Lipid Management: Guidelines From the Canadian PEER Group for Primary Care

Cardiovascular disease (CVD) is the leading cause of death globally, and lipid level testing is one aspect of screening to assess risk. Options for testing and treatment have grown complex as more tests and lipid-lowering agents become available. The Canadian PEER group for primary care released guidelines for preventing and managing CVD through lipid management. Acknowledging the many competing demands on family physicians, the guideline considers the “time needed to treat,” meaning the time clinicians spend implementing recommendations.

The guideline is summarized in a two-page reference (https://www.cfp.ca/content/cfp/suppl/2023/10/10/69.10.675.DC1/Figure_1_2-page_Guideline_Summary.pdf) and a free online tool (https://decisionaid.ca/cvd) can facilitate shared decision-making conversations about risks and interventions.

For patients without known CVD who are not taking statins, lipid testing is recommended when men reach 40 years of age and women reach 50 years of age. Earlier testing can be considered for patients with CVD risk factors, such as smoking and diabetes mellitus.

Frequent (e.g., yearly) lipid measurement is not useful in estimating risk. Without treatment, lipid levels vary about 1% per year, which is dwarfed by a variation of up to 20% due to testing inaccuracy. Frequent lipid measurements will likely reflect testing variability instead of changes in overall risk. Lipid screening is recommended no more than every 5 years and preferably every 10 years unless new risk factors are identified. Fasting lipid testing is not needed because nonfasting results accurately estimate risk.

The PEER group discourages assessing risk beyond lipid levels and the presence of risk factors. Coronary artery calcium scores only slightly increase accuracy and are not recommended. Lipoprotein(a) and apoprotein B tests are not helpful in determining risk.

For patients with cardiac disease, risk calculation and lipid testing and monitoring are unnecessary because statin therapy is universally recommended.

Physical activity is beneficial for primary and secondary prevention. Commitment to an exercise routine is more important than the type, duration, or intensity of exercise. The strongest evidence is for exercise-based cardiac rehabilitation, which reduces all-cause mortality, cardiovascular mortality, and myocardial infarction after a cardiac event.

The PEER group recommends the Mediterranean diet for patients with and without CVD. Compared with lowfat diets, the Mediterranean diet decreases cardiovascular events over 5 to 7 years.

For primary prevention, the 10-year cardiovascular risk estimation determines treatment recommendations. Patients with a 10-year risk of 20% or greater benefit from high-intensity statin therapy. Those with a 10-year risk between 10% and 19% may benefit from moderate-intensity statins. Once treatment is started, the PEER group recommends against repeat lipid testing or treating to a target cholesterol level. For patients with a 10-year risk less than 10%, statin therapy is not recommended and lipid levels should be reassessed in 5 to 10 years.

In primary prevention, statins are the only drugs proven to decrease major adverse cardiovascular events, cardiovascular mortality, and all-cause mortality. Using nonstatin medications as monotherapy or combined with statins is not recommended.

Patients with a history of a cardiovascular event have significant risk reduction from taking a high-intensity statin. For additional cardiovascular protection for these patients, ezetimibe or a proprotein convertase subtilisin-kexin 9 (PCSK9) inhibitor can be considered.

Eicosapentaenoic acid ethyl ester (icosapent) therapy can also reduce the risk of cardiovascular events and cardiovascular mortality in secondary prevention. Icosapent is recommended only for patients who cannot take ezetimibe and PCSK9 inhibitors because of an increased risk of atrial fibrillation and bleeding.

Because evidence of benefit is lacking for adults older than 75 years, the PEER group recommends not initiating statin therapy in this population but continuing statin therapy previously started. Statin therapy is recommended for secondary prevention. Evidence does not suggest an increased risk of cancer, cognitive decline, or death due to statin use.

Most muscle symptoms reported by patients taking statins are not statin-induced. Although 15% of patients started on a statin will experience muscle symptoms, 14% of patients taking placebo experience similar symptoms. In patients with nonsevere muscle symptoms, the PEER group recommends switching to a different class of statins, reducing the dose, or trying alternate-day dosing.

For patients who are truly intolerant of statins, the PEER group recommends against nonstatin therapy for primary prevention, given the paucity of evidence of benefit. For patients with a history of CVD, the guideline recommends shared decision-making about initiating ezetimibe, PCSK9 inhibitors, fibrates, or icosapent.

Fixed-dose statin therapy leads to reduced cardiovascular events without attempting to achieve cholesterol level targets. To stay consistent with the evidence and reduce low-value tasks in primary care, the PEER group recommends against retesting lipid levels and resetting cholesterol level targets after lipid-lowering therapy is started.

The guideline also recommends against routine baseline or monitoring levels of creatine kinase or alanine transaminase with statin therapy.

Editor's Note: This Canadian guideline is useful because it is written for primary care and is simple to implement. For primary prevention, the recommendation is to start a statin at 20% calculated risk and consider initiation between 10% and 20%. Because there is no clear cutoff in risk, different organizations use different cutoffs—20% and 7.5% for the American College of Cardiology, 12% and 6% for the U.S. Departments of Veterans Affairs and Defense, and 10% and 7.5% with a risk factor for the U.S. Preventive Services Task Force (USPSTF). Whereas the USPSTF is uncertain about starting a statin in patients older than 75 years, the PEER group recommends not initiating therapy but continuing statins in this age group.—Michael J. Arnold, MD, Assistant Medical Editor

The views expressed are those of the authors and do not necessarily reflect the official policy or position of the U.S. Department of Veterans Affairs or the U.S. government.

Guideline source: Canadian PEER Group

Published source: Kolber MR, Klarenbach S, Cauchon M, et al. PEER simplified lipid guideline 2023 update: prevention and management of cardiovascular disease in primary care. Can Fam Physician. 2023;69(10):675–686.

Available at: https://www.cfp.ca/content/cfp/69/10/675.full.pdf