New Guideline on Dyslipidemia: Less Is More

Taking a joint approach, the VA and DoD have released a clinical guideline about managing dyslipidemia to reduce the risk of cardiovascular disease (CVD). The 5 main recommendations “of most relevance to general practice” are about doing less in a more focused way.

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No treatment targets. The VA/DoD concluded that the available evidence does not support the use of low-density lipoprotein cholesterol or non–high-density lipoprotein cholesterol levels as treatment targets. The committee added that using target cholesterol goals can lead to prescribing escalating doses of statins and combinations of drugs, which in turn can lead to higher rates of adverse effects without a known benefit in outcomes. However, the panel notes as well that “clear evidence” shows that moderate fixed-dose statin monotherapy improves total mortality and results in fewer CVD events.

Fewer tests. Only C-reactive protein and coronary artery calcium testing have shown “minimal additive predictive risk” beyond conventional risk factors, the committee says, but adds that the evidence for or against recommending the tests is insufficient. The guideline advises against routine use of the tests because of the lack of evidence about improved patient outcomes, the costs of testing, and patient exposure to potentially harmful radiation.

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More nuanced primary prevention. For patients with a 10-year risk of > 12%, the guideline panel suggests that the benefits in CVD risk reduction substantially outweigh the risks, and those patients should be treated with a moderate-dose statin. For patients in the intermediate range (10-year risk of 6%-12%), the decision is nuanced and depends on the individual patient assessment.

Cautious secondary prevention. Research did not show that a higher-dose statin, compared with a moderate-dose statin, consistently improved the primary outcome of major cardiovascular events, the panel said. Thus, the guideline recommends that if high-dose statins are considered, patients and practitioners should carefully consider the “known added harms and small additional benefits.

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No more fasting or monitoring. A nonfasting lipid profile provides acceptably accurate measures for risk calculation, the panel said. And because some patients are unwilling to fast or return to the clinic, or avoid testing altogether, and laboratories may be burdened by the large number of patients who present early in the morning after an overnight fast, drawbacks may outweigh the “small gain in accuracy” of a fasting lipid profile. The panel also does not recommend routine monitoring of lipids (except for patients on high doses) or liver enzymes once a statin is initiated. Serious liver injury is rare and unpredictable, they note, and routine monitoring does not seem to effectively detect or prevent it. Frequent laboratory testing, the panel said, has negative consequences, including possible cellulitis, pain, and inconvenience for the patient and excess workload and opportunity costs for the practitioner.

The VA/DoD guideline differs in some ways from the American College of Cardiology and American Heart Association guideline, the panel members say, and “will undoubtedly provoke criticism.” However, they add, they hope to have brought “some ‘order to the chaos’ of clinical guidelines.”

Source
Downs JR, O’Malley PG. Ann Intern Med. 2015;163(4):291-297.
doi: 10.7326/M15-0840.