fewer CV events in AVS 80 mg group5.8% versus 8.1%-

SPARCL, 20064731AVS versus placebo--93% versus 91%16% relative reduction in the risk of stroke

JUPITER, 200817,802RSV versus placebo50% lower LDL in RSV group20% reduction for each 1 mmol/L decline in LDL level15.2% versus 15.5%Median LDL in RSV group of 55 g/dl at 12 months

IMPROVE-IT, 201518,144EZE + statin versus statinEZE lowered LDL-C further by 24%7.2% lower risk of major vascular eventsNo significant differenceMean LDL level I EZE group of 53.2 mg/dl

YUKAWA-2, 2016404E-mAb versus placebo75.9% reduction in E-mAb group-46.5% versus 51%Median LDL in E-mAb group of 28 g/dl

Post hoc analysis of 10 ODYSSEY trials, 20164974A-mAb versus placebo, A-mAb versus EZE−55.4% versus +2.7%
−48.1% versus −18.0%
Every 39 mg/dl fall in LDL was translated into 24% lower risk of MACE79.9% versus 81.3%, 76% versus 73.9%33.1% of the pooled cohort achieved LDL < 50 mg/dl

Pooled analysis of 14 randomized trials, 20175234A-mAb versus control (placebo or EZE)LDL levels reported to be as low as 15 mg/dl in A-mAb group with an increase in adverse event rates-Low LDL levels (even <15 mg/dl) were not associated-

FOURIER, 201727,564E-mAb versus placebo59% reduction as compared to placebo-No significant differences except injection site reactions were more common with E-mAbRate of CV events was 9.8% versus 11.3%

ORION-1 (dose ranging trial), 2017501Inclisiran versus placebo51% reduction with 2 dose regimen-11% versus 8%48% subjects attained LDL levels below 50 mg/dl

PVS: pravastatin, RSV: rosuvastatin, AVS: atorvastatin, EZE: ezetimibe, A-mAb: alirocumab, E-mAb: evolocumab, MACE: major adverse cardiac event.