Top Tweets for #LowerIsBetter

In the phase 3 CORALreef Lipids trial, the oral PCSK9 inhibitor enlicitide reduced LDL cholesterol by 57% at 24 weeks and also lowered non-HDL cholesterol, apolipoprotein B, and lipoprotein(a). Adverse events were similar in the two groups. Full trial results: https://t.co/o5RS02KCWi Editorial: Exploring a New “Reef” in Dyslipidemic Risk Reduction https://t.co/W3KfZHkxMD

🫀🎯 LDL-C targets should follow plaque, not labels: CAC reframes prevention This 2025 American Journal of Preventive Cardiology commentary argues for a long-overdue shift in lipid management: LDL-C targets should be driven by coronary plaque burden, not by the artificial primary vs secondary prevention divide . 🧠 The core problem Traditional prevention frameworks rely on risk calculators and binary categories: Primary prevention → “moderate” LDL targets Secondary prevention → aggressive LDL lowering But coronary artery calcium (CAC) exposes a large, overlooked group: patients with advanced subclinical atherosclerosis whose risk rivals—or exceeds—that of patients with prior ASCVD events. 📊 What CAC really tells us CAC is a direct measure of cumulative coronary plaque, integrating lifetime exposure to risk factors. The evidence is clear: CAC >100 → risk well beyond what calculators predict CAC ≥300 → MACE rates comparable to established ASCVD CAC ≥1000 → extreme risk, clearly “secondary-prevention–level” Yet many of these patients are still treated conservatively because they’ve never had an event. 🎯 Advancing the 2022 ACC ECDP (Figure 6) The authors build on the 2022 ACC Expert Consensus Decision Pathway and propose: 🔹 CAC >100 → LDL-C <70 mg/dL 🔥 CAC >300 (or >90th percentile) → LDL-C <55 mg/dL, equivalent to secondary prevention 🚨 CAC ≥1000 → upfront combination therapy (statin + ezetimibe ± PCSK9) This is a “see disease, treat disease” philosophy. ⚠️ Why this matters Risk scores predict events. CAC detects disease. Relying on population averages delays therapy in people who already have advanced atherosclerosis—while overtreating others with no plaque at all. 🔮 Bottom line CAC dissolves the false comfort of “primary prevention.” 👉 When plaque burden is high, prevention should be just as aggressive as after an MI. Precision prevention doesn’t start with calculators. It starts with seeing atherosclerosis—and acting accordingly 🧭