The evolution of lipid-lowering drugs in the management of cardiovascular disease risk: From the first cardiovascular disease risk–reducing therapies to the novel challenging strategies

Before the Framingham Heart Study, the concept of cardiovascular disease (CVD) risk factors did not exist, and CVDs were seen as a consequence of aging. The first 2 reports in 1957 and 1961 identified high cholesterol levels as a major risk factor for CVD, highlighting the importance of lipid management to reduce CVD risk. Since then, the growing knowledge of CVD pathophysiology has led to the development of many drug classes to manage dyslipidemia and consequently, cardiovascular disease risk. Unfortunately, many of them, such as high-density lipoprotein-targeted or triglyceride-modulating drugs, have so far failed in clinical trials due to a lack of efficacy in cardiovascular disease protection or due to the appearance of side effects. Interestingly, low-density lipoprotein-targeted statin therapy revolutionized cardiovascular risk management and remains today the reference treatment in primary and secondary CVD prevention. In the last decades, novel low-density lipoprotein-targeted drugs, such as ezetimibe, proprotein convertase subtilisin/kexin type 9-targeted therapies, and bempedoic acid, have been approved by the Food and Drug Administration and have now found their place among the therapeutic arsenal of hypolipidemic drugs used in CVD risk management, in case of intolerance to statins or often in association with statins. This review focuses on the historical evolution of development strategies and on the successes and failures of lipid-lowering drugs to reduce cardiovascular disease risk, from the mid-20th century to the present, and concludes with novel challenging strategies in progress. SIGNIFICANCE STATEMENT: This review highlights the evolution of lipid-lowering therapies in atherosclerotic cardiovascular disease management, from statins to proprotein convertase subtilisin/kexin type 9 inhibitors. It underscores key successes, limitations, and emerging strategies, offering essential insights into their current and future roles in reducing atherosclerotic cardiovascular disease risk for a broad medical and scientific audience.