US Departments of VA, DoD Release Guidelines for Management of Dyslipidemia

The US Departments of Veteran Affairs (VA) and Defense (DoD) have released an update of their clinical practice guideline for the management of dyslipidemia in adults with cardiovascular disease (CVD) risk.

Both departments based their guidelines on a systematic evaluation of relevant literature between December 2013-May 2019. This evaluation was guided by key questions based on similar questions used by the American College of Cardiology and American Heart Association, which developed their own guideline on cholesterol management. 

As a result, the VA/DoD Evidence-Based Practice Work Group (EBPWG) developed 27 recommendations in addition to a 1-page simple algorithm. All recommendations were graded using the Grading of Recommendations Assessment, Development and Evaluation system, with the outcome of CVD mortality as the primary factor in rating grade strength.

They considered cardiovascular morbidity an important but less critical outcome in their grading of recommendations.

Thus, it was recommended by the EBPWG to continue to use target medication doses rather than LDL-C level targets. The committee’s review found no direct evidence to support association of targeting cholesterol levels with improved outcomes.

Since no study has prospectively evaluated LDL-C goals, the committee thus focused their recommendation on treatment intensity so as to match the available evidence and simplify point-of-case decision making. They noted that the use of LDL-C targets may lead to harm associated with higher statin doses or combination medical therapy.

Additionally, they did not recommend routine coronary artery calcium (CAC) testing since there is no evidence that it improves patient outcomes. Furthermore, such testing is costly and increases patient exposure to potentially harmful radiation.

Moderate-dose statin therapy was still emphasized as an appropriate goal for primary prevention. The use of high-dose/high-intensity statin was strongly discouraged, given that such dosage is associated with a higher risk of adverse effects and lack of evidence for increased benefit.

Furthermore, the use of PCKS9 inhibitors as primary prevention was not recommended because of its high cost and uncertain long-term safety.

As for high-risk secondary prevention populations, it was recommended to begin initially with moderate statin doses before proceeding to a stepwise intensification, which may include the addition of ezetimibe and PCSK9 (which was considered a last choice). 

This recommendation was based on clinical evidence which demonstrated the effect of “add-ons” on improvement in cardiovascular morbidity but not mortality.

There are currently no studies that have directly compared the use of additional treatments to high-dose statin therapy.

The committee also recommended against routine lipid level testing for risk assessment and monitoring, unless the purpose is to specifically guide decision-making. According to their review, they found that there is little variation in patient lipid levels over time. True variation was found to exceed random variation if testing is spaced by 9-10 years.

Therefore, they believed assessing fasting lipid levels adds little clinical value to risk prediction and that measurements should be taken every 10 or so years.

And finally, the guideline included a focus on exercise and nutrition. For example, they suggested increasing aerobic exercises as part of cardiac rehabilitation following a recent CVD event.

Additionally, they encouraged implementing a dietitian-led Mediterranean diet for high-risk patients as primary and secondary CVD prevention.

However, they did acknowledge that such evidence is weak and mostly observational.

Even though their guideline is similar to that put forth by the American College of Cardiology and American Heart Association, they concluded by underscoring their different perspectives on statin dosage, routine laboratory testing, aerobic activity and nutritional effects, among others.

The guideline, “Management of Dyslipidemia for Cardiovascular Disease Risk Reduction: Synopsis of the 2020 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline,” was published online in Annals of Internal Medicine.