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LDL cholesterol: controversies and future therapeutic directions
Abstract
Lifelong exposure to raised concentrations of LDL cholesterol increases cardiovascular event rates, and the use of statin therapy as an adjunct to diet, exercise, and smoking cessation has proven highly effective in reducing the population burden associated with hyperlipidaemia. Yet, despite consistent biological, genetic, and epidemiological data, and evidence from randomised trials, there is controversy among national guidelines and clinical practice with regard to LDL cholesterol, its measurement, the usefulness of population-based screening, the net benefit-to-risk ratio for different LDL-lowering drugs, the benefit of treatment targets, and whether aggressive lowering of LDL is safe. Several novel therapies have been introduced for the treatment of people with genetic defects that result in loss of function within the LDL receptor, a major determinant of inherited hyperlipidaemias. Moreover, the usefulness of monoclonal antibodies that extend the LDL-receptor lifecycle (and thus result in substantial lowering of LDL cholesterol below the levels achieved with statins alone) is being assessed in phase 3 trials that will enrol more than 60,000 at-risk patients worldwide. These trials represent an exceptionally rapid translation of genetic observations into clinical practice and will address core questions of how low LDL cholesterol can be safely reduced, whether the mechanism of LDL-cholesterol lowering matters, and whether ever more aggressive lipid-lowering provides a safe, long-term mechanism to prevent atherothrombotic complications.
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“However, their hepatotoxicity, high cost, inconvenience, and a general lack of availability outside the tertiary referral centers imply that their use is limited [10].”
From Effects of aerobic exercise on lipids and lipoproteins (2017) · cites this paper as [10]
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Next-generation gene discovery for variants of large impact on lipid traits
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“Treatments targeting other pathways or genes may reduce the complications and the health burdens associated with hyperlipidemia [5,6].”
BackgroundHypercholesterolemias: Pathogenesis and pathophysiological implications
Vučević, D. B., Đorđević, D., Stanojević, M., Jorgačević, B. Z., Đorović, D., Radak, Đ., & Radosavljević, T. S. (2016) · Medicinska istrazivanja · doi:10.5937/medist1602030v · Cited by 3
Wang, D., Zhang, P., & Li, J. (2023) · Frontiers in Physiology · doi:10.3389/fphys.2023.1190109 · Cited by 3
“Many studies have shown that drug treatment and lifestyle changes can improve dyslipidemia and maintain body health (Garelnabi, et al., 2014; Ridker, 2014).”
BackgroundHuang, K., Huang, S., & Xiong, M. (2024) · Lipids in Health and Disease · doi:10.1186/s12944-024-02026-y · Cited by 3
Seki, R., Inoue, K., Yamamoto, S., & Akimoto, K. (2017) · Biomedical Research and Clinical Practice · doi:10.15761/brcp.1000141 · Cited by 3
“This feature of non-HDL-C presents a contrast with LDL-C, which has been intended for description of cholesterol of LDL, only one of the several apoB-containing lipoproteins [6].”
BackgroundThe very high residual degree of death and disease from atherosclerosis needs new approaches
Makover, M. E., & Schloss, M. G. (2016) · Journal of clinical lipidology · doi:10.1016/j.jacl.2016.01.002 · Cited by 3
Khodaei, M., Torki, M., Khajali, F., & Karimi, I. (2025) · PLoS ONE · doi:10.1371/journal.pone.0330363 · Cited by 2
“LDL, commonly referred to as “bad cholesterol,” is a key contributor to lipid accumulation in blood vessels and a known risk factor for cardiovascular disease [67].”
Genome-wide gene-sleep interaction study identifies novel lipid loci in 732,564 participants
Noordam, R., Wang, W., Nagarajan, P., Wang, H., Brown, M. R., Bentley, A. R., Hui, Q., Kraja, A. T., Morrison, J. L., O’Connel, J. R., et al. (2025) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2025.120603 · Cited by 3
Yüksel, B., Özgör, F., Şahan, M., Öztürk, S., Can, M. M., & Sarılar, Ö. (2020) · Journal of College of Physicians And Surgeons Pakistan · doi:10.29271/jcpsp.2020.06.622 · Cited by 2
Lourida, K. G., & Louridas, G. E. (2022) · Cardiogenetics · doi:10.3390/cardiogenetics12020015 · Cited by 2
Bempedoic acid a novel drug used for the treatment of Hyperlipidaemia: A Review
Shimpi, R. D., Barhate, S. D., & Jain, M. S. (2023) · Asian Journal of Pharmaceutical Research · doi:10.52711/2231-5691.2023.00013 · Cited by 2
Huang, A., Wu, X., Lin, J., Wei, C., & Xu, W. (2024) · Frontiers in Endocrinology · doi:10.3389/fendo.2024.1331031 · Cited by 2
Nuevos tratamientos para la hipercolesterolemia
Pintó, X., & Gómez, M. C. G. (2015) · Medicina Clínica · doi:10.1016/j.medcli.2015.01.016 · Cited by 2
Pedro‐Botet, J., & Pintó, X. (2015) · Clínica e Investigación en Arteriosclerosis · doi:10.1016/j.arteri.2015.10.006 · Cited by 2
New agents for hypercholesterolemia
Pintó, X., & Gómez, M. C. G. (2016) · Medicina Clínica (English Edition) · doi:10.1016/j.medcle.2016.04.058 · Cited by 2
Risk factors for atherosclerosis in the light of existing scientific facts
Vučević, D. B., Jorgačević, B. Z., Radosavljević, M., Đorđević, D., & Radak, Đ. (2017) · Medicinska istrazivanja · doi:10.5937/medist1703007v · Cited by 2
“LDL u odnosu na sve ostale lipidne materije u krvi najviše doprinosi razvoju ateroskleroze (12, 16).”
BackgroundInfluentialShpakov, A. O. (2023) · Журнал эволюционной биохимии и физиологии · doi:10.31857/s0044452923070021 · Cited by 2
Lipids and Cardiovascular Disease Risks with a Focus on Dairy Foods
Givens, D. I. (2021) · Springer eBooks · doi:10.1007/978-3-030-56909-9_6 · Cited by 2
A Contemporary Evaluation of Calculated and Directly Measured LDL
Lau, C. S., Loh, W. J., Phua, S. K., & Aw, T. C. (2021) · Japan Journal of Clinical & Medical Research · doi:10.47363/jjcmr/2021(1)109 · Cited by 1
Pathophysiologische Prinzipien von Dyslipoproteinämien
Müller‐Wieland, D., Merkel, M., Verket, M., März, W., & von Eckardstein, A. (2021) · DMW - Deutsche Medizinische Wochenschrift · doi:10.1055/a-1516-2441 · Cited by 2
Luan, H., Wang, T., Wang, R., Wang, Y., Liu, Y., Sheng, W., Guo, J., Ji, H., Liu, X., Xue, X., et al. (2025) · COPD Journal of Chronic Obstructive Pulmonary Disease · doi:10.1080/15412555.2025.2513601 · Cited by 1
“Pharmacological target coding genes for these drugs were identified using the DrugBank database (https://go.drugbank.com/) and related literature [28–30].”
Zhu, R., Wang, W., Gao, Y., Li, B., Wang, W. “., Liu, J., Wu, L., Yang, S., & Wang, X. (2025) · Journal of Inflammation Research · doi:10.2147/jir.s571886 · Cited by 1
Fan, F., Chen, Y., Peng, W., Yan, W., Tan, H., Zhang, C., Tan, S., Xiao, Q., Gao, Y. H., Zhang, J., et al. (2025) · Journal of Cellular and Molecular Medicine · doi:10.1111/jcmm.70967 · Cited by 1
Mesoscopic Insights Into Low-Density Lipoprotein Transport: A Dissipative Particle Dynamics Study
Fan, Z., Wang, J., Zhang, X., Deng, X., & Yan, C. (2026) · Journal of Biomechanical Engineering · doi:10.1115/1.4071212 · Cited by 1
Metadata
- Authors
- Ridker, P. M.
- Affiliations
- Brigham and Women's Hospital (US)
- Corresponding author
- Ridker, Paul M
- ORCID
- Ridker, Paul M
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2014-08
- Volume
- 384
- Issue
- 9943
- Pages
- 607-617
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W2058652637
- Cited by
- 274
- References
- 104
- Citations by year
- 2026: 7 · 2025: 23 · 2024: 13 · 2023: 20 · 2022: 13 · 2021: 14 · 2020: 25 · 2019: 22 · 2018: 31 · 2017: 29 · 2016: 35 · 2015: 38 · 2014: 4
- FWCI
- 6.67
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipoproteins and Cardiovascular Health
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Biochemistry › Cholesterol and Lipid Metabolism
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- LDL cholesterol, hyperlipidemia, statin therapy, LDL receptor, PCSK9 inhibitors, monoclonal antibodies, LDL cholesterol measurement, mass screening, treatment goals, cardiovascular risk, atherothrombotic complications
- MeSH terms
- Animals, Hypolipidemic Agents, Humans, Hypercholesterolemia, Cholesterol, LDL, Risk Factors, Risk Assessment, Hydroxymethylglutaryl-CoA Reductase Inhibitors
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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