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Chapter 37: Drug Therapy for Dyslipidemias

Natalia Ruiz-Negrón; Donald K. Blumenthal

INTRODUCTION

Dyslipidemia is a disorder of lipoprotein metabolism, including lipoprotein overproduction or deficiency. Dyslipidemia is a major cause of atherosclerotic cardiovascular disease (ASCVD), ischemic cerebrovascular disease, and peripheral vascular disease. Cardiovascular disease is the number one cause of death globally (World Health Organization, 2020). Genetic disorders, metabolic diseases such as diabetes mellitus, and lifestyle factors are common causes of dyslipidemias, including hypercholesterolemia and low levels of high-density lipoprotein (HDL) cholesterol.

In 2018, various professional organizations, including the American Heart Association (AHA) and the American College of Cardiology (ACC), published updated guidelines for the management of blood cholesterol (Grundy et al., 2019). Contrary to the 2014 ACC/AHA cholesterol guidelines (Stone et al., 2014), these updated guidelines recommend cholesterol percent reduction targets in certain high-risk groups for the primary prevention of cardiovascular disease. This change signaled a shift to previous approaches used for cholesterol management, like those highlighted in the 2004 Adult Treatment Panel III guidelines (Grundy et al., 2004; NCEP, 2002). However, fixed-dose statin recommendations, like those emphasized in the 2014 ACC/AHA guideline, remained in place in the 2018 AHA/ACC cholesterol guidelines, particularly when managing secondary prevention of cardiovascular disease and patients with diabetes mellitus. With these changes, the most recent guidelines appear to merge recommendations and varying schools of thought on cholesterol management from previously published guidelines (Table 37–1). Since its release, part of the 2018 AHA/ACC cholesterol guidelines have been updated and published separately as the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease (Arnett et al., 2019). However, only updates on aspirin use and more specific recommendations on nonpharmacological aspects of ASCVD prevention were added.

TABLE 37–1COMPARISON OF KEY CLINICAL GUIDELINES FOR THE MANAGEMENT OF CHOLESTEROL IN ADULTS
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TABLE 37–1 COMPARISON OF KEY CLINICAL GUIDELINES FOR THE MANAGEMENT OF CHOLESTEROL IN ADULTS
  ATPIII 2004 ACC/AHA 2014 AHA/ACC 2018 ACC/AHA 2019
Risk assessment strategy 10-year FRS; CHD risk factors 10-year PCE 10-year or lifetime PCE 10-year or lifetime PCE
Candidates for treatment Patients above LDL-C goal Patients in four statin benefit groups Patients above LDL-C goal Primary prevention in all patients
Recommended statin intensity Titrated to achieve LDL-C goal Moderate-to-high intensity Moderate-to-high intensity (may be titrated to achieve a specific LDL-C percent reduction goal) Moderate-to-high intensity (may be titrated to achieve a specific LDL-C percent reduction goal)
Recommendations

Risk groups and LDL-C goals:

  • High risk if CHD, risk equivalent, or FRS ≥20% (LDL-C goal <100 mg/dL; <70 mg/dL optional)

  • Moderate-high risk if ≥2 risk factors or FRS 10% to <20% (LDL-C goal <130 mg/dL; <100 mg/dL optional)

  • Moderate risk if ≥2 risk factors or FRS <10% (LDL-C goal <130 mg/dL; therapy started if LDL-C >160 mg/dL)

  • Lower risk if 0 or 1 risk factor (LDL-C goal <160 mg/dL; therapy started if LDL-C >190 mg/dL)

Four statin benefit groups:

  • If ≥21 years old, clinical ASCVD, high-intensity statin (or moderate, if >75 ...

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