Suboptimal Management of Hypercholesterolemia in Countries with High or Very High Cardiovascular Risk: Findings from the International DISCOVERY Study

Mišo Šabović^1,2*Hristo Pejkov³Alexandru Caraus⁴Ivan Gruev⁵Vlad Damian Vintilă⁶Zoltan Csanadi⁷Sodgerel Batjargal⁸Tamara Kovačević-Preradović⁹Zumreta Kušljugić¹⁰Draško Kuprešak¹¹Zaim Jatić¹²Gani Bajraktari¹³

• ¹Clinical Department of Vascular Diseases, Univerzitetni klinicni center Ljubljana Interna klinika, Ljubljana, Slovenia
• ²Univerza v Ljubljani Medicinska fakulteta, Ljubljana, Slovenia
• ³University Clinic of Cardiology, Medical Faculty Skopje, St. Cyril and Methodius University, Skopje, North Macedonia, Skopje, North Macedonia
• ⁴Universitatea de Stat din Moldova, Chisinau, Moldova
• ⁵National Transport Hospital Tzar Boris III, Sofia, Bulgaria, Sofia, Bulgaria
• ⁶Universitatea de Medicina si Farmacie Carol Davila din Bucuresti Facultatea de Medicina, Bucharest, Romania
• ⁷University of Debrecen, Cardiology and Heart Surgery Clinic, Debrecen, Hungary, Debrecen, Hungary
• ⁸Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
• ⁹Department of Cardiology, University Clinical Center of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina
• ¹⁰Kardio Centar prof. dr. Zumreta Kušljugić, Tuzla, Bosnia and Herzegovina, Tuzla, Bosnia and Herzegovina
• ¹¹Family Medicine, Health Centre Čelinac, Čelinac, Bosnia and Herzegovina, Čelinac, Bosnia and Herzegovina
• ¹²Department of Family Medicine, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina
• ¹³Medical Faculty, University of Prishtina Hasan Prishtina; University Clinical Centre of Kosova, Prishtina, Kosovo, Prishtina, Albania

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.