Suboptimal management of hypercholesterolemia in countries with high or very high cardiovascular risk: findings from the international DISCOVERY study

Mišo Šabović; Hristo Pejkov; Alexandru Caraus; Ivan Gruev; Vlad Damian Vintilă; Zoltán Csanádi; Sodgerel Batjargal; Tamara Kovačević-Preradović; Zumreta Kušljugić; Draško Kuprešak; Zaim Jatić; Gani Bajraktari

doi:10.3389/fcvm.2025.1665059

Suboptimal management of hypercholesterolemia in countries with high or very high cardiovascular risk: findings from the international DISCOVERY study

Front Cardiovasc Med. 2025 Sep 5:12:1665059. doi: 10.3389/fcvm.2025.1665059. eCollection 2025.

Authors

Affiliations

¹ Clinical Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.
² Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
³ Medical Faculty Skopje, University Clinic of Cardiology, St. Cyril and Methodius University, Skopje, North Macedonia.
⁴ National Cardiology Institute, Chisinau, Moldova.
⁵ National Transport Hospital Tzar Boris III, Sofia, Bulgaria.
⁶ Cardiology Department, Carol Davila University of Medicine and Pharmacy, University and Emergency Hospital, Bucharest, Romania.
⁷ Cardiology and Heart Surgery Clinic, University of Debrecen, Debrecen, Hungary.
⁸ Department of Cardiovascular Surgery, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia.
⁹ Department of Cardiology, University Clinical Center of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina.
¹⁰ Kardio Centar Prof. dr. Zumreta Kušljugić, Tuzla, Bosnia and Herzegovina.
¹¹ Family Medicine, Health Centre Čelinac, Čelinac, Bosnia and Herzegovina.
¹² Department of Family Medicine, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina.
¹³ Medical Faculty, University of Prishtina Hasan Prishtina, University Clinical Centre of Kosova, Prishtina, Kosovo.

Abstract

Introduction: The 2019 ESC/EAS guidelines introduced stricter low-density lipoprotein cholesterol (LDL-C) targets, particularly for patients at high and very high cardiovascular (CV) risk. However, data on the implementation of these targets in real-world clinical practice-especially in countries with high/very high CV risk-remain limited. The DISCOVERY study aimed to assess LDL-C management, lipid-lowering therapy (LLT) use, and guideline adherence across multiple countries in Central and Eastern Europe and Central Asia.

Methods: This prospective, observational, multicenter study enrolled adult patients with hypercholesterolemia (HCL) from 10 countries grouped into three regions. Data was collected at baseline and after 12 weeks of follow-up. LLT patterns, LDL-C levels, target attainment (both investigator-defined and 2019 ESC/EAS-recommended), and physician adherence to guidelines were analyzed.

Results: A total of 6,447 patients were included; 53.2% were female, and the mean age was 60.5 ± 11.9 years. Most patients (66%) were in secondary prevention. At baseline, 36.8% had been treated with LLT. After the first visit, treatment was changed in 78% of patients, but only 42.4% received high-intensity statins and 9.3% received statin-ezetimibe combinations at follow-up. LDL-C target achievement was poor: only 5.6% of patients met the guideline-recommended LDL-C goals, compared to 45.5% who met physician-defined targets. Among patients with ASCVD, only 3.3% achieved guideline LDL-C targets. The most significant gap was observed between guideline recommendations and physician-set LDL-C goals. No significant difference in LDL-C target attainment was observed between specialists and general practitioners.

Discussion: The DISCOVERY study reveals suboptimal LDL-C control and low adherence to the 2019 ESC/EAS guidelines in routine practice across countries with high/very high CV risk. These findings highlight the urgent need for strategies to improve physician awareness, promote intensive LLT use, and close the gap between guidelines and clinical practice. A paradigm shift toward proactive LDL-C management is essential to reduce residual CV risk in these populations.

Keywords: ESC/EAS guidelines; LDL-C; cardiovascular risk; ezetimibe; hypercholesterolemia; lipid-lowering therapy; real-world evidence; statins.