Clinical Question

For the primary and secondary prevention of cardiovascular disease (CVD), how should risk be assessed, and what should be done about elevated lipid levels?

Bottom Line

The authors of this guideline give a more nuanced and less aggressive approach to lipid lowering than other groups. For the primary prevention of CVD, check blood pressure and lipids (nonfasting is fine) to calculate the 10-year CVD risk. If greater than 12%, treat; if 12% or less, discuss treatment with the patient. Pick a moderate-dose statin and do not check lipid levels again. For secondary prevention, use moderate-dose statins and titrate to a higher dose only in a few high-risk patients. Again, do not titrate based on lipid levels. (Level of Evidence = 5)

Synopsis

This guideline was developed by two government agencies tasked with providing health care for active duty military personnel and veterans. The guideline was based on a systematic review of the literature; the authors graded the evidence and the strength of their recommendations using the GRADE system. The panel members had no conflicts of interest.

For primary prevention, calculate 10-year CVD risk using a risk calculator (weak recommendation). The authors suggest three cutoffs: less than 6% risk of CVD: there is no evidence of benefit with treatment; 6% to 12% risk: there is limited evidence of benefit with treatment; greater than 12%: there is a 20% to 30% decrease in risk with treatment (weak recommendation). Treat most patients at the highest risk, but allow patients at lower risk levels to weigh possible benefit vs. possible risk, such as muscle symptoms and a small risk of diabetes mellitus (weak recommendation). Use a moderate, fixed-dose statin; that is, do not continue to check lipid levels and adjust dosing (strong recommendation).

For secondary prevention, also use a moderate, fixed-dose statin (strong recommendation). In some patients—those with recurrent cardiac events or who have multiple uncontrolled risk factors—consider using higher doses, weighing questionable benefits against a slightly higher risk of developing diabetes (weak recommendation).

Study design: Practice guideline

Funding source: Government

Setting: Various (guideline)

Reference: DownsJRO'MalleyPGManagement of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Ann Intern Med2015; 163( 4): 291– 297.