Page 30 - GALENIKA MEDICAL JOURNAL

Table 1. Criteria for assessing cardiovascular risk and therapeutic target values for LDL cholesterol
Therapeutic target
Category of CV risk Criteria
LDL-cholesterol level

Low risk 3.0 mmol/L • SCORE < 1%

• SCORE ≥ 1% i < 5%
Moderate risk 2.6 mmol/L
• Younger individuals (T1DM < 35 years; T2DM < 50 years) with duration of DM < 10 years, without other RF.
• SCORE ≥ 5% i < 10%
• 1 major RF (fasting plasma glucose > 8 mmol/L, LDL-h > 4.9 mmol/L or blood pressure ≥ 180/110 mmHg.
High risk 1.8 mmol/L • FH without other major risk factors.
• DM without target organ damage, with DM duration ≥ 10 years or other RF
• Moderate CKD (eGFR 30-59 mL/min/1.73 m 2 ).

• ACVD (clinical/imaging)
• SCORE ≥ 10%
Very high risk 1.4 mmol/L • FH with ACVD or other significant RF
• Severe CKD (eGFR < 30 mL/min/1.73 m²).
• DM with target organ damage, or ≥ 3 major risk factors, or early onset T1DM with duration > 20 years.
Legend: CV - Cardiovascular; LDL-h - Low density lipoprotein; SCORE - Systematic Coronary Risk Estimation; T1DM - Type 1 Diabetes Mellitus; T2DM - Type 2 Diabetes Mellitus; RF - Risk
Factor; TC - Total cholesterol; AP - Arterial Pressure; FH - Familial Hypercholesterolemia; CKD - Chronic Kidney Disease; ACVD - Atherosclerotic Cardiovascular Disease. Modified according
to ref. 9.
Image 1. Assessment of cardiovascular risk and determination of Ezetimibe
LDL cholesterol levels
Ezetimibe is a relatively older drug that inhibits the in-
testinal absorption of cholesterol by binding to NPC1L1
(Niemann-Pick C1-like 1 protein). Ezetimibe can be used
as monotherapy at a dose of 10 mg once daily; however,
the efficacy of ezetimibe monotherapy is relatively weak. In
patients with heterozygous familial hypercholesterolemia
(FH), it reduces total cholesterol by 13.5% and LDL chole-
sterol by 18.6% compared to placebo . Therefore, this drug
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is most commonly used in combination with statins, bem-
pedoic acid, and fibrates. Considering its mild side effects,
ezetimibe is the treatment of choice for patients who do not
tolerate statins . The results of the randomized IMPROVE-IT
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study, which included over 18,000 patients after an acute
coronary event, with a follow-up period of 6 years, showed
that the combination of simvastatin and ezetimibe signifi-
cantly reduces the risk of new cardiovascular events. This
finding has reinstated the importance of ezetimibe in new
recommendations, particularly in combined therapy .
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Bempedoic acid
Bempedoic acid inhibits the enzyme adenosine trip-
hosphate citrate lyase, which catalyzes the synthesis of
acetyl coenzyme A, thus preventing the synthesis of cho-
lesterol . Unlike statins, the use of bempedoic acid carries
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a significantly lower risk of myopathy and rhabdomyolysis,
making it a therapeutic choice for patients who do not tole-
rate statins. Interestingly, bempedoic acid has a beneficial
effect on glycemia, unlike statins which, especially at high
doses, can increase the risk of new-onset diabetes . The
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most common adverse effects after the administration of
bempedoic acid are elevated liver enzymes and concentra-
Legend: CV - Cardiovascular; LDL-h - Low density lipoprotein; PCSK9 - Proprotein Con-
vertase Subtilisin Kexin-9; High-intensity statin - rosuvastatin at a dose of 20-40 mg or tions of uric acid 22, 23 .
atorvastatin at a dose of 40-80 mg. Modified according to ref. 9.

28 DOI: 10.5937/Galmed2409031L