Hyperlipoproteinemia medical therapy: Difference between revisions

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__NOTOC__
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{{Hyperlipidemia}}
{{Hyperlipidemia}}
{{CMG}}
{{CMG}}; {{AE}} {{HP}}
 
==Overview==
==Overview==
==Medical Therapy==
Hyperlipidemia requires early detection, careful evaluation and aggressive treatment with combination of therapeutic lifestyle changes and lipid-lowering drug therapies to reduce the risk of cardiovascular and cerebrovascular complications.
* [[Hyperlipidemia NCEP recommendations for drug therapy of high-risk hyperlipidemia in children and adolescents | Recommendations for drug therapy]]
 
* [[Hyperlipidemia statins in children and adolescents with hyperlipidemia | Statins]]
==Medical Therapy for Adults==
* [[Hyperlipidemia NCEP guidelines for adjuvant therapies in children and adolescents | Adjuvant therapies]]
===NCEP ATP III Recommendations for Medical Therapy of Hyperlipidemia in Adults===
===Original Recommendations of the National Cholesterol Education Program (NCEP) ATP III for Medical Therapy of Hyperlipidemia in Adults<ref name="pmid12485966">{{cite journal| author=National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)| title=Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. | journal=Circulation | year= 2002 | volume= 106 | issue= 25 | pages= 3143-421 | pmid=12485966 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12485966  }} </ref> (DO NOT EDIT)===
 
*Obtain [[Hyperlipidemia laboratory tests | complete lipid profile]] after 9 to 12-hour fast.
 
====Detect Presence of Coronary Heart Disease (CHD) Risk Equivalent====
#Previous personal history of clinical [[CHD]]
#Clinical [[carotid artery disease]]
#[[Abdominal aortic aneurysm]]
#[[Peripheral arterial disease]]
#[[Diabetes]]
 
====Determine Presence of Major Risk Factors====
(Other than LDL)
#[[Hypertension]] (BP≥140/90 mmHg or on antihypertensive medication)
#Cigarette smoking
#Low HDL-cholesterol (<40 mg/dL)
#*HDL-cholesterol ≥60 mg/dL counts as a "negative" risk factor and removes one risk factor from the total count.
#Age (men ≥45 years; women ≥55 years)
#Family history of premature CHD in first degree relative (CHD in men <55 years; CHD in women <65 years)
 
 
If 2+ major risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk using Framingham Risk Score. The Framingham Risk Score is based on data obtained from the Framingham Heart Study. There are two Framingham Risk Scores, one for men and one for women. Three levels of 10-year risk:
{|class="wikitable"
|-
| Low risk || <10%
|-
| Intermediate risk || 10 - 20%
|-
| High risk<br>(CHD risk equivalent) || >20%
|}
 
====Determine Risk Category, LDL Goal of Therapy, Level for Therapeutic Lifestyle Changes (TLC), and Level for Drug Therapy====
{|class="wikitable" border="1" style="text-align:center; width:800px;"
|-style="background:#CDC9C9"
| Risk Category || LDL Goal<br>(mg/dL) || LDL Level to<br>Initiate TLC (mg/dL) || LDL Level to<br>Consider Drug Therapy (mg/dL)
|-
| CHD or CHD risk equivalents<br>(10-year risk >20%) || <100 || ≥100 || ≥130
|-
| 2+ major risk factors<br>(10-year risk ≤20%) || <130 || ≥130 || 10-year risk 10-20%<br>≥130<br>10-year risk <10%<br>≥160
|-
| 0-1 major risk factor || <160 || ≥160 || ≥190
|}
 
====Therapeutic Lifestyle Changes (TLC)====
Therapeutic lifestyle changes (TLC) should be initiated, if LDL level is above goal.
#TLC diet - consists of saturated fat <7% of calories, cholesterol <200 mg/day, increased viscous (soluble) fiber (10-25 g/day), and plant sterols (2g/day) to enhance LDL lowering.
#Weight management
#Increased physical activity
 
====Drug Therapy====
Drug therapy should be initiated, if LDL exceeds levels shown in above table. Initiate drug simultaneously with TLC for CHD and CHD equivalents, whereas add drug to TLC after 3 months for other risk categories.
{|class="wikitable" border="1" style="text-align:center; width:800px;"
|-style="background:#CDC9C9"
| Drug Class || Agents<br>(Daily Doses) || Effects on Lipid || Side Effects || Contraindications
|-
| [[Statins]]<br>(HMG-CoA reductase<br>inhibitors) || Lovastatin (20-80 mg)<br>Pravastatin (20-40 mg)<br>Simvastatin (20-80 mg)<br>Fluvastatin (20-80 mg)<br>Atorvastatin (10-80 mg)<br>Cerivastatin (0.4-0.8 mg) || Decrease LDL<br>Increase HDL<br>Decrease TG || [[Myopathy]]<br>Elevated liver<br>enzymes || Absolute:<br>Active or chronic<br>liver disease<br>Relative:<br>Concomitant use of<br>[[cyclosporine]],<br>[[macrolide antibiotic]]s,<br>anti-fungal agents,<br>cytochrome P-450 inhibitors
|-
| Bile acid<br>sequestrants || [[Cholestyramine]] (4-16 g)<br>[[Colestipol]] (5-20 g)<br>[[Colesevelam]] (2.6-3.8 g) || Decrease LDL<br>Increase HDL<br>No change or<br>increase TG || GI distress<br>[[Constipation]]<br>Decreased absorption<br>of other drugs || Absolute:<br>Dysbetalipoproteinemia<br>TG >400 mg/dL<br>Relative:<br>TG >200 mg/dL
|-
| [[Nicotinic acid]]<br>(Niacin) || Immediate release<br>niacin (1.5-3 gm)<br>Extended release<br>niacin (1-2 g)<br>Sustained release<br>niacin (1-2 g) || Increase HDL<br>Decrease TG<br>Decrease LDL || Flushing<br>[[Hyperglycemia]]<br>[[Hyperuricemia]]<br>[[Hepatotoxicity]]<br>Upper GI distress || Absolute:<br>[[Chronic liver disease]]<br>Severe [[gout]]<br>Relative:<br>[[Diabetes]]<br>Hyperuricemia<br>[[Peptic ulcer disease]]
|-
| [[Fibric acid]]s<br>(Fibrates) || Gemfibrozil (1.2 g)<br>Clofibrate (2 g)<br>Fenofibrate (200 mg) || Decrease TG<br>Increase HDL || [[Dyspepsia]]<br>[[Gallstones]]<br>Myopathy || Absolute:<br>Severe hepatic disease<br>Severe renal disease
|}([[LDL]]=LDL cholesterol, [[HDL]]=HDL cholesterol, [[TG]]=Triglycerides)


===[[Hypertriglyceridemia medical therapy | Pharmacotherapy]]===
====Treatment of Elevated Triglycerides====
*In case of hyperlipidemia with elevated triglycerides (≥150 mg/dL), primary aim of therapy is to reach LDL goal, intensify weight management and increase physical activity.


* [[Statins]]
*If triglycerides are ≥200 mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol (total - HDL) 30 mg/dL higher than the LDL goal for respective categories.
* [[Niacin]]
{|class="wikitable" border="1" style="text-align:center; width:800px;"
* [[Fibrate]]
|-style="background:#CDC9C9"
* [[Omega-3 fatty acids]]
| Risk Category
===Trial supportive data===
| LDL Goal (mg/dL)
====[[Niacin]]====
| Non-HDL Goal (mg/dL)
|-
| CHD or CHD risk equivalents (10-year risk >20%)
| < 100
| < 130
|-
| 2+ major risk factors (10-year risk ≤20%)
| < 130
| < 160
|-
| 0-1 major risk factor
| < 160
| < 190
|-
|}
#If triglycerides are 200-499 mg/dL after LDL goal is reached, consider adding drug if needed to reach non-HDL goal:
#*Intensify therapy with LDL-lowering drug
#*Add niacin or fibrate to further lower triglycerides
#If triglycerides are ≥500 mg/dL, first lower triglycerides to prevent [[pancreatitis]]:
#*Very low-fat diet (<15% of calories from fat)
#*Intensified weight management and increased physical activity
#*Add niacin or fibrate
#*When triglycerides reach <500 mg/dL, turn to LDL-lowering drug


=====[[Niacin AIM HIGH study | AIM HIGH study]]=====
====Treatment of Low HDL Cholesterol (<40 mg/dL)====
First reach LDL goal, intensify weight management, and increase physical activity; then if triglycerides are 200-499 mg/dL, achieve non-HDL goal and if triglycerides are <200 mg/dL (isolated low HDL) in CHD or CHD equivalent, add niacin or fibrate.
 
====Treatment of the Metabolic Syndrome====
*Identification of the [[metabolic syndrome]] (any 3 of the following):
*#Abdominal [[obesity]] - waist circumference of >102 cm (>40 in) in men and >88 cm (>35 in) in women
*#Serum triglyceride level ≥150 mg/dL
*#HDL cholesterol level of <40 mg/dL in men and <50 mg/dL in women
*#Blood pressure ≥130/85 mmHg
*#Fasting glucose ≥110 mg/dL.
 
*Treat underlying causes:
**Intensify weight management
**Increase physical activity.
 
*Treat lipid and non-lipid risk factors, if they persist despite TLC:
**Treat hypertension
**Use [[aspirin]] for CHD patients to reduce thromboembolic risk
**Treat elevated triglycerides and/or low HDL as shown above.
 
===Other Lipid Lowering Agents===
====Omega-3 Fatty Acids====
{|class="wikitable" border="1" style="width:800px"
|-style="background:#CDC9C9"
|''' Drug '''
|''' Mechanisms of Benefit '''
|''' Dosage '''
|''' Advantages '''
|''' Side Effects '''
|''' Contraindications '''
|-
| '''Omega-3 fatty acids'''
|
↓ hepatic [[lipogenesis]]<br>↓ plasma [[lipoprotein lipase]] activity<br>↑ hepatic mitochondrial and peroxisomal [[beta-oxidation]]<br>Inhibition of acyl CoA:1,2-[[diacylglycerol acyltransferase]] enzyme<br>[[EPA]] and [[DHA]] are poor enzyme substrates for [[triglyceride]] synthesis in [[liver]] and inhibits esterification of other fatty acids.
|
3 g/day of EPA and DHA<ref name="pmid16825676">{{cite journal| author=Wang C, Harris WS, Chung M, Lichtenstein AH, Balk EM, Kupelnick B et al.| title=n-3 Fatty acids from fish or fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular disease outcomes in primary- and secondary-prevention studies: a systematic review. | journal=Am J Clin Nutr | year= 2006 | volume= 84 | issue= 1 |pages= 5-17 | pmid=16825676 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16825676  }} </ref>
|
↓ [[VLDL]]<ref name="pmid6736254">{{cite journal| author=Nestel PJ, Connor WE, Reardon MF, Connor S, Wong S, Boston R| title=Suppression by diets rich in fish oil of very low density lipoprotein production in man. | journal=J Clin Invest | year= 1984 | volume= 74 | issue= 1 | pages= 82-9 | pmid=6736254 | doi=10.1172/JCI111422 | pmc=PMC425187 | url=}} </ref>, <ref name="pmid11303007">{{cite journal| author=Durrington PN, Bhatnagar D, Mackness MI, Morgan J, Julier K, Khan MA et al.| title=An omega-3 polyunsaturated fatty acid concentrate administered for one year decreased triglycerides in simvastatin treated patients with coronary heart disease and persisting hypertriglyceridaemia. |journal=Heart | year= 2001 | volume= 85 | issue= 5 | pages= 544-8 | pmid=11303007 | doi= | pmc=PMC1729738 | url= }}</ref><br>↓ [[TG]] by ≥50%
|
[[Bleeding]], at high doses<br>
Fishy smell, can be reduced by
*freezing of medication
*trying different formulation
*taking medication with food
[[Nausea]]
|
Hypersensitivity
|} (↑ - Increase, ↓ - Decrease)
 
====Ezetimibe====
[[Ezetimibe]] is a new class of lipid lowering agents. It inhibits intestinal absorption of cholesterol. It has been approved as a monotherapy or in combination with [[statins]] to treat hypercholesterolemia. It has also been approved in combination with [[fenofibrate]] to treat mixed hyperlipidemia.
 
==Medical Therapy in Children and Adolescents==
Click on the respective microchapter to read more about it:
*'''[[Hyperlipidemia NCEP recommendations for drug therapy of high-risk hyperlipidemia in children and adolescents | Drug Therapy]]'''
*'''[[Hyperlipidemia statins in children and adolescents with hyperlipidemia | Statins]]'''
*'''[[Hyperlipidemia NCEP guidelines for adjuvant therapies in children and adolescents | Adjuvant Therapies]]'''
 
==A Trial Based Approach to Statin Guidelines==
Shown below is a table suggesting an approach to the use of statin according to different trials.<ref>Ridker P, Wilson PF. A Trial-Based Approach to Statin Guidelines. JAMA. 2013;():-. doi:10.1001/jama.2013.276529.</ref>
{| class="wikitable" border="1"
| '''Patient Group''' || '''Supporting Trials'''
|-
|  '''Secondary prevention'''
|-
| High-quality randomized clinical trial data support the use of statin therapy as an effective adjunct to diet, exercise, and smoking cessation for secondary prevention patients with a history of myocardial infarction, stroke, or clinically apparent atherosclerosis. || 4S, CARE, LIPID, PROSPER, HPS
|-
| High-quality randomized clinical trial data in secondary prevention support maximizing the intensity of statin treatment and maintaining compliance with the treatment regimen.|| PROVE-IT, TNT, IDEAL, A to Z, SEARCH
|-
|  '''Primary prevention'''
|-
| High-quality randomized clinical trial data support the use of statin therapy as an effective adjunct to diet, exercise, and smoking cessation in the setting of primary prevention for middle-aged and older individuals with elevated low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, elevated C-reactive protein, or multiple risk factors inclusive of diabetes and hypertension.|| WOSCOPS, MEGA, AFCAPS/TexCAPS, CARDS, ASCOT-LLA, JUPITER
|-
| '''Heart failure and renal insufficiency:'''
|-
| High-quality randomized clinical trial data do not support the use of statin monotherapy for adults with isolated heart failure or those underlying hemodialysis.|| CORONA, GISSI-HF, 4-D, AURORA
|-
| High-quality randomized clinical trial data support the use of statin therapy among adults with chronic renal insufficiency, at least when given in combination with ezetimib. || SHARP
|-
| '''Other conditions:'''
|-
| For adults who do not meet the above criteria, physicians may consider issues such as genetic predisposition or a strong family history of premature coronary disease when making decisions for individual patient. <br> For some patients, such as those suspected of having familial hyperlipidemia, referral to lipid or atherosclerosis specialists may be useful for consideration of further evaluation and the use of statins despite the absence of hard end point trial data. || None-clinical judgement, expert opinion
|-
|}


==References==
==References==
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{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Cardiology]]
[[Category:Lipid disorders]]
[[Category:Mature chapter]]
[[Category:Genetic disorders]]
[[Category:Metabolic disorders]]

Latest revision as of 22:15, 29 July 2020

Lipoprotein Disorders Microchapters

Patient Information

Overview

Causes

Classification

Hyperlipoproteinemia
Hypolipoproteinemia

Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hardik Patel, M.D.

Overview

Hyperlipidemia requires early detection, careful evaluation and aggressive treatment with combination of therapeutic lifestyle changes and lipid-lowering drug therapies to reduce the risk of cardiovascular and cerebrovascular complications.

Medical Therapy for Adults

NCEP ATP III Recommendations for Medical Therapy of Hyperlipidemia in Adults

Original Recommendations of the National Cholesterol Education Program (NCEP) ATP III for Medical Therapy of Hyperlipidemia in Adults[1] (DO NOT EDIT)

Detect Presence of Coronary Heart Disease (CHD) Risk Equivalent

  1. Previous personal history of clinical CHD
  2. Clinical carotid artery disease
  3. Abdominal aortic aneurysm
  4. Peripheral arterial disease
  5. Diabetes

Determine Presence of Major Risk Factors

(Other than LDL)

  1. Hypertension (BP≥140/90 mmHg or on antihypertensive medication)
  2. Cigarette smoking
  3. Low HDL-cholesterol (<40 mg/dL)
    • HDL-cholesterol ≥60 mg/dL counts as a "negative" risk factor and removes one risk factor from the total count.
  4. Age (men ≥45 years; women ≥55 years)
  5. Family history of premature CHD in first degree relative (CHD in men <55 years; CHD in women <65 years)


If 2+ major risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk using Framingham Risk Score. The Framingham Risk Score is based on data obtained from the Framingham Heart Study. There are two Framingham Risk Scores, one for men and one for women. Three levels of 10-year risk:

Low risk <10%
Intermediate risk 10 - 20%
High risk
(CHD risk equivalent)
>20%

Determine Risk Category, LDL Goal of Therapy, Level for Therapeutic Lifestyle Changes (TLC), and Level for Drug Therapy

Risk Category LDL Goal
(mg/dL)
LDL Level to
Initiate TLC (mg/dL)
LDL Level to
Consider Drug Therapy (mg/dL)
CHD or CHD risk equivalents
(10-year risk >20%)
<100 ≥100 ≥130
2+ major risk factors
(10-year risk ≤20%)
<130 ≥130 10-year risk 10-20%
≥130
10-year risk <10%
≥160
0-1 major risk factor <160 ≥160 ≥190

Therapeutic Lifestyle Changes (TLC)

Therapeutic lifestyle changes (TLC) should be initiated, if LDL level is above goal.

  1. TLC diet - consists of saturated fat <7% of calories, cholesterol <200 mg/day, increased viscous (soluble) fiber (10-25 g/day), and plant sterols (2g/day) to enhance LDL lowering.
  2. Weight management
  3. Increased physical activity

Drug Therapy

Drug therapy should be initiated, if LDL exceeds levels shown in above table. Initiate drug simultaneously with TLC for CHD and CHD equivalents, whereas add drug to TLC after 3 months for other risk categories.

Drug Class Agents
(Daily Doses)
Effects on Lipid Side Effects Contraindications
Statins
(HMG-CoA reductase
inhibitors)
Lovastatin (20-80 mg)
Pravastatin (20-40 mg)
Simvastatin (20-80 mg)
Fluvastatin (20-80 mg)
Atorvastatin (10-80 mg)
Cerivastatin (0.4-0.8 mg)
Decrease LDL
Increase HDL
Decrease TG
Myopathy
Elevated liver
enzymes
Absolute:
Active or chronic
liver disease
Relative:
Concomitant use of
cyclosporine,
macrolide antibiotics,
anti-fungal agents,
cytochrome P-450 inhibitors
Bile acid
sequestrants
Cholestyramine (4-16 g)
Colestipol (5-20 g)
Colesevelam (2.6-3.8 g)
Decrease LDL
Increase HDL
No change or
increase TG
GI distress
Constipation
Decreased absorption
of other drugs
Absolute:
Dysbetalipoproteinemia
TG >400 mg/dL
Relative:
TG >200 mg/dL
Nicotinic acid
(Niacin)
Immediate release
niacin (1.5-3 gm)
Extended release
niacin (1-2 g)
Sustained release
niacin (1-2 g)
Increase HDL
Decrease TG
Decrease LDL
Flushing
Hyperglycemia
Hyperuricemia
Hepatotoxicity
Upper GI distress
Absolute:
Chronic liver disease
Severe gout
Relative:
Diabetes
Hyperuricemia
Peptic ulcer disease
Fibric acids
(Fibrates)
Gemfibrozil (1.2 g)
Clofibrate (2 g)
Fenofibrate (200 mg)
Decrease TG
Increase HDL
Dyspepsia
Gallstones
Myopathy
Absolute:
Severe hepatic disease
Severe renal disease

(LDL=LDL cholesterol, HDL=HDL cholesterol, TG=Triglycerides)

Treatment of Elevated Triglycerides

  • In case of hyperlipidemia with elevated triglycerides (≥150 mg/dL), primary aim of therapy is to reach LDL goal, intensify weight management and increase physical activity.
  • If triglycerides are ≥200 mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol (total - HDL) 30 mg/dL higher than the LDL goal for respective categories.
Risk Category LDL Goal (mg/dL) Non-HDL Goal (mg/dL)
CHD or CHD risk equivalents (10-year risk >20%) < 100 < 130
2+ major risk factors (10-year risk ≤20%) < 130 < 160
0-1 major risk factor < 160 < 190
  1. If triglycerides are 200-499 mg/dL after LDL goal is reached, consider adding drug if needed to reach non-HDL goal:
    • Intensify therapy with LDL-lowering drug
    • Add niacin or fibrate to further lower triglycerides
  2. If triglycerides are ≥500 mg/dL, first lower triglycerides to prevent pancreatitis:
    • Very low-fat diet (<15% of calories from fat)
    • Intensified weight management and increased physical activity
    • Add niacin or fibrate
    • When triglycerides reach <500 mg/dL, turn to LDL-lowering drug

Treatment of Low HDL Cholesterol (<40 mg/dL)

First reach LDL goal, intensify weight management, and increase physical activity; then if triglycerides are 200-499 mg/dL, achieve non-HDL goal and if triglycerides are <200 mg/dL (isolated low HDL) in CHD or CHD equivalent, add niacin or fibrate.

Treatment of the Metabolic Syndrome

  • Identification of the metabolic syndrome (any 3 of the following):
    1. Abdominal obesity - waist circumference of >102 cm (>40 in) in men and >88 cm (>35 in) in women
    2. Serum triglyceride level ≥150 mg/dL
    3. HDL cholesterol level of <40 mg/dL in men and <50 mg/dL in women
    4. Blood pressure ≥130/85 mmHg
    5. Fasting glucose ≥110 mg/dL.
  • Treat underlying causes:
    • Intensify weight management
    • Increase physical activity.
  • Treat lipid and non-lipid risk factors, if they persist despite TLC:
    • Treat hypertension
    • Use aspirin for CHD patients to reduce thromboembolic risk
    • Treat elevated triglycerides and/or low HDL as shown above.

Other Lipid Lowering Agents

Omega-3 Fatty Acids

Drug Mechanisms of Benefit Dosage Advantages Side Effects Contraindications
Omega-3 fatty acids

↓ hepatic lipogenesis
↓ plasma lipoprotein lipase activity
↑ hepatic mitochondrial and peroxisomal beta-oxidation
Inhibition of acyl CoA:1,2-diacylglycerol acyltransferase enzyme
EPA and DHA are poor enzyme substrates for triglyceride synthesis in liver and inhibits esterification of other fatty acids.

3 g/day of EPA and DHA[2]

VLDL[3], [4]
TG by ≥50%

Bleeding, at high doses
Fishy smell, can be reduced by

  • freezing of medication
  • trying different formulation
  • taking medication with food

Nausea

Hypersensitivity

(↑ - Increase, ↓ - Decrease)

Ezetimibe

Ezetimibe is a new class of lipid lowering agents. It inhibits intestinal absorption of cholesterol. It has been approved as a monotherapy or in combination with statins to treat hypercholesterolemia. It has also been approved in combination with fenofibrate to treat mixed hyperlipidemia.

Medical Therapy in Children and Adolescents

Click on the respective microchapter to read more about it:

A Trial Based Approach to Statin Guidelines

Shown below is a table suggesting an approach to the use of statin according to different trials.[5]

Patient Group Supporting Trials
Secondary prevention
High-quality randomized clinical trial data support the use of statin therapy as an effective adjunct to diet, exercise, and smoking cessation for secondary prevention patients with a history of myocardial infarction, stroke, or clinically apparent atherosclerosis. 4S, CARE, LIPID, PROSPER, HPS
High-quality randomized clinical trial data in secondary prevention support maximizing the intensity of statin treatment and maintaining compliance with the treatment regimen. PROVE-IT, TNT, IDEAL, A to Z, SEARCH
Primary prevention
High-quality randomized clinical trial data support the use of statin therapy as an effective adjunct to diet, exercise, and smoking cessation in the setting of primary prevention for middle-aged and older individuals with elevated low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, elevated C-reactive protein, or multiple risk factors inclusive of diabetes and hypertension. WOSCOPS, MEGA, AFCAPS/TexCAPS, CARDS, ASCOT-LLA, JUPITER
Heart failure and renal insufficiency:
High-quality randomized clinical trial data do not support the use of statin monotherapy for adults with isolated heart failure or those underlying hemodialysis. CORONA, GISSI-HF, 4-D, AURORA
High-quality randomized clinical trial data support the use of statin therapy among adults with chronic renal insufficiency, at least when given in combination with ezetimib. SHARP
Other conditions:
For adults who do not meet the above criteria, physicians may consider issues such as genetic predisposition or a strong family history of premature coronary disease when making decisions for individual patient.
For some patients, such as those suspected of having familial hyperlipidemia, referral to lipid or atherosclerosis specialists may be useful for consideration of further evaluation and the use of statins despite the absence of hard end point trial data.
None-clinical judgement, expert opinion

References

  1. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (2002). "Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report". Circulation. 106 (25): 3143–421. PMID 12485966.
  2. Wang C, Harris WS, Chung M, Lichtenstein AH, Balk EM, Kupelnick B; et al. (2006). "n-3 Fatty acids from fish or fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular disease outcomes in primary- and secondary-prevention studies: a systematic review". Am J Clin Nutr. 84 (1): 5–17. PMID 16825676.
  3. Nestel PJ, Connor WE, Reardon MF, Connor S, Wong S, Boston R (1984). "Suppression by diets rich in fish oil of very low density lipoprotein production in man". J Clin Invest. 74 (1): 82–9. doi:10.1172/JCI111422. PMC 425187. PMID 6736254.
  4. Durrington PN, Bhatnagar D, Mackness MI, Morgan J, Julier K, Khan MA; et al. (2001). "An omega-3 polyunsaturated fatty acid concentrate administered for one year decreased triglycerides in simvastatin treated patients with coronary heart disease and persisting hypertriglyceridaemia". Heart. 85 (5): 544–8. PMC 1729738. PMID 11303007.
  5. Ridker P, Wilson PF. A Trial-Based Approach to Statin Guidelines. JAMA. 2013;():-. doi:10.1001/jama.2013.276529.

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