Treatment of lipids (including hypercholesterolemia) in primary prevention
- Michael Pignone, MD, MPH
Michael Pignone, MD, MPH
- Chair, Department of Medicine
- The University of Texas at Austin
Patients with known coronary heart disease (CHD; including myocardial infarction, angina, and prior coronary revascularization), other cardiovascular disease (CVD; including symptomatic carotid artery disease, peripheral vascular disease, abdominal aortic aneurysm), or combinations of risk factors that result in a 10-year risk of CVD events of more than 20 percent (table 1) clearly benefit from treatment with a statin (over a wide range of initial lipid levels) and, in some cases, with a proprotein convertase subtilisin kexin 9 (PCSK9) inhibitor in combination with a statin or if a statin cannot be used. (See "Treatment of lipids (including hypercholesterolemia) in secondary prevention".)
Patients without known CVD are generally at much lower and more varied baseline risk of cardiovascular (CV) events. As such, the treatment approach 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.
This topic reviews the evidence for treating patients with increased CVD risk due to elevated low-density lipoprotein cholesterol (LDL-C) and/or low high-density lipoprotein cholesterol (HDL-C) but no known CVD or CVD equivalents. The clinical trials are discussed in more detail separately. (See "Clinical trials of cholesterol lowering for primary prevention of coronary heart disease".)
The management of patients with familial hypercholesterolemia and related disorders are also discussed separately. (See "Inherited disorders of LDL-cholesterol metabolism".)
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- LIFESTYLE MODIFICATION
- PHARMACOLOGIC THERAPY
- Nonstatin therapy
- - PCSK9 inhibitors
- DECIDING WHOM TO TREAT
- General approach
- Choice of risk calculator
- - Lifetime risk
- Cost-effectiveness modeling
- Specific populations
- - Young patients
- - Older patients
- USE OF STATINS
- Side effects and monitoring
- Statin intolerance
- FAILURE TO ACHIEVE GOAL LDL
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS