National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2

Abstract

An Expert Panel convened by the National Lipid Association previously developed a consensus set of recommendations for the patient-centered management of dyslipidemia in clinical medicine (part 1). These were guided by the principle that reducing elevated levels of atherogenic cholesterol (non-high-density lipoprotein cholesterol and low-density lipoprotein cholesterol) reduces the risk for atherosclerotic cardiovascular disease. This document represents a continuation of the National Lipid Association recommendations developed by a diverse panel of experts who examined the evidence base and provided recommendations regarding the following topics: (1) lifestyle therapies; (2) groups with special considerations, including children and adolescents, women, older patients, certain ethnic and racial groups, patients infected with human immunodeficiency virus, patients with rheumatoid arthritis, and patients with residual risk despite statin and lifestyle therapies; and (3) strategies to improve patient outcomes by increasing adherence and using team-based collaborative care.

Advances in dyslipidemia management for prevention of atherosclerosis: PCSK9 monoclonal antibody therapy and beyond

“…Recent guidance has been given for the use of PCSK9 mAb therapy by both the National Lipid Association (NLA) (30) and by the American College of Cardiology (ACC) (31). The NLA first noted in part 2 of their recently published dyslipidemia recommendations that until the results of cardiovascular outcomes trials are available, a conservative approach would be to use PCSK9 inhibitors primarily in those with ASCVD who have LDL-C ≥100 mg/dL (or non-HDL-C ≥130 mg/dL) while on maximally tolerated statin (± ezetimibe) therapy and in those with heterozygous FH without ASCVD who have an LDL-C ≥130 mg/dL (or non-HDL-C ≥160 mg/dL) while on maximally tolerated statin (± ezetimibe).…”

“…The NLA first noted in part 2 of their recently published dyslipidemia recommendations that until the results of cardiovascular outcomes trials are available, a conservative approach would be to use PCSK9 inhibitors primarily in those with ASCVD who have LDL-C ≥100 mg/dL (or non-HDL-C ≥130 mg/dL) while on maximally tolerated statin (± ezetimibe) therapy and in those with heterozygous FH without ASCVD who have an LDL-C ≥130 mg/dL (or non-HDL-C ≥160 mg/dL) while on maximally tolerated statin (± ezetimibe). They also note such therapy may be considered for selected high risk patients with ASCVD (e.g., with recurrent events) with LDL-C ≥70 mg/dL (or non-HDL ≥100 mg/dL) despite the use of other lipid-lowering therapies (30). Following this, the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk (31) that PCSK9 mAb therapy may be considered (after considering ezetimibe) when a patient still has not achieved at least a 50% LDL-C reduction (or LDL-C <100 mg/dL in the case of stable ASCVD without comorbidities, or <70 mg/dL for ASCVD with comorbidities) on maximally tolerated statin therapy.…”

Efficacy and Safety of Lipid-Lowering Drugs in Primary and Secondary Prevention of Cardiovascular Diseases in the Elderly

“…Безопасность статинов у пожилых пациентов и приверженность лечению Серьезные и фатальные НР при применении стати-нов регистрируются редко, однако в целом побочные эф-фекты развиваются примерно у 10% пациентов [13,14]. Частота НР в крупных клинических исследованиях не раз-личалась между пациентами пожилого и более моло-дого возраста, однако в этих исследованиях практиче-ски не участвовали лица старше 80 лет с «хрупкостью» и существенной коморбидностью [15].…”

“…В исследовании HPS (Heart Protection Study) наблюдалась тенденция к повышению частоты немеланомного рака кожи у по-жилых [38]. Однако в мета-анализе, включавшем дан-ные 4032 пациентов в возрасте 65-74 лет и 885 па-циентов 75 лет, значительного влияния статинов на ча-стоту возникновения онкологических заболеваний или смертности от них не выявлено [4]. Аналогичные ре-зультаты получены и в мета-анализе 26 РКИ (170000 участников) для пациентов разных возрастных групп [39].…”

“…Первый сердечный приступ развивается в среднем в возрасте 65,0 лет у мужчин и 71,8 лет -у женщин, и преиму-щественно связан с наличием атеросклеротического по-ражения коронарного русла [3]. Подавляющее боль-шинство (около 80%) умирающих от ССЗ, ассоции-рованных с атеросклерозом, составляют люди в воз-расте старше 65 лет [4]. Во Франции лица в возрасте 85 лет и старше составляют 43% среди умерших от ИБС, и 49% -от инсульта [5].…”