Dyslipidemia is a major cause of ASCVDs, such as CHD, ischemic cerebrovascular disease, and peripheral vascular disease. Cardiovascular disease represents the number one cause of death among adults in many developed nations (Mozaffarian et al., 2015). Both genetic disorders and lifestyle contribute to the dyslipidemias, including hypercholesterolemia and low levels of HDL-C.
Classes of drugs that modify cholesterol levels include the following:
Inhibitors of HMG-CoA reductase (statins)
Bile acid–binding resins
Nicotinic acid (niacin)
Fibric acid derivatives (fibrates)
Inhibitor of cholesterol absorption (ezetimibe)
Omega-3 fatty acid ethyl esters (fish oil)
MTP inhibitor (lomitapide)
Inhibitor of apolipoprotein B-100 synthesis (mipomersen)
The 2014 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults (Stone et al., 2014) recommends a substantial shift in approach to cholesterol management compared to the ATPIII (Grundy et al., 2004; NCEP, 2002). Whereas ATPIII advocated treating to specific lipoprotein targets, the 2014 ACC/AHA guideline focuses on offering fixed doses of statins to patients in four statin benefit groups to reduce morbidity and mortality. Since the 2014 release of the ACC/AHA guideline, several additional expert consensus recommendations have been published, providing alternative opinions on cholesterol management (Jacobson et al., 2015) and recommendations regarding the role of nonstatin cholesterol treatments (Lloyd-Jones et al., 2016) in reduction of ASCVD risk (see Table 33–1).
Table 33–1Comparison of Key Clinical Guidelines for The Management of Cholesterol in Adults ||Download (.pdf) Table 33–1 Comparison of Key Clinical Guidelines for The Management of Cholesterol in Adults
| ||ATPIII 2004 ||ACC/AHA 2014 ||NLA 2015 ||USPSTF 2016 |
|Risk assessment strategy ||10-year FRS; CHD risk factors ||10-year PCE ||ASCVD risk factors used; FRS, PCE, or other ||10-year PCE |
|Candidates for treatment ||Patients above LDL goal ||Patients in four statin benefit groups ||Patients above LDL goal ||Primary prevention in patients with risk |
|Recommended statin intensity ||Titrated to achieve LDL goal ||Moderate-to-high intensity ||Titrated to achieve LDL goal ||Low-to-moderate intensity |
|Recommendations || |
Risk groups and LDL goals:
High risk (LDL goal < 100, < 70 optional) if CHD, risk equivalent, or FRS ≥ 20%
Moderate-high risk (LDL goal < 130, < 100 optional) if ≥ 2 risk factors or FRS 10% to < 20%
Moderate risk (LDL goal <130, therapy started if LDL >160) if ≥2 risk factors or FRS <10%
Lower risk (LDL goal <160, therapy started if ...