Gregory Weiss, MD: Meeting the Challenges of Cholesterol Management

Gregory Weiss, MD

The enormous importance of cholesterol management for reduction and prevention of atherosclerotic cardiovascular disease (ASCVD) cannot be overstated.

While ample evidence exists that reductions in low-density lipoprotein cholesterol (LDL-C) reduce the risk of cardiovascular events and death in patients with ASCVD, data gathered by the American College of Cardiology (ACC) from the PINNACLE registry reveal that 21.1% of these patients had no history of lipid-lowering therapy use and 84.5% did not meet LDL-C goal of less than 70mg/dL.^1​

Patients with ASCVD least likely to achieve LDL-C goals while on a statin include younger patients, African Americans, and hypertensive patients.¹ These facts underscore the importance of determining and overcoming barriers to achieving optimal cholesterol management.

Timothy Attebery, DSc, MBA, FACHE, Chief Executive Officer of the American College of Cardiologists states, “Management of lipid disorders has become more complex as new data, drugs and clinical standards around lipid management are introduced. The College has many successful tools and initiatives that have helped our members provide the most advanced and effective lipid management strategies for their patients, but there is more work to be done.”^2​

In 2019, the American College of Cardiology in cooperation with the American Heart Association (AHA) issued updated guidelines, made simple, for management of blood cholesterol. In these guidelines they highlight ten take-home messages to reduce the risk of ASCVD through cholesterol management.³​

• Clinicians should always emphasize a heart-healthy lifestyle throughout life with particular focus on avoidance of developing the metabolic syndrome.
• High-intensity statin therapy (if tolerated) should be instituted in patients with clinical ASCVD with the goal of lowering LDL-C levels by greater than or equal to 50%.
• Consider adding a non-statin cholesterol lowering agent (such as ezetimibe) in very high-risk ASCVD with a LDL-C threshold of 70mg/dL.
• Clinicians should begin high-intensity statin therapy in patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]).
• Moderate intensity statin therapy should be instituted in patients 40-75 years of age with diabetes mellitus and LDL-C levels greater than 70mg/dL.
• Clinicians should have a discussion with their patients about primary ASCVD prevention before starting statin therapy.
• Moderate-intensity statin therapy should be considered in non-diabetic adults 40-75 and LDL-C levels greater than 70mg/dL.
• Statin therapy should be considered in non-diabetic adults with a 10-year risk of 7.5% to 19.9%.
• If a decision about statin therapy is uncertain in Non-diabetic adults with LDL-C levels greater than 70mg/dl to 189 mg/dL and a 10-year risk for ASCVD of greater than 7.5%-19.9% a Coronary Artery Calcium (CAC) Score should be calculated to aid in the decision.
• Four to twelve weeks after statin initiation clinicians should assess adherence and percentage response to LDL -C lowering medications and lifestyle changes with repeat LDL levels and then every 3 to 12 months as needed.

These guidelines are concise and should be easily attainable with the tools we possess. However, being armed with a primer for good care clearly is not enough. The American College of Cardiology in conjunction with Sanofi and Regeneron Pharmaceuticals Inc. have developed an initiative called the TRANSFORM LDL-C trial aimed at addressing the gaps in treatment for ASCVD patients with regards to cholesterol-lowering therapy.

Dharam Kumbhani, MD, SM, FACC is a senior author of the TRANSFORM LDL-C trial. Dr. Kumbhani states, “Large groups of patients with ASCVD are not achieving low enough LDL-C levels, which puts them at greater risk of recurrent cardiovascular events and death.”^1​

The TRANSFORM LDL-C initiative aims to optimize patients’ access to the latest evidence-based treatments for LDL-C lowering and cardiovascular event risk reduction based on the ACC/AHA guidelines.¹ Dr. Kumbhani goes on to say, “It’s apparent that large gaps exist and that more efforts are needed in implementing the cholesterol guidelines. Next steps are examining what barriers exist in achieving these treatment goals and how to address these barriers.” These barriers, once identified, will need to be addressed if the gaps in treatment, access, and goal achievement are to be eliminated.

In general, before the results of the TRANSFORM LDL-C initiative are known, things can be done to reduce barriers to achieving the recommended LDL-C targets in patients with ASCVD. Simplifying treatment regimens can increase adherence especially in patients with several comorbidities such as hypertension and hyperlipidemia. Prescribing single-pill combinations containing treatment for both conditions makes it more likely the patient will comply with their regimen.⁴

Further, initiating treatment early with regular follow up and positive reinforcement from clinicians at each office visit are a good first step toward reducing cardiovascular risk in patients with hyperlipidemia. Together we can take the evidence and guidelines at our disposal and eliminate barriers to achieving the results our patients deserve improving outcomes and the quality of their lives.