Recommendation #3: Prioritize statin therapy.
ATP III recommends starting a “statin or bile acid sequestrant or nicotinic acid”
• However, statins have more effect and much more data
• Statins should be first-line; guidelines from the AHA/ACC2 explicitly state this
• If a patient does not tolerate initial statin therapy, try a lower dose, alternative dosing schedule, or a different statin before switching to another drug class
Recommendation #4: Relax the follow-up interval for repeat lipid testing.
When a drug is started, ATP III recommends that we repeat the LDL-C in 6 weeks: if the level is not at goal, repeat the measurement 6 weeks later
• Not an evidence-based, practical, or cost-effective approach to care
• In fact, some experts believe we should blindly titrate statins and not retest lipids
• However, patients and doctors like knowing the numbers and this allows greater personalization of care, as well as additional risk stratification
• We recommend relaxing follow-up testing and individualizing the interval to the patient
» Some might be encouraged early in treatment by lipid number improvement
» Others may find testing inconvenient and want to wait longer to assess response to important lifestyle changes, in addition to drug effect
Recommendation #5: Designate <70 mg/dL as an “ideal” LDL-C target.
Currently, a LDL-C <70 mg/dL is only a therapeutic option for “very high-risk patients”
• With data from additional trials (TNT,3 IDEAL,4 JUPITER5) and meta-analyses supporting LDL-C levels <70 mg/dL, we view this as “ideal”
• Indeed, the ESC/EAS6 joint task force on management of dyslipidemia recently adopted this as a routine goal for patients with atherosclerosis
Recommendation #6: Endorse targets beyond LDL-C.
We have no clinical trial data that primarily examine treat-to-target strategies, a fact that should temper any clinical therapeutic recommendations for targets in general, or one over another
• LDL-C goals are justified by the biology of atherosclerosis, epidemiologic studies that link high LDL-C to atherosclerosis, and data from multiple RCTs that show a correlation between lowering LDL-C and improved outcomes
• ATP III identifies HDL-C only as a secondary target; however, multiple lines of evidence cited within the guideline’s cholesterol-based framework support non-HDL-C as the preferred target
• Non-HDL-C can be measured in a nonfasting state and adds no cost to testing
• There is a similar scientific basis for measurement of the number of cholesterol particles (eg, apolipoprotein B [apoB]) rather than their cholesterol content
• At a given LDL-C, there are more atherogenic particles when there is a small dense LDL-C pattern (eg, in DM); risk may be underestimated by cholesterol measurement alone
• Measurement of apoB is standardized by the WHO,7and endorsed by the ADA/ACC8 and in guidelines from Europe6 and Canada9
• A simple message: do not stop at LDL-C, particularly in high-risk patients