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Lipid control

How to enable lipid control?

Lowering of LDL-C is one of the main objectives in secondary prevention. Intensive statin treatment and if necessary, combination therapy can reach the treatment goals for most patients. In addition to the drug treatment, the patients should be encouraged to adopt a healthy lifestyle including a diet that improves the lipid profile.



Treatment target

  • The primary treatment target should be LDL-cholesterol (LDL-C). An alternative target is non-HDL-C (Total cholesterol minus HDL-cholesterol). Non-HDL is of special relevance for patients with high triglycerides, where LDL-C may be difficult to estimate.
  • Other lipid measures that affect the risk but are not considered as treatment targets are Triglycerides (TG), HDL and lipoprotein(a) (Lp(a)).
  • In addition, TG >1.7 mmol/L (150 mg/dL), HDL< 1.0 (40 mg/dL) for men 1.2 mmol/L (46 mg/dL) and Lp(a) above 50mg/100ml is associated with increased risk.

Treatment goal

Please visit the webpage Cardioprotective drugs: Statins & more for treatment goal  recommendations.

Intervention strategies

  • Patients in secondary prevention are always at very high risk, and should be intensively treated to reach goals
  • Unless untreated LDL-C is below 1.8 mmol/L, 70 mg/dL, statin treatment in adequate doses should be initiated
  • Life style measures/recommendations should be the basis for treatment.
  • In patients with acute coronary syndrome, intensive statin treatment should be initiated at an early stage, irrespective of LDL-C level
  • If the goals are not reached with highest tolerated dose of potent statin, an add-on therapy with ezetimibe is recommended.

Lifestyle recommendations

Lifestyle changes should include all aspects of healthy living/a healthy lifestyle

  • Diet
    Switch to a healthier diet improves plasma lipid levels
    • Reduce saturated fat, trans-fat and sugar
    • Increase intake of mono- and polyunsaturated fat (oil and fat fish)
    • Increase dietary fibre 
  • Weight
    Obesity or being overweight is associated with several risk factors such as high TG and low HDL.
    • Weight loss reduces TG and increases HDL
  • Exercise/Physical Activity
    Regular exercise and increased physical activity are essential for several aspects of lifestyle recommendation. It may also improve lipid levels.
    • Physical activity reduces TG and increases HDL

Pharmacological treatment

Please visit the webpage Cardioprotective drugs: Statins & more for detailed recommendations

Statin side effects

Please visit the webpage Cardioprotective drugs: Statins & more for information on the Adverse Effects of Statins.

How to handle Statin side effects

  • Stop statin treatment, and record symptoms then start treatment again and record symptoms
  • Try another statin
  • Lower the dose, and try high potency statin once or twice a week
  • Give the highest tolerated dose combined with ezetimibe
  • If no statin is tolerated, suggest ezetimibe, consider the combination with bile acid sequester
  • Consider PCSK9 inhibitor if available

FLOW CHART: dyslipidaemia treatment strategy (1) 

dyslipidaemi--treatment-strategy.png

References


Reiner Z, Wiklund O, Betteridge J. Chapter 15 Lipids. In: Gielen S, De Backer G, Piepoli MF, Wood D, editors. The ESC Textbook of Preventive Cardiology. 2nd ed. United Kingdom: Oxford University Press, 2016.

Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Eur Heart J 2016; 37: 2315–2381.

Catapano AL, Graham I, De Backer G, et al. 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias The Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). Eur Heart J 2016; 37: 2999-3058.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer, and Sanofi and Regeneron in the form of educational grants.

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