Intensity of lipid lowering therapy in secondary prevention of cardiovascular disease
- David M Rind, MD
David M Rind, MD
- Section Editor — General Medicine
- Chief Medical Officer
- Institute for Clinical and Economic Review
- Assistant Professor of Medicine, Part-time
- Harvard Medical School
- Rodney A Hayward, MD
Rodney A Hayward, MD
- Professor of Medicine and Public Health
- University of Michigan
Patients with known cardiovascular disease (CVD) are at high risk for CV events. Treatment in such patients, as well as in other patients known to have a similar risk of CV events, is discussed as secondary prevention. In secondary prevention, statins have been shown in multiple large trials to reduce CV events and to reduce all-cause mortality. Meta-analysis of fairly short-term clinical trials in high-risk patients found that proprotein convertase subtilisin kexin 9 antibodies (PCSK9-abs) also appear to decrease CV events and mortality. Trials of other lipid-lowering agents have generally only shown reductions in CV events.
Trials of statins, and other medications used in combination with statins, have provided additional information that is related to the appropriate serum low-density lipoprotein cholesterol (LDL-C) target in patients being treated for secondary prevention. However, the results of these trials are open to various interpretations and the ideal target LDL-C level has not been completely defined.
This topic will review the evidence for LDL-C goals in patients treated with statins for secondary prevention of CHD, as well as the evidence for using agents other than statins in patients who are unable to tolerate statins or who do not achieve LDL-C goals with statins alone. The general approach to lipid lowering therapy for secondary prevention and in patients with an acute coronary syndrome, as well as an overview of the treatment of hypercholesterolemia, are discussed separately. (See "Prevention of cardiovascular disease events in those with established disease or at high risk", section on 'Dyslipidemia' and "Low density lipoprotein-cholesterol (LDL-C) lowering after an acute coronary syndrome" and "Treatment of lipids (including hypercholesterolemia) in secondary prevention".)
Treatment to prevent cardiovascular events in patients with known coronary heart disease (CHD; including myocardial infarction, angina, and prior coronary revascularization), other cardiovascular disease (CVD; including stroke, transient ischemic attack, and peripheral arterial disease), or combinations of risk factors that result in a 10-year risk of CVD events of more than 20 percent (table 1), is discussed as secondary prevention. (See "Treatment of lipids (including hypercholesterolemia) in secondary prevention", section on 'Identification of patients at risk'.)
Moderate-intensity statin therapy includes daily treatment with:
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- INTENSIVE THERAPY
- Baseline LDL-C
- Differential effects on events and mortality
- - Acute coronary syndrome
- - Stable CHD
- - Pleiotropic effects
- Medication choice versus goal LDL
- - Medication choice strategy
- - Minimum LDL
- Putting the evidence together
- USE OF MEDICATIONS OTHER THAN STATINS OR PCSK9-ABS
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Acute coronary syndrome
- Stable CVD