In the Ez-PAVE trial, the first randomized head-to-head comparison of LDL-C targets, 3,048 patients with ASCVD were shown to have a 33% lower risk of cardiovascular events with a target of <55 mg/dL vs <70 mg/dL (HR 0.67; P=0.002). At 3 years, the primary composite endpoint occurred in 6.6% vs 9.7%. Safety profiles were similar. This is the first randomized evidence that the lower target in the 2026 ACC/AHA dyslipidemia guideline is superior.
Randomized evidence evaluating the optimal low-density lipoprotein (LDL) cholesterol target for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD) remains limited.
In this multicenter, randomized, open-label, superiority trial, we randomly assigned 3048 patients with ASCVD to a target LDL cholesterol level of <55 mg/dL (intensive targeting) or <70 mg/dL (conventional targeting). The primary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, any revascularization, or hospitalization for unstable angina at 3 years.
A total of 1526 patients were assigned to the intensive-targeting group and 1522 to the conventional-targeting group. The median follow-up was 3.0 years. The median LDL cholesterol level during the study was 56 mg/dL in the intensive-targeting group and 66 mg/dL in the conventional-targeting group. A primary endpoint occurred in 100 patients (6.6%) in the intensive-targeting group and in 147 patients (9.7%) in the conventional-targeting group (hazard ratio, 0.67; 95% confidence interval, 0.52-0.86; P=0.002). The incidence of prespecified safety endpoints was similar between the groups, except for a lower incidence of creatinine elevation in the intensive-targeting group.
In patients with ASCVD, targeting an LDL cholesterol level of <55 mg/dL resulted in a lower risk of cardiovascular events than targeting a level of <70 mg/dL.
