Management of elevated low density lipoprotein-cholesterol (LDL-C) in primary prevention
- Michael Pignone, MD, MPH
Michael Pignone, MD, MPH
- Chair, Department of Medicine
- The University of Texas at Austin
- Dell Medical School
The management of the risk factors for atherosclerotic cardiovascular disease (CVD), of which elevated LDL-C level is one, is called primary prevention if this process is done in someone who has not previously experienced an atherosclerotic vascular event. The rationale for activities focused on LDL-C reduction is based upon epidemiologic data documenting a continuous, positive, graded relationship between LDL-C concentration and CVD events and mortality and evidence that lowering of LDL-C in patients across a broad range of LDL-C levels reduces CVD events in patients with and without CVD [1-4]. (See "Overview of the risk equivalents and established risk factors for cardiovascular disease".)
Patients without known CVD are generally at much lower baseline risk of cardiovascular events than patients with known CVD. As such, the treatment approach to lowering LDL-C will depend on a determination of global CVD risk, as the potential absolute risk reduction with treatment for hypercholesterolemia will usually be smaller than for patients with established CVD.
For the purpose of risk reduction in patients without manifest CVD, only LDL-C lowering, among all lipid components, has been shown to be of clinical benefit. (See "Hypertriglyceridemia", section on 'Summary and recommendations' and "HDL-cholesterol: Clinical aspects of abnormal values", section on 'Summary and recommendations'.)
This topic reviews the evidence for treating patients with increased CVD risk due to elevated LDL-C but no known CVD or CVD equivalents. The management of patients with established disease is discussed separately.
RATIONALE FOR LDL-C LOWERING IN PRIMARY PREVENTION
The preponderance of evidence from randomized trials that have evaluated the impact of LDL-C lowering (or the surrogate of total cholesterol) have demonstrated a reduction in cardiovascular disease events, irrespective of the pre-therapy LDL-C level (figure 1). Among these events, it is the risk of myocardial infarction that is reduced the most.
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- RATIONALE FOR LDL-C LOWERING IN PRIMARY PREVENTION
- LIFESTYLE MODIFICATION
- Specific populations
- - Young patients
- - Older patients
- INITIAL DRUG THERAPY
- Nonstatin therapy
- USE OF STATINS
- Side effects and intolerance
- GOAL SETTING
- Failure to achieve goal LDL-C
- RECOMMENDATIONS OF OTHERS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS