Lipid management: Individualize treatment

Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity and mortality. An acute cardiac event can be prevented by effective management of risk factors including dyslipidemia, which is a major risk factor for initiation and progression of the atherosclerotic process and thereby to cardiovascular events. Hence, managing the dyslipidemia-related cardiovascular risk in these patients is important for secondary prevention of CAD.

Major professional cardiology and endocrinology associations have issued guidelines on management of dyslipidemia, which differ in their approaches in managing lipids in these patients regarding assessment of risk, lipid goals and targets and pharmacological treatment.

Latest in this list of guidelines on management of dyslipidemia are recommendations from the American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) released in 2017. These guidelines have for the first time defined an “extreme” cardiovascular risk category and also bring back the concept of ‘target’-based lipid management.

The AHA/ACC guidelines issued in 2013 had recommended “appropriate intensity” of statin therapy for the four groups of primary- and secondary-prevention patients instead of treating dyslipidemia to specific ‘targets’. Hence, these guidelines removed specific targets or goals for LDL- or non-HDL-cholesterol … a change from the ATP III recommendations in 2001, which advised determination of risk category and set goals according to the risk category.

The 2017 AACE/ACE guidelines have categorized patients into five atherosclerotic cardiovascular disease (ASCVD) risk categories – low risk, moderate risk, high risk, very high and extreme risk - and now recommend lipid goals for all the five categories.

·         Low risk: Individuals with no risk factors: LDL < 130 mg/dL, non-HDL < 160 mg/dL, apoB not relevant is recommended.

·         Moderate risk: Individuals with 2 or fewer risk factors and a calculated 10-year risk < 10%: LDL < 100 mg/dL, non-HDL < 130 mg/dL, apoB < 90 mg/dL is recommended.

·         High risk: Individuals with an ASCVD equivalent including diabetes or stage 3/4 CKD with no other risk factors, or individuals with ≥2 risk factors and a 10-year risk of 10%- 20%: LDL < 100 mg/dL, non-HDL < 130 mg/dL, apoB < 90 mg/dL is recommended.

·         Very high risk: Individuals with established or recent hospitalization for acute coronary syndrome (ACS); coronary, carotid or peripheral vascular disease; diabetes or stage 3/4 CKD with ≥1 risk factors; a calculated 10-year risk > 20%; or heterozygous familial hypercholesterolemia [HeFH]): LDL < 70 mg/dL, non-HDL < 80 mg/dL, apoB < 80 mg/dL is recommended.

·         Extreme risk: Individuals with progressive ASCVD, including unstable angina that persists after achieving an LDL <70 or established clinical ASCVD in individuals with diabetes, stage 3/4 CKD, and/or HeFH, or in individuals with a history of premature ASCVD (males <55 years; females <65 years): LDL < 55 mg/dL, non-HDL < 80 mg/dL, apolipoprotein B (apoB) < 70 mg/dL is recommended.

Lowering cholesterol is important for all age groups, both men and women, regardless of the presence of absence of heart disease. A 1% rise in cholesterol level can raise the chances of heart attack by 2%. 1% reduction of “good” HDL cholesterol increases the chances of suffering from a heart attack by 3%.

However, it is important to keep in mind that every patient is different; hence, treatment, including lipid goals should be individualized according to that particular patient. 

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA