Atherosclerosis: Recent trials, new targets and future directions

•Future trials targeting LDL-cholesterol shall be powered to its absolute reduction.•Mendelian randomization studies may identify new causal risk factors for CVD.•Imaging techniques may represent in a near future robust “soft” endpoints.•We aim to provide strategies to support future clinical trial design.

Mortality from cardiovascular diseases (CVD) represents the primary cause of death worldwide. Prevention or treatment of atherosclerosis and its clinical sequelae is a central goal in the management of patients with established vascular disease or those at high-risk for vascular events. This paper provides a review of the contemporary pharmacological armamentarium targeting atherosclerosis and also highlights strategies to support future clinical trial design. Powering future trials targeting LDL-cholesterol to its absolute reduction and including patients with a higher LDL-C despite optimal medical therapy (or unable to tolerate statins) will increase the odds of meaningful results. Mendelian randomization studies may identify new causal risk factors for CVD that would help in the selection of the patients most likely to benefit from a specific new compound. Furthermore, imaging techniques integrating a morphological and functional assessment such as IVUS, OCT, PET/CT and PET/MRI may represent in a near future robust “soft” endpoints to support successful translation of early research into meaningful phase III clinical outcome trials.