The National Lipid Association has issued recommendations for patient-centered management of dyslipidemia. The recommendations differ from guidelines issued in 2013 by the American College of Cardiology and American Heart Association in that they do not abandon the principle of LDL and non-HDL treatment goals, and do not advocate the use of a particular risk calculator.
The recommendations are similar to the ACC/AHA guidelines, however, as statins are encouraged as first-line therapy for reducing risk for atherosclerotic CVD and discussion about risk reduction between physicians and patients is encouraged.
In May, the National Lipid Association (NLA) issued similar recommendations in draft form. The new document contains more detail and explanation, James Underberg, MD, MS, FACP, FNLA, member of the NLA board of directors, told Cardiology Today.
The goal is to “give the people doing the day-to-day work taking care of patients a roadmap and a set of tools to allow them to manage everyone,” said Underberg, clinical assistant professor of medicine at the New York University School of Medicine and the NYU Center for the Prevention of Cardiovascular Disease and director of the Bellevue Hospital Lipid Clinic.
Driving the recommendations, Underberg said, is a consensus that a cause of atherosclerosis is atherogenic lipoproteins, and that one of the best ways to reduce risk for atherosclerotic CVD is to treat the atherogenic lipoproteins, best measured by non-HDL, apolipoprotein B or LDL particle number.
Treatment goals effective
Terry A. Jacobson, MD, from the department of medicine at Emory University School of Medicine, and colleagues on the writing panel wrote that treatment goals are an effective means of reducing risk for atherosclerotic CVD.
“The expert panel’s consensus view is that treatment goals are useful as a means to ensure that the aggressiveness of therapy to lower atherogenic cholesterol is matched to absolute risk for an event,” they wrote. “Moreover, treatment goals facilitate effective communication between patients and clinicians, providing an easily interpretable means through which the clinician can communicate progress toward meeting treatment objectives, thus supporting efforts to maximize long-term adherence to the treatment plan.”
The ACC/AHA guidance did not recommend for or against lipid goals, but “we felt that because we did not limit ourselves to only the highest-quality randomized clinical trials, there was enough good evidence out there to support the continued use of lipid goals,” Underberg, who was not a member of the writing panel, said in an interview. He noted that the NLA recommends the primary goal be a non-HDL level because previous research showed non-HDL is a better predictor of atherosclerotic CVD morbidity and mortality than LDL.
The recommendations set non-HDL and LDL goals based on whether a patient is in one of four risk categories:
- Low: no or one major atherosclerotic CVD risk factors.
- Moderate: two major atherosclerotic CVD risk factors.
- High: three or more major atherosclerotic CVD risk factors, diabetes with no or one other major atherosclerotic CVD risk factors, chronic kidney disease stage 3B or 4, severe hypercholesterolemia (LDL ≥190 mg/dL) or a quantitative risk score reaching the high-risk threshold.
- Very high: atherosclerotic CVD, diabetes with two or more other major atherosclerotic CVD risk factors or evidence of end-organ damage.
“We highlighted some additional risk groups that seemed to be left out of the ACC/AHA document,” including those with CKD, Underberg said.
Diet and lifestyle therapies should be tried first in patients at low and moderate risk, while drug therapies can be started concurrently in those at very high risk and in some at high risk, according to the document
Statins used first
Drug therapy should be initiated with a statin, with the exception of patients who are intolerant, and treatment should be determined on a case-by-case basis whether to begin with a moderate-intensity statin and titrate upward if necessary or to begin with a high-intensity statin and titrate downward if necessary, Jacobson and colleagues wrote.
Although the ACC/AHA guideline discourages the use of nonstatin drug therapies except in statin-intolerant patients, the NLA recommendations state that some with evidence of reducing CHD or CVD rates, including bile acid sequestrants, fibric acids and nicotinic acid, may be appropriate, Underberg told Cardiology Today.
“Our message is that after statins, it is OK to use nonstatins for the appropriate reasons,” he said. “And we list them very clearly: in high-risk patients, in patients with inherited cholesterol disorders. It is important that people realize there is still a role, but the role is clearly after statin therapy.” – by Erik Swain
For more information:
Jacobson TA. J Clin Lipidol. 2014;8:473-488.
Disclosure: Underberg serves on the board of directors of and is a spokesman for the NLA but receives no compensation for either role. See the recommendations for a full list of the writing panel members’ relevant financial disclosures.