*compared to those without established CAD
CAD: coronary artery disease; CV: cardiovascular; CVD: cardiovascular disease.
Introducing a simple, practical patient audit to assist in
the prevention of secondary cardiovascular (CV) events
through treat to target low density lipoprotein
cholesterol (LDL-C) management.
How do I identify patients for the audit?
Establish a clinical history from electronic medical records (eMRs): Patients with a previous
history of CV events such as ischaemic heart disease, ischaemic cerebrovascular disease.
Patients with a family history of premature CV events in first degree relatives before the age of
60 years. Adults with any of the following conditions are known to be at clinically determined
high risk of cardiovascular disease (CVD):3,4
Previous history of CV event
History of premature CV event in first-degree relative
Diabetes and age >60 years
Diabetes with microalbuminuria 
>20 mcg/min or
urinary albumin:creatinine ratio (UACR) >2.5 mg/mmol for males and >3.5 mg/mmol for females
Moderate or severe chronic kidney disease (CKD) (persistent proteinuria or estimated glomerular filtration rate [eGFR] <45 mL/min/1.73m2)
A previous diagnosis of familial hypercholesterolaemia
Systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg
Serum total cholesterol >7.5 mmol/L
LDL-C >1.8 mmol/L (secondary prevention target <1.8 mmol/L)
Aboriginal and Torres Strait Islander adults aged >74 years
What are the treat-to-target goals?
Having identified the secondary prevention target population an assessment of treat-to-target
goals will identify within this population those patients that might require a more focussed

Guideline-based treat-to-target goals for secondary prevention in patients with a history of CV
events such as ischaemic heart disease and ischaemic cerebrovascular disease are summarized
Blood Pressure
• ≤140/90 mmHg in general or people with CKD
• ≤130/80 mmHg in all people with diabetes
Urinary albumin
Assess albuminuria in all patients with CHD by performing a UACR
on a spot urine specimen (preferably an early morning void). If UACR > 2.5 mg/mmol (men) or > 3.5 mg/mmol (women), repeat to confirm
• TC <4.0 mmol/L
• HDL-C ≥1.0 mmol/L
• LDL-C <1.8 mmol/L
• Non HDL-C <2.5 mmol/L
• TG <2.0 mmol/L
CHD: coronary heart disease; CKD: chronic kidney disease; HDL-C: high-density lipoprotein cholesterol; LDL-C: low-density lipoprotein cholesterol; TC: total cholesterol; TG: triglycerides; UACR: urine albumin:creatinine ratio.
How do I attain treat-to-target goals in the management
of high-risk patients?
There are two essential components for the appropriate management of lipids for patients with existing atherosclerotic CVD:4
1. Healthy eating and lifestyle advice
2. Pharmacologic treatment must be commenced early after an event.
Given that every 1 mmol/L absolute reduction in LDL-C achieved with statins reduces all-cause mortality by ~10% and major vascular events by 22%,5 the attainment of target LDL-C goals becomes a key element in a secondary prevention strategy. A meta-analysis showed that more potent statin therapy has greater efficacy compared to less intensive regimens and is associated with added improvements in CVD event rates.5
The use of lipid-lowering therapies should be geared towards achieving guideline-based treat-to-target goals using high-intensity statin monotherapy thereafter progressing to the addition of non-statin lipid-lowering agents such as ezetimide or proprotein convertase subtilsin-kexin type 9 (PCKS9) inhibitors where appropriate.6,7
The addition of a PCSK9 inhibitor to a high-intensity statin regimen has been shown to achieve an LDL-C target of <1.8 mmol/L in 69% of patients. When used as an adjunct therapy with ezetimibe treatment that rate increases to 86% and adding on a PCSK9 inhibitor increased it further for the remaining 14%.8
This suggests that over 99% of the population with atherosclerotic CVD could reach recommended LDL-C levels by using PCSK9 inhibitors when target LDL-C levels were previously unattainable with current standards of care.8
*Please refer to local prescribing guidelines and appropriate eligibility criteria for PBS reimbursement.
ACEi: angiotensin-converting enzyme inhibitor; ARB: angeotensin receptor blocker; BB: beta blocker; CABG: coronary artery bypass graft surgery; CHD: coronary heart disease; CV: cardiovascular; PCSK9i: proprotein convertase subtilisin/kexin type 9 inhibitor; T1: type 1; T2: type 2.

Adapted from the National Vascular Disease Prevention Alliance. Guideline for the Management of Absolute Cardiovascular Disease Risk 2012.
This is a self-directed continuing professional development (CPD) Accredited Activity. On completion of the audit, you will be able to claim 8 CPD points by using the 'Quick log' function on your myCPD dashboard via the Royal Australian College of General Practitioners (RACGP) website.
1. Australian Bureau of Statistics. Causes of Death 2019. Cat. no. 3303.0. October 2020.
2. Rossouw JE, et al. N Engl J Med. 1990;323:1112.
3. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Reducing risk in heart disease: An expert guide to clinical practice for secondary prevention of coronary heart disease. Melbourne: National Heart Foundation of Australia, 2012.
4. National Vascular Disease Prevention Alliance. Guidelines for the Management of Absolute Cardiovascular Disease Risk 2012.
5. Baigent C, et al. Lancet. 2010;376(9753):1670–81.
6. Cannon CP, et al. N Engl J Med. 2015;372(25):2387–97.
7. Chaudhary R, et al. World J Cardiol. 2017;9(2):76–91.
8. Cannon CP, et al. JAMA Cardiol. 2017;2(9):959–966.

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