The National Lipid Association (NLA) has released new recommendations to guide healthcare providers in the diagnosis and treatment of dyslipidemia using a patient-centered approach. The American College of Cardiology and the American Heart Association have previously developed clinical guidelines for managing cholesterol, but the NLA recommendations are different in that they offer an alternative perspective that may benefit clinicians in their care of patients.
“The NLA recommendations aim to help clinicians collaborate with patients to ensure that they understand their treatment options and the importance of reducing cardiovascular risk,” explains James A. Underberg, MD. “They emphasize that a strong patient-provider relationship is essential to achieving long-term success. They’re intended to inform—not replace—clinical judgment.”
The recommendations, published in the Journal of Clinical Lipidology and available for free online at http://www.lipidjournal.com, are intended to be a complimentary tool to currently available guidelines. In order to take a patient-centered approach, clinicians must use their own judgment but also take into account the circumstances, objectives, and preferences of each individual patient. Patients should be active participants in the process and engage with clinicians in conversations about objectives of therapy, potential risks and side effects, and expected benefits and costs. “Patients who better understand their options and participate in treatment decisions tend to be more committed to sticking with therapies for the long term,” adds Dr. Underberg.
According to the NLA expert panel that developed the recommendations, non-HDL cholesterol (non-HDL-C) and LDL cholesterol (LDL-C) are key lipoproteins by which success of treatment is assessed. Non-HDL-C is preferred over LDL-C because it more accurately predicts risk among patients who are on or off cholesterol-lowering therapy. It is also preferred because non-HDL-C is uniformly available, inexpensive, and can be obtained with or without fasting.
The NLA recommendations provide treatment goals for non-HDL-C, LDL-C, and apolipoprotein (apo) B (Table). “Non-HDL-C should be considered as a co-target with LDL-C,” Dr. Underberg says. “In addition, high levels of cholesterol carried by circulating apo B-containing lipoproteins are a root cause of most clinical atherosclerotic cardiovascular disease (ASCVD) events. Reducing these particle levels with multiple modalities, including lifestyle and drug therapies, may lower ASCVD risk according to clinical trial data.”
Examining Risks & Value
The NLA notes that the intensity of risk-reduction therapy should be adjusted to absolute risks for ASCVD events. “Atherosclerosis is a process that usually begins early in life and progresses over time before an ASCVD event occurs,” says Dr. Underberg. “Both intermediate-term and long-term lifetime risks should be considered when assessing the pros and cons of risk-reduction therapies.” He adds that non-lipid ASCVD risk factors—most notably high blood pressure, cigarette smoking, and diabetes—should be managed. The value of lipid goals should be considered in context of other important risk factors, such as blood pressure and AIC levels.
There is some concern regarding the limitations and potential overestimation of cardiovascular risk using an approach that advocates widespread use of risk calculators. For that reason, the NLA recommends using a variety of approaches to assess risk in patients with two major cardiovascular risk factors and in those who may not achieve the “classic” benefits of statins as noted in clinical guidelines.
Many approaches can safely lower cholesterol levels, including improved dietary and exercise habits and the use of medications. These therapies have been shown to reduce cardiovascular risk in higher-risk individuals, but Dr. Underberg stresses that clinical judgment be used when determining optimal approaches for each patient. For example, the importance of using intensity of statins has been supported in randomized control trials, but statin dosage titration may also be appropriate in some cases. Clinicians should not hesitate to use non-statin therapy if atherogenic cholesterol goals are not achieved with evidence-based statin therapy, according to the NLA.
The NLA emphasizes using lifestyle therapies for ASCVD prevention and offers an algorithm to assist clinicians in the continuum of care. “While pharmacotherapy has been shown in clinical trials to be effective for many patients with dyslipidemia, observational studies also strongly suggest that lifestyle habits have an important effect on atherogenic cholesterol levels,” Dr. Underberg says. “Lifestyle therapies can also impact other related disturbances, such as obesity, hypertension, and insulin resistance. Accordingly, the NLA views lifestyle therapies as an important element of risk-reduction efforts, regardless of whether or not drug therapy is also used.”
Keep Goals in Mind
An important emphasis of the NLA recommendations is that patients and providers work in partnership to achieve mutually agreed-upon cholesterol and lifestyle goals in order to prevent and reduce cardiovascular events. Lipid monitoring can help assess medication adherence and allow clinicians to emphasize the importance of lifestyle changes and ensure that atherogenic cholesterol goals are met. “Treatment goals are useful to ensure that the aggressiveness of therapy to lower atherogenic cholesterol matches the absolute risk for an event,” Dr. Underberg says. “With effective communication, clinicians can articulate areas of progress when treatment objectives are reached. This can support efforts to maximize long-term adherence to treatment plans.”
According to Dr. Underberg, the NLA is developing additional patient-centered recommendations that will account for special populations. These patient groups will include recommendations specific to pediatrics, geriatrics, individuals with HIV, and women who are pregnant, among others. “The NLA is trying to capture the entire spectrum of people who develop lipid disorders so that clinicians can be armed with recommendations for all types of individuals,” says Dr. Underberg. “Such efforts are paramount to ensuring that clinicians are truly taking a patient-centered approach to managing dyslipidemia.”
Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: executive summary. J Clin Lipidol. 2014;8:473-488. Available at: http://www.lipidjournal.com/article/S1933-2874(14)00274-8.
Jellinger PS, Smith DA, Mehta AE, et al. AACE Task Force for Management of Dyslipidemia and Prevention of Atherosclerosis. American Association of Clinical Endocrinologists’ guidelines for management of dyslipidemia and prevention of atherosclerosis. Endocr Pract. 2012;18:1-78.
Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2935-2959.
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2889-2934.