Highlights
- •Using equations based on clinical trials, we assess lipid-lowering guidelines.
- •Guidelines should be based on both LDL-C level and absolute CVD risk.
- •Optimal CVD risk reduction in those with higher LDL-C requires treatment targets.
- •Individuals with raised LDL-C can benefit from therapy at lower CVD risk.
- •Fixed dose statins are better for people at higher risk with lower LDL-C levels.
Abstract
Background and aims
Guidelines for cholesterol-lowering medication either advocate fixed dose statin treatment
without low density lipoprotein (LDL) cholesterol targets or treatment aimed at LDL
cholesterol goals. The decrease in LDL cholesterol concentration determines the reduction
in atherosclerotic cardiovascular disease (CVD) risk.
Methods
As indices of the effectiveness of reductions in LDL cholesterol concentration achieved
by the various guidelines, the number of CVD events prevented in 100 people during
10 years of treatment (N100) and the number of people, who must be treated for 10 years to prevent one CVD event
(NNT), were calculated taking into account both CVD risk and pretreatment LDL cholesterol
concentration. That our method of calculating NNT and N100, could be extended to statin regimens of different intensity or of statin combined
with adjunctive cholesterol-lowering medication was demonstrated by meta-analysis.
Results
Reductions in LDL-cholesterol concentration are determined by the choice and dose
of medication and by the pre-treatment LDL-cholesterol concentration. At similar CVD
risk, whatever cholesterol-lowering strategy is adopted, people with higher pre-treatment
LDL cholesterol benefit more than those with lower levels. Fixed dose statin regimens
are less effective than target LDL cholesterol levels of 1.8 or 1.4 mmol/l when pre-treatment
LDL-cholesterol levels exceed 4 mmol/l. However, fixed dose statin is more effective
in people with lower initial LDL cholesterol. The predicted NNT and N100 were closely related to the observed reduction in CVD risk in our meta-analysis.
Conclusions
In hypercholesterolaemia, aiming for LDL cholesterol targets with statin dose titration
(and when necessary adjunctive medication) is essential to optimise benefit.
Keywords
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Article Info
Publication History
Published online: August 30, 2018
Accepted:
August 29,
2018
Received in revised form:
June 26,
2018
Received:
February 19,
2018
Identification
Copyright
© 2018 Published by Elsevier B.V.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Reply to: "Comments on 'Optimising treatment of hyperlipidaemia: Quantitative evaluation of UK, USA and European guidelines taking account of both LDL cholesterol levels and cardiovascular disease risk' "AtherosclerosisVol. 281
- PreviewWe are grateful to Dr Shah for his appreciative comments about our article [1]. He raises a number of important points. However, these stem from issues arising as consequences of the guidelines themselves. The purpose of our paper was to determine which guidance was most appropriate for cholesterol-lowering medication in people throughout the range of LDL cholesterol, from below to above average, at differing degrees of atherosclerotic cardiovascular disease (CVD) risk. Our main conclusion was that for people whose LDL cholesterol was <4 mmol/l (154 mg/dl), fixed dose atorvastatin 20 mg daily (or an equally efficacious dose of another statin) was optimal, whereas for those with LDL cholesterol ≥4 mmol/l, treatment aimed at a target of <1.8 mmol/l (70 mg/dl) was more clinically effective.
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- Comments on “Optimising treatment of hyperlipidaemia: Quantitative evaluation of UK, USA and European guidelines taking account of both LDL cholesterol levels and cardiovascular disease risk”AtherosclerosisVol. 281
- PreviewWe read with great interest the recent updated article by Soran et al. suggesting lowering of low density lipoprotein (LDL) would further reduce cardiovascular risk [1]. The authors did a great work and we would like to congratulate them. However, we would like to comment on a few issues in the study that are important for clinicians dealing with this situation and expand on the pooled analysis using the same data included in the paper. We would like to emphasize some important points about this well-written study.
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