Hyperlipidemia management: A calibrated approach
Gauge the level of LDL cholesterol and assess risk-enhancing factors for ASCVD—thus setting the table for primary and secondary prevention with medical therapy.
PRACTICE RECOMMENDATIONS
› Use an alternative to the Friedewald equation, such as the Martin–Hopkins equation, to estimate the low-density lipoprotein cholesterol (LDL-C) value; order direct measurement of LDL-C; or calculate non–high-density lipoprotein cholesterol to assess the risk for atherosclerotic cardiovascular disease (ASCVD) in patients who have a low LDL-C or a high triglycerides level. C
› Consider the impact of ASCVD risk-enhancing factors and coronary artery calcium scoring in making a recommendation to begin lipid-lowering therapy in intermediate-risk patients. C
› Add ezetimibe if a statin does not sufficiently lower LDL-C or if a patient cannot tolerate an adequate dosage of the statin. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
> 75 years, without ASCVD. In this group, the benefit of statin therapy is less clear and might be lessened by an increased potential for adverse effects. A meta-analysis of 28 trials demonstrated that people ages > 75 years had a 24% relative reduction in major coronary events for every 38.7 mg/dL (1.0 mmol/L) reduction in LDL-C, which is comparable to the risk reduction seen in people ages 40 to 75 years.15
With increasing age, however, the relative reduction in major coronary events with statin therapy decreased,15 although other trials have not demonstrated age heterogeneity.16 Because people > 75 years of age have a significantly higher ASCVD event rate, a comparable relative rate reduction with statin therapy results in a larger absolute rate reduction (ARR) and, therefore, a smaller number needed to treat (NNT) to prevent an event, compared to the NNT in younger people.
Secondary prevention
ACC/AHA guidelines define clinical ASCVD as a history of:
- acute coronary syndrome
- myocardial infarction
- coronary or other arterial revascularization
- cerebrovascular event
- symptomatic peripheral artery disease, including aortic aneurysm.
High-intensity statin therapy is indicated for all patients ≤ 75 years who have clinical ASCVD. In patients > 75 years, consider a taper to moderate-intensity statin therapy. An upper age limit for seeing benefit from statin therapy in secondary prevention has not been identified.4
In high-risk patients, if LDL-C remains ≥ 70 mg/dL despite maximally tolerated statin therapy, ezetimibe (discussed in the next section) can be added. In very-high-risk patients, if LDL-C remains ≥ 70 mg/dL despite maximally tolerated statin therapy plus ezetimibe, a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (also discussed next) can be added. Always precede initiation of a PCSK9 inhibitor with a discussion of the net benefit, safety, and cost with the patient.4
Continue to: Options for lipid-lowering pharmacotherapy
