Hyperlipidemias and Atherosclerotic Cardiovascular Disease ________________________________________
AHA/ACC RECOMMENDATIONS TO IMPROVE ADHERENCE TO GUIDELINE IMPLEMENTATION Provide interventions focused on improving adherence to therapy (e.g., telephone reminders, calendar reminders, integrated multidisciplinary educational activities, pharmacist-led interventions) (Class I, based on high-quality evidence). Identify patients not receiving guideline-directed medical therapy, and facilitate initiation of appropriate guideline-directed medical therapy using multifaceted strategies to improve guideline implementation (Class I, based on moderate-quality evidence). Conduct patient-clinician discussion prior to therapy to promote shared decision-making (Class I, based on moderate-quality
evidence). Source: [24]
Table 7
achieved a 94% reduction in mean serum concentrations of apoprotein(a), sustained during the period 60 to180 days after administration [249]. All three siRNAs are in phase III clinical trials assessing cardiovascular disease outcomes in patients with high lipoprotein(a) levels (>70 mg/dL), most of whom have ASCVD, with the earliest expected progress reports in 2026 and 2029 [248]. ROLE OF LIPID-LOWERING DRUGS IN THE PREVENTION OF ASCVD MORBIDITY AND MORTALITY As discussed, the clinical approach to hyperlipidemias is aimed at the primary and secondary prevention of ASCVD. As the evidence has shown, it is clear that lipid-lowering strategies play a fundamental role in the primary prevention of ASCVD. Primary prevention is defined as the long-term management of individuals at increased risk for but without clinical evidence of ASCVD and who have not undergone revascularization procedures [220]. Secondary prevention is defined as the clinical management of individuals with a history of ASCVD. Primary prevention of hyperlipidemias aims to avert new onset CHD and is considered an important aspect of the societal approach to the promotion of cardiovascular health [25]. The goal of primary prevention is to assess and reduce risk factors for CHD in each age group and to emphasize adherence to a healthy lifestyle. This is achieved through two complementary approaches: population strategies and clinical “individual” strategies [24]. Population (public health) strategies shift the distribution of risk factors of the target population to more desirable levels. For example, the 2018 AHA/ACC guideline emphasizes promotion of a heart-healthy lifestyle that improves cardiovascular health and prevents dyslipidemia and other ASCVD risk factors for all age groups. Successful implementation of these recommendations on a population level requires the multidisciplinary team of healthcare providers to help bridge the gap between public health and patient management by supporting and advocating for continued public health initiatives and by encouraging a collaborative effort among healthcare professionals, government agencies, schools, the food industry, and the media [25].
Healthcare delivery is complex, and barriers to guideline implementation can occur at both the public and individual level ( Table 7 ) [24]. The effectiveness of primary prevention on the cholesterol levels of aging patients has been validated by the slower rate of increase in cholesterol levels associated with aging in patients for whom primary prevention strategies have been implemented [23; 25; 221]. Attaining lower LDL and triglyceride plasma concentrations can be achieved by a combination of lifestyle changes and drug therapy. As stated, the 2018 AHA/ACC guideline continues to emphasize the adoption of a heart-healthy lifestyle from adolescence onward, as this reduces ASCVD risk at all ages. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome [24]. Secondary prevention should be initiated in patients with clinical ASCVD. A meta-analysis of randomized controlled trials conducted by the Cholesterol Treatment Trialists demonstrated that lowering LDL with statins reduces major ASCVD events and also benefits patients with stroke or peripheral artery disease [222; 223]. Compared with moderate-intensity statin therapy, high-intensity statin therapy significantly reduced major vascular events by 15% with no significant reduction in coronary deaths. High-intensity statin therapy generally reduces LDL levels by ≥50%. However, as stated, absolute benefit depends on baseline levels [24]. Lifestyle changes provide only moderate improvement of the lipid profile in patients with previous ASCVD, so although they should be implemented, pharmacotherapy is required to attain therapeutic goals [23; 24]. The complexity of health status in patients with a history of ASCVD requires an approach of multifactorial risk reduction. Multifactorial risk reduction has a synergistic effect on disease progression and clinical outcomes and should be associated with a case management approach [23; 224; 225]. Case management allows for collaborative and effective expert evaluation, systematic intervention, and regular follow-up. Management should focus not only on the appropriate drug choices but also on patient education and counseling [23; 24; 225; 226].
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