Scientific letter
LDL cholesterol in one step
Colesterol LDL en un paso
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EZE: ezetimibe; CVR: cardiovascular risk; Rx: treatment, therapy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In line with the joint recommendation of the <span class="elsevierStyleItalic">European Society of Cardiology</span> and the <span class="elsevierStyleItalic">European Atherosclerosis Society</span> of 2016 on the control of dyslipidemia<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>, the 2019 guidelines provide additional data from observational, randomized-clinical, and genetic Mendelian randomization studies that unequivocally show the causal effect of <span class="elsevierStyleItalic">low density lipoproteins</span> (LDL) cholesterol in the development of cardiovascular disease of atherosclerotic origin. The therapeutic objectives of the current guidelines point to the concentration of LDL cholesterol as the main therapeutic target and has incorporated a higher level of demand based on new clinical evidence. In this sense, the recommended therapeutic target for very high-risk subjects based on the results of the IMPROVE-IT<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>, FOURIER<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and ODISSEY<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> studies is LDL cholesterol <55<span class="elsevierStyleHsp" style=""></span>mg/dl and a reduction ≥50% with respect to baseline LDL. Furthermore, this evidence points to switching high-potency statins to high-intensity lipid-lowering therapies. In the therapeutic algorithm for the pharmacological reduction of LDL cholesterol, the guidelines recommend using the statin with the necessary potency to achieve the required reduction based on the target LDL cholesterol, then go to the maximum tolerated dose if the objective is not achieved, then add ezetimibe and, if the goal is still not achieved, add a PCSK9 inhibitor.</p><p id="par0010" class="elsevierStylePara elsevierViewall">All of this implies that in the case of a very high-risk patient with baseline LDL cholesterol >140<span class="elsevierStyleHsp" style=""></span>mg/dl, it will require the use of triple lipid-lowering therapy and, therefore, the therapeutic objective will not be achieved before 6 months. We know that the main obstacle in clinical practice is still the lack of achievement of therapeutic targets for LDL cholesterol, as a result of under-treatment. Prior treatment planning using the updated tables of Masana and Plana<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>, or the use of computerized tools incorporated into the clinical history have demonstrated a significant improvement in the rate of therapeutic objective achievement. Given the importance of “the lower the better” LDL cholesterol, but also “the sooner the better” according to the results of the Mendelian randomization studies, we consider it appropriate to follow the algorithm proposed in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> in order to reach the LDL cholesterol goal in one step and, in this way, achieve an effective cardiovascular prevention.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0015" class="elsevierStylePara elsevierViewall">Juan Pedro-Botet reports having received consulting fees from Amgen, Mylan and Sanofi, and conference fees from Amgen, AstraZeneca, Esteve, Ferrer, MSD, Mylan, Sanofi, activities not related to this study.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Elisenda Climent declares that she has no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pedro-Botet J, Climent E. Colesterol LDL en un paso. Med Clín. 2020;155:316–317.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1383 "Ancho" => 2917 "Tamanyo" => 157491 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Therapeutic algorithm to reach the LDL cholesterol goal in one step.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Note: PCSK9 inhibitors are not included as they are only indicated according to the therapeutic positioning report in cases of secondary prevention and/or familial hypercholesterolemia that do not reach the therapeutic objective despite being treated with the maximum tolerated statin dose or being intolerant to statins.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">LDL-C: cholesterol linked to <span class="elsevierStyleItalic">low density lipoproteins</span>; EZE: ezetimibe; CVR: cardiovascular risk; Rx: treatment, therapy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016 ESC/EAS guidelines for the management of dyslipidaemias" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "ESC Scientific Document Group" "etal" => true "autores" => array:6 [ 0 => "A.L. Catapano" 1 => "I. Graham" 2 => "G. de Backer" 3 => "O. Wiklund" 4 => "M.J. Chapman" 5 => "H. Drexel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehw272" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2016" "volumen" => "37" "paginaInicial" => "2999" "paginaFinal" => "3058" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27567407" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ezetimibe added to statin therapy after acute coronary syndromes" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "IMPROVE-IT Investigators" "etal" => true "autores" => array:6 [ 0 => "C.P. Cannon" 1 => "M.A. Blazing" 2 => "R.P. Giugliano" 3 => "A. McCagg" 4 => "J.A. White" 5 => "P. 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