Hyperlipidemia: Drugs for Cardiovascular Risk Reduction in Adults
Am Fam Physician. 2017 Jan 15;95(2):78-87.
Related editorial: The Cholesterol Dilemma: Treating the Risk or Treating to LDL-C Goal?
Related U.S. Preventive Services Task Force recommendation statement: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Recommendation Statement
Author disclosure: No relevant financial affiliations.
Guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and the U.K. National Institute for Health and Care Excellence (NICE) indicate that lipid-lowering drugs have benefit for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) events. The evidence is strongest for statins. ACC/AHA, NICE, and U.S. Preventive Services Task Force (USPSTF) guidelines recommend statin therapy based on patients' risk of an ASCVD event, rather than treating to specific lipid levels. For patients with no previous ASCVD event, risk calculators should be used to determine the 10-year risk of ASCVD. The ACC/AHA guideline recommends starting moderate- to high-intensity statins if the risk is 7.5% or greater, whereas the NICE and USPSTF guidelines recommend statins if the risk is 10% or greater. Patients with known ASCVD should receive high-intensity statins unless they fall into special categories (e.g., older age) or do not tolerate high-intensity statins, in which case moderate-intensity statins are appropriate. Liver transaminase levels should be checked before starting statins; guidelines vary on if and when to recheck them in the absence of symptoms. Lipid levels should be rechecked one to three months after starting statins, although guidelines differ on subsequent checks. Other lipid-lowering drugs (e.g., bile acid sequestrants, ezetimibe) can be considered if patients do not tolerate statins. Niacin should not be used. Some evidence supports adding ezetimibe to statin therapy in patients with acute coronary syndrome or chronic kidney disease. The role of proprotein convertase subtilisin/kexin type 9 inhibitors is unclear, but initial studies suggest a decrease in the rate of acute ASCVD events in patients with hypercholesterolemia.
The American College of Cardiology (ACC) and the American Heart Association (AHA) jointly issued a new guideline in 2013 on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults.1 This guideline presented significant changes to previous recommendations on the management of hyperlipidemia for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), which includes acute coronary syndrome, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, and peripheral arterial disease presumed to be of atherosclerotic origin.
WHAT IS NEW ON THIS TOPIC: HYPERLIPIDEMIA
A Cochrane review found that for every 1,000 persons treated with a statin for five years, 18 avoid myocardial infarction, angina, or stroke (number needed to treat = 56). This review focused on studies that included fewer than 10% of participants with known cardiovascular disease.
A meta-analysis of 13 trials involving more than 90,000 patients found that statin use increases the overall absolute risk of developing diabetes mellitus by 0.39% (number needed to harm = 255) over four years.
In early 2016, the U.S. Food and Drug Administration withdrew approvals for extended-release niacin and delayed-release fenofibric acid (fibrate) in combination with statins based on lack of cardiovascular benefit.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References||Comments|
Patients with a high risk of ASCVD (a 10-year risk of at least 7.5% or 10%, depending on the guideline) should receive statin therapy for primary prevention.
Inconsistent results from meta-analyses regarding benefit in low-risk patients
Statin therapy should be prescribed for secondary prevention in patients with known ASCVD, unless contraindicated.
Recommendation from consensus guidelines and meta-analyses
Niacin, fibrates, and omega-3 fatty acids should not be routinely prescribed for primary or secondary prevention of ASCVD. Although these agents lower cholesterol levels, they do not affect patient-oriented outcomes.
Consistent results in meta-analyses and systematic review
A moderate-intensity statin plus ezetimibe should be considered as an alternative in patients with acute coronary syndrome who do not tolerate high-intensity statin therapy.
One randomized controlled trial with high discontinuation rates
ASCVD = atherosclerotic cardiovascular disease.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.
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