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Top tips on treating lipids to target

Cardiology GPSI Dr Peter Savill gives tips on assessment tools, starting choices and non-statin lipid lowerers.

Cardiology GPSI Dr Peter Savill gives tips on assessment tools, starting choices and non-statin lipid lowerers.

1 Measure lipids in young patients with a strong family history of cardiovascular disease (CVD). Patients under 40 with a family history of premature cardiovascular disease – first-degree male relatives under 55 years and females under 65 years – should have a CV risk assessment with measurement of total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C).

2 The Joint British Societies' guidelines (JBS 2) are still the tool of choice for CV risk assessment. The risk assessment charts require knowledge of a patient's age, sex, smoking status, blood pressure and TC:HDL-C ratio.

Newer risk scores such as QRISK offer theoretical advantages by including additional risk factors and population data that is more relevant to the UK than the Framingham-based charts. But these are still being evaluated.

3 Treat anyone with established CVD, and diabetes patients over the age of 40. Patients with established CVD, familial hypercholesterolaemia, and diabetes patients over 40 should all be treated with a statin regardless of their baseline lipid profile.

Younger diabetes patients should be treated if they have evidence of macro or microvascular disease, poor glycaemic control, hypertension or TC greater than 6mmol/l.

4 Treat anyone with a TC:HDL-C ratio greater than six. These patients are at high risk of CVD regardless of other risk factors and should receive statins if they fail to achieve target cholesterol with dietary measures alone.

The Scottish Intercollegiate Guidelines Network (SIGN) suggests a threshold of 8mmol/l for total cholesterol but does not incorporate HDL and I would suggest sticking to the ‘treat if ratio is more than six' maxim.

5 Aim for a TC of 4mmol/l. Once the decision has been made to treat, the aim should be a reduction in TC to less than 4mmol/l and a LDL-C of less than 2mmol/l, or a 25% reduction in TC and 30% reduction in LDL-C, whichever results in the lowest number.

Targets of 5mmol/l for TC and 3mmol/l for LDL-C are still advocated elsewhere, such as by SIGN and the QOF of the new GMS contract.

The rationale for this is that until further studies on mortality, safety and cost-effectiveness become available, the lower target cannot be supported. I think in practice the aim should be to achieve a minimum of 5mmol/l and 3mmol/l but to strive for 4mmol/l and 2mmol/l – particularly in those at highest risk.

6 Use simvastatin 40mg as first-line treatment. Simvastatin has a robust evidence base and should be the first-line statin once the decision to treat has been made.

Some clinicians will opt for starting at 10mg and titrating upwards according to response, and there is some logic in this approach for patients without established disease. However, in those with known CVD and diabetes I advocate going straight in at 40mg.

7 Switch statin or add ezetimibe if targets are not achieved with simvastatin 40mg. There are several options if simvastatin 40mg fails to take the patient to target: increase to 80mg simvastatin, switch to a more potent statin such as atorvastatin 40mg or add in ezetimibe – a cholesterol uptake inhibitor that can reduce LDL-C by a further 20-25% with a statin.

My preference would be a switch to atorvastatin. Titrating simvastatin is likely to be the least effective strategy and if a significant further reduction was required this could be discounted.

8 Be aware of the role of other lipid-lowering drugs. The fibrates and nicotinic acid raise HDL-C and reduce triglycerides, and omega-3 fish oil supplements reduce triglycerides.

These agents are not particularly useful for reducing TC/LDL-C and as such are reserved for specific dyslipidaemias or if statin-ezetimibe treatment fails or is not tolerated. It is worth remembering the bile acid sequestrants such as cholestyramine can reduce LDL-C, but tolerance issues may limit their usefulness.

9 Consider atorvastatin 80mg in acute coronary syndromes. There is evidence to support the use of high-dose statins, namely atorvastatin 80mg, in this group of patients. It would also seem logical that patients with high-grade coronary lesions and complex percutaneous procedures should be maintained on high-dose statins.

10 Statins offer little benefit in heart failure. Most patients with heart failure will already be on statins for secondary prevention of underlying coronary disease and it would be unwise to discontinue these. However, recent data from the CORONA study showed no mortality benefit from starting statins in heart failure patients, most likely because of the primary arrhythmogenic cause of death.

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