There is now categorical evidence that lowering LDL cholesterol reduces major adverse cardiovascular events in patients who have had previous events. Historically we have only had statins but more recently we have had the benefit of ezetimibe and the PCSK9 inhibitors. Soon there will be a fourth agent to lower LDL-cholesterol called bempedoic acid. There are also therapies coming to reduce lipoprotein [a]. The REDUCEIT study suggested that highly concentrated fish oil may also have a role.
This all suggests that cholesterol reduction has become easier and is more suited to whole populations because of the variety of therapies available. There is also increasing evidence that lifetime exposure to high LDL levels is more important than short time exposure. It therefore makes sense that long-term exposure to cholesterol reducing agents also gives better results.
Using molecular biology techniques there is evidence that polygenic polymorphisms account from most of the high-risk patients. Increasingly molecular biology will have a role to play and identifying those at highest risk. We have therefore come along way in cholesterol management with the promise of more therapies to come.
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