Management of dyslipidemia for CVD risk reduction

In 2015, the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) issued a guideline on the management of dyslipidemia for primary and secondary prevention of cardiovascular disease (CVD) events. The guideline was just updated last month, with a focus on preventing CVD-related mortality.

Check out the recommendations: 

  • Treat patients with dyslipidemia to achieve target statin dosing (NOT to achieve a target LDL level), based on 10-year CVD risk.
  • For primary prevention*, prescribe moderate-dose statin therapy for patients with 10-year CVD risk >12%. PCSK9 inhibitors should NOT be used for primary prevention.
    • *Remember that primary prevention is an action taken before disease onset to prevent disease occurrence.
  • For secondary prevention**, prescribe moderate-dose statin therapy for most patients, with escalation to high-dose statin therapy for higher-risk patients — MI or ACS in the past 12mo; recurrent ACS, MI, or CVA; or CVD with additional risk factors (i.e. current smoking, DM, PAD, previous PCI or CABG).
    • **Remember that secondary prevention is an action taken that halts/delays disease progression at an initial stage (i.e. most screening tests are forms of secondary prevention.)
  • Monitor non-fasting lipid levels infrequently (every 10 years) rather than annually.
    • The calculation of CVD risk is affected only minimally by lipid levels and depends much more on other major risk factors (i.e. age, sex, HTN, DM, tobacco use).
    • Lipid levels vary little in a patient over time; true variation exceeds random variation only if testing is spaced by 9-10 years. 
    • Clinicians can reliably use a previously measured lipid value in assessing CVD risk.
  • Limit additional testing (e.g. CAC score, apolipoprotein level, CRP) that is of little value in refining CVD risk for most patients.
  • For primary and secondary prevention, encourage patients to engage in regular aerobic physical activity. For secondary prevention in patients with recent CVD events, prescribe a structured exercise-based rehabilitation program, initiated early (within 2-8wk) following the CVD event.
  • For primary and secondary prevention, recommend the Mediterranean diet. Do NOT recommend supplementation with omega-3 fatty acids, niacin, or fibrates.
  • For patients who cannot tolerate statins (due to adverse drug effects), offer a washout period, followed by rechallenge with the same or a different statin; this protocol will lead to statin adherence in >90% of patients who stopped taking statins. Non-daily statin dosing can also increase tolerance and adherence for some patients.

These recommendations differ significantly from those in the 2018 ACC/AHA guideline, particularly in that they suggest moderate-intensity (rather than high-intensity) statins for secondary prevention, with escalation based on patient risk factors rather than LDL levels, and recommend against using CAC scores for primary-prevention risk stratification. 

In response, this editorial argues that clinicians who are trying to prevent both CVD-related mortality and morbidity might undertreat patients if this guideline’s recommendations are followed strictly.

What do you think? Will this guideline change your practice?