February 1, 2019
New Cholesterol Management Guidelines Emphasize Practicality and Clinical Judgment: The 2018 AHA/ACC Guideline on the Management of Blood Cholesterol reinforces the need to encourage lifestyle modification to prevent atherosclerotic cardiovascular disease (ASCVD) and to use high-potency statins in patients at high risk of major adverse cardiovascular (CV) events. LDL-C targets have been re-introduced into the guidelines. Combination therapy using a statin plus either ezetimibe or a PCSK-9 inhibitor should be considered in very high-risk patients who do not reach their LDL-C target. Clinicians and patients can now consider a wider array of risk-enhancing factors when making treatment decisions. Most patients no longer need to fast before obtaining a lipid profile.
Upon completion of the chapter, the reader will be able to:
Identify the common types of lipid disorders.
Identify the statin-benefit groups and intensity of statin therapy according to the American College of Cardiology/American Heart Association.
Recommend appropriate therapeutic lifestyle changes (TLC) and pharmacotherapy interventions for dyslipidemia.
Determine a patient’s atherosclerotic cardiovascular disease risk and corresponding treatment goals according to the National Lipid Association, American Association of Clinical Endocrinologist/American College of Endocrinology, and American College of Cardiology.
Identify patients who are indicated for nonstatin therapy according to the American College of Cardiology.
Describe components of a monitoring plan to assess effectiveness and adverse effects of pharmacotherapy for dyslipidemias.
Educate patients about the disease state, appropriate TLC, and drug therapy required for effective treatment.
Hypercholesterolemia or dyslipidemia play a major role in atherosclerosis and plaque formation leading to coronary heart disease (CHD) as well as other forms of atherosclerotic cardiovascular disease (ASCVD), such as carotid and peripheral artery disease.1 CHD is the leading cause of death in adults in the United States and most industrialized nations. It is also the chief cause of premature, permanent disability in the US workforce.
EPIDEMIOLOGY AND ETIOLOGY
It is estimated that 94.6 million US adults have high cholesterol with a value of 200 mg/dL (5.17 mmol/L) or greater.2 Further, one out of every three US adults has a high level of low-density lipoprotein (LDL) cholesterol.2 Elevated cholesterol values are a major risk factor for the development of ASCVD. Annually, approximately 580,000 Americans experience a new heart attack and 210,000 will have a recurrent event.2 Lowering cholesterol reduces atherosclerotic progression and mortality from CHD and stroke. The development of CHD is a lifelong process. Except in rare cases of severely elevated serum cholesterol levels, years of poor dietary habits, sedentary lifestyle, and life-habit risk factors (eg, smoking, overweight/obesity) contribute to the development of atherosclerosis.3
Cholesterol and Lipoprotein Metabolism
Cholesterol, an essential substance manufactured by most cells in the body, is used to maintain cell wall integrity and for the biosynthesis of bile acids...