Cholesterol Management 101

Earlier this year, I was fortunate to be able to publish a wonderful book with two noted lipidologists called Lipid and Lipoprotein Disorders: Current Clinical Solutions. The purpose of this pocket guide was fourfold:

1. to educate health care professionals about atherosclerosis,
2. identify and apply risk criteria to patients,
3. introduce guidelines for lipid and lipoprotein values, and
4. present goals of therapy.

I thought it would be very helpful to briefly explain the portion on current guidelines that are in place to help clarify goals of treatment. Believe it or not, the majority of health care professionals are unaware of many of these guidelines and continue to treat patients based on what they learned in medical school and/or antiquated guidelines.

The definition: Atherosclerosis is a disease caused by a buildup of cholesterol within the arterial intima. The sterols are trafficked there as passengers inside of apolipoprotein-wrapped particles called lipoproteins, and thus atherosclerosis is a lipoprotein mediated disease.

The clinician has two chores: 1) identifying who is at risk for CHD and what is the severity of that risk and 2) aggressively and appropriately treating those risk factors.

Numerous evidence-based guidelines from several organizations exist to help clinicians better understand risk, therapeutic goals and lifestyle and pharmacological therapies to achieve those goals. Since the original National Cholesterol Education Program Adult Treatment Panel Guidelines came out in 1988, the emphasis has shifted from cholesterol, to LDL-cholesterol (LDL-C), to non-HDL-C (Total Cholesterol-HDL Cholesterol) and now to atherogenic lipoprotein measurements such as apolipoprotein B (apoB) or LDL-P. The last full version of NCEP, Adult Treatment Panel-III was published in 2002 with an addendum issued in 2004.

The National Heart Lung and Blood Institute is now in the long and complex process of formulating a new, integrative guideline encompassing hypertension, lipids and lipoproteins and obesity. Until then, providers have to rely on the more important guidelines or position statements in existence, listed temporally below:

1. National Cholesterol Education Program, Adult Treatment Panel III (NCEP, ATP-III) 2002
2. NCEP-ATP-III Addendum 2004
3. American Heart Association/American College of Cardiology Secondary Prevention 2006
4. American Heart Association Evidenced Based Guidelines for CVD Prevention in Women 2007
5. American Diabetes Association/American College of Cardiology Consensus Statement Lipoprotein Management in Patients with Cardiometabolic Risk 2008
6. American Diabetes Association Standards of Medical Care in Diabetes 2009
7. Position Statement from the American Association of Clinical Chemistry on Apolipoprotein B and CVD risk 2009

NCEP ATP-III 2002 and 2004 addendum synopsis

List known and emerging risk factors

Ascertaining CV Risk (low, moderate, moderately high, high, very high)

Existence of known atherosclerosis

CHD risk equivalents: including T2DM

Framingham Risk Scoring

Metabolic Syndrome determination

Imaging (CIMT and coronary calcium)

Initiation of Treatment:

Determined by LDL-C levels and risk category

Goals of Therapy: Suggested and optional

LDL-C and non-HDL-C if TG = 200 mg/dL

Determined by risk category

Statements on TG and low HDL-C

Therapeutic strategies including combination therapy

Start with appropriate statin dose

Start with lower statin dose and combine with niacin, bile acid
sequestrant or ezetimibe

AHA SECONDARY PREVENTION

More aggressive LDL-C goals of therapy.

AHA WOMEN’S GUIDELINES

Please see my prior blog posting titled “Heart Disease in Women: Where Do We Stand?“

ADA/ACC CONSENSUS STATEMENT ON LIPOPROTEIN MANAGEMENT
For use in patients with cardiometabolic risk (high TG, Low HDL-C)

First guideline to advocate lipoprotein quantification using apoB or LDL-P

Discusses the discordance between LDL-C, non HDL-C and apoB

Established apoB goals of therapy

Inability of statins to lower non-HDL-C and apoB compared to LDL-C

Need for combination therapy when apoB on statin not at goal

Order of preference: niacin, fibrates, N-3 Fatty acids

AACC POSITON STATEMENT ON APO B

Strong statement to replace lipid concentrations in favor of apoB or LDL-P

Suggested uniform goals of therapy for apoB and LDL-P

Comment on this post and ask your questions on the Cholesterol Management Exchange.