Lipoprotein management in patients with cardiometabolic risk is the focus of a joint consensus statement from the American Diabetes Association and American College of Cardiology Foundation.
The evidence-based statement, written by a seven-member panel, advises assessing global “cardiometabolic risk” (CMR), followed by a multifactorial risk-reduction strategy targeting individual risk factors with lifestyle and pharmacologic therapy. Specific recommendations are given for management of dyslipidemia in patients by risk level (Diabetes Care 2008;31:811–22).
Among the clinical entities considered to increase CMR are type 2 diabetes, familial combined hyperlipidemia, familial hypoalphalipoproteinemia, and polycystic ovary syndrome. All share the characteristics of central obesity, insulin resistance, dyslipoproteinemia, and hypertension. For such patients, the panel recommended statin therapy for the majority of dyslipidemic adult patients with CMR and guiding therapy for patients with CMR on statin therapy, with measurements of apolipoprotein B (apoB) and treatment to apoB goals in addition to LDL-cholesterol and non-HDL-cholesterol assessments.
The panel also recommended treatment goals that address the high lifetime risk of patients with cardiometabolic risk and dyslipidemia:
▸ For patients with either known cardiovascular disease (CVD) or diabetes plus one or more additional major CVD risk factors, LDL cholesterol should be less than 70 mg/dL, non-HDL cholesterol less than 100 mg/dL, and apoB less than 80 mg/dL.
▸ For those with no diabetes or known clinical CVD risk factors but who have two or more additional major CVD risk factors or who have diabetes but no other major CVD risk factors, LDL cholesterol should be less than 100 mg/dL, non-HDL cholesterol less than 130 mg/dL, and apoB less than 90 mg/dL.
The panel also recommended clinical trials to determine whether the pharmacologic therapy for achieving very low levels of atherogenic lipoproteins is safe and cost effective. It also advocated for a public health effort focusing on lifestyle modification for reducing those levels.
Two panelists disclosed no conflicts of interest. The other five each disclosed multiple dualities of interest, including four who accepted consulting fees/honoraria from Merck & Co, and Schering-Plough Corp., three from Abbott Laboratories and Pfizer Inc., and two from Astra-Zeneca Pharmaceuticals, Kos Pharmaceuticals, Sanofi-Aventis, and Daiichi-Sankyo.