We thank Renilla et al. for their comments regarding our article on insufficient lipid control in patients with coronary artery disease,1 and we must agree with the majority of their comments and reflections.

The results of our study may appear somewhat disheartening, with good control (low-density lipoprotein [LDL] < 70 mg/dL) being achieved in only 26% of patients with coronary artery disease in Spain. However, we must bear in mind that this is an improvement: 95% of patients currently receive lipid-lowering therapy and 45% receive high-intensity lipid-lowering therapy; not too long ago, in 2006, 31% received no statins and only 10% received high-intensity therapy.2 It is true that there is a lack of awareness among professionals regarding the appropriate measures to avoid clinical inertia, but it is equally true that with a purely statin-based treatment, such ambitious targets are unlikely to be met. It is known that LDL-cholesterol is significantly reduced when treatment with statins is started (up to 50% if started directly on a high-intensity statin), but dose increases cause only small percentage decreases (7% to 9% when the dose is doubled); when ezetimibe is added, this can be up to 20%.3 Therefore, if high LDL values in patients on treatment are used as a means of evaluation, the target values will never be met. Renilla et al. also raised the point of the variable response to lipid-lowering therapy; regarding this, one of the most notable aspects of the REPAR study at one-year follow-up (data as yet unpublished) is that some of the patients that were initially well-controlled (LDL-cholesterol < 70 mg/dL) at the start of the study were no longer well-controlled at follow-up, despite unchanged lipid-lowering therapy.

Renilla et al. highlight the opportunity presented by the incorporation of PCSK9 inhibitors to the therapeutic arsenal. However, these drugs come with several limitations, as initial government guidelines4 indicate that these will be funded only for patients already on maximum treatment doses and with LDL-cholesterol levels > 100 mg/dL. This leaves a group of patients with LDL-cholesterol between 70mg/dL and 100mg/dL, which contains most of the patients who are already on treatment but are not well controlled, in a limbo with no therapeutic solution.