Lipid Guidelines: Screening & Treatment Goals

Please find below key recommendations and rationales on lipid screening and treatment goals as a way of preventing or delaying cardiovascular disease. Text has been slightly modified for easier and succinct reading. Part 1 of guidelines were published by National Lipids Association in April 2015

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Excerpts from the Guidelines:

Most randomized clinical trials of lipid-lowering drug therapies have tested drug treatment against a placebo control, or a more intensive with a less-intensive treatment regimen. The strategy of treating patients to a specific level of LDL-C or non–HDL-C has not been tested in any of the large trials assessing ASCVD morbidity and mortality. However, the lack of RCTs explicitly designed to test goals does not invalidate the considerable evidence supporting use of goals. Taken together, results from RCTs that have used various methods for lowering atherogenic cholesterol (pharmacotherapy, diet, and ileal bypass surgery) have indicated that lower on-treatment levels have been consistently associated with lower absolute risk for an ASCVD event.

These findings align with results from observational studies that suggest a log-linear relationship between the levels of atherogenic cholesterol and absolute ASCVD event risk. The Expert Panel’s consensus view is that treatment goals, which have been used historically by health care providers for the past ~25 years, continue to be useful as a systematic means to ensure that the aggressiveness of therapy to lower atherogenic cholesterol is matched to absolute risk for an event. Furthermore, the view is that using treatment goals, compared with prescribing moderate- to high-intensity statins without treatment targets, will not result in undertreatment as suggested in the American College of Cardiology (ACC)/American Heart Association (AHA) 2013 dyslipidemia recommendations.

Moreover, treatment goals facilitate effective communication between patients and clinicians, providing an easily interpretable means through which the clinician can communicate progress toward meeting treatment objectives, thus supporting efforts to maximize long-term adherence to the treatment plan. Many patients have periods of nonadherence and nonpersistence with use of atherogenic cholesterol–lowering medications, including statins. Follow-up cholesterol testing to monitor goal achievement may promote increased long-term adherence, which has been shown to increase the clinical benefits of statin use in primary and secondary ASCVD prevention patients. A very important point regarding the treatment goals recommended by the NLA Expert Panel is that the goal is less than the stated value. Simply achieving a non–HDL-C or LDL-C level equal to the threshold value of the treatment goal is not adequate or desirable, and, in some cases, the clinician may opt to treat to values well below the thresholds.

In all adults (>20 years of age), a fasting or nonfasting lipoprotein profile should be obtained at least every 5 years. At a minimum, this should include total cholesterol and HDL-C, which allows calculation of non-HDL-C (total-C – HDL-C). If fasting (generally 9–12 hours), the LDL-C level may be calculated, provided that the triglyceride concentration is <400 mg/dL. Lipoprotein lipid levels should be considered in conjunction with other ASCVD risk determinants to assess treatment goals and strategies, as covered later in this report. If atherogenic cholesterol levels (non–HDL-C and LDL-C) are in the desirable range, lipoprotein lipid measurement and ASCVD risk assessment should be repeated in 5 years, or sooner based on clinical judgment. Examples of changes that might prompt earlier rescreening include changes in ASCVD risk factors (including weight gain), a premature ASCVD event in a first-degree relative, evidence of ASCVD in the patient, or a new potential secondary cause of dyslipidemia. For those with atherogenic cholesterol in the desirable range, public health recommendations regarding lifestyle should be emphasized.