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Featured Clinical Topic - Cardiology/Anticoagulation: Comparison of major lipid guidelines

22 Sep 2017 3:53 AM | Anonymous


Kristine Reckenberg, PharmD Candidate 2018: St. Louis College of Pharmacy
Christine Kelso, Pharm.D., BCPS, AE-C: Barnes-Jewish Hospital

Cardiovascular disease (CVD) is responsible for approximately one out of every three deaths in the United States (US).1        One major indicator, considered a predictor of cardiovascular health by the American Heart Association (AHA), is cholesterol. Thirty-three percent of Americans have elevated low density lipoprotein (LDL) cholesterol.1 LDL and other lipoproteins containing apolipoprotein B (apoB) may accumulate within the intima of arteries, ultimately leading to plaque formation and atherosclerotic cardiovascular disease (ASCVD).4 This increase in LDL is an established biomarker and modifiable risk factor for CVD, included in the current ASCVD risk assessment tool.3 Non-high density lipoprotein cholesterol (non-HDL-C) measures the cholesterol content of all atherogenic lipoproteins that contribute to this ASCVD development.10 However, conflicting evidence exists regarding whether non-HDL-C or LDL has a more significant impact on CVD development. Thus, whether or not to treat to an LDL target is the subject of debate and variations in guidelines.2 Due to this conflicting evidence, it leads to a discussion as to whether treating to an LDL target is appropriate.

Currently there are three guidelines for the management of hyperlipidemia in the US, comprised of those from the American College of Cardiology/American Heart Association (ACC/AHA), American Association of Clinical Endocrinologists and American College of Endocrinology (AACE), and National Lipid Association (NLA). Table 1 provides a brief summary of the goals and risk stratification for these major US recommendations. As outlined below, all organizations recommend similar initial treatment and differ primarily in the time of therapy initiation and treatment goals.7.8.9 Notably, not all guidelines endorse a target LDL goal. While the AACE and NLA promote this endpoint in their recommendations, the ACC/AHA instead focuses on a percent reduction in LDL achieved with statin therapy. Additionally, HDL levels have been shown to contrast with those of LDL elevation. Measured HDL is inversely proportional to atherosclerotic cardiovascular events, but no major landmark trials have shown success in pharmacologic interventions increasing HDL and reducing these incidents.5 Further exploration into this topic is warranted.

As previously mentioned, LDL targets are a source of much controversy within the guidelines. Overall there is no evidence to support targeting a specific LDL and the safety of this approach has not been scientifically proven.6 Moreover, targeted LDL therapy increases patient costs, as it requires more than the annual fasting lipid panels recommended in the ACC/AHA guidelines.7 While acknowledging that no large randomized controlled trials designed to test this are available, the NLA guidelines suggest, with expert panel consensus, that providing a targeted goal for patients allows the individual and practitioner to understand progress in their treatment which has shown to be the standard of practice for healthcare professionals throughout history.9 Similarly, the AACE guidelines endorse the use of LDL targets with a strong recommendation with strong evidence.8 In sum, further studies are needed on LDL targeted therapy in order to make a more conclusive recommendation regarding this approach.

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1. Benjamin EJ, Blaha MJ, Chiuve SE et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135(10):146-603. 

2. Harari G, Green MS, Magid A et al. Usefulness of non–high-density lipoprotein cholesterol as a predictor of cardiovascular disease mortality in men in 22-year follow-Up. Am J Cardiol. 2017;119(8):1193-98.

3. Ference BA, Ginsberg HN, Graham I et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society consensus panel.  Eur Heart J. 2017.

4. Shapiro MD, Fazio S. Apolipoprotein B-containing lipoproteins and atherosclerotic cardiovascular disease. F100Research. 2017;6:134.

5. Ali KM, Wonnerth A, Huber K et al. Cardiovascular disease risk reduction by raising HDL cholesterol – current therapies and future opportunities. Br J Pharmacol. 2012;167(6):1177-94.

6. Hayward RA, Krumholz HM. Three reasons to abandon low-density lipoprotein targets: an open letter to the Adult Treatment Panel IV of the National Institutes of Health. Circ Cardiovasc Qual Outcomes. 2012;5(1):2-5.

7. Andrus B, Lacaille D. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. J Am Coll Cardiol. 2014;63(25 Pt A).

8. Jellinger PS, Handelsman Y, Rosenblit PD et al. American association of clinical endocrinologists and American college of   endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease. Endocr Pract. 2017;23(Suppl 2):1-87.

9. Jacobson TA, Ito MK, Maki KC et al. National lipid association recommendations for patient-centered management of dyslipidemia: part 1-full report. J Clin Lipidol.2015;9(2):129-69.

10. Virani AA, Coulter SA. Non-HDL cholesterol as a metric of good quality of care: opportunities and challenges. Tex Heart Inst J. 2011;38(2):160-62.

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