2015 NLA Recommendations for Patient-Centered Management of Dyslipidemia: Parts 1 and 2

BySteven Lome, MD

Year Released: 2015

Society: National Lipid Association (NLA)

Summary:

The NLA convened a panel of experts to develop a consensus set of recommendations for patient-centered management of dyslipidemia.

The panel used a hybrid of the rating system developed by the National Heart, Lung, and Blood Institute (NHLBI) Evidence-Based Methodology Lead and adapted from the original Grades of Recommendation Assessment, Development and Evaluation (GRADE) system to classify the type and strength of evidence that supported its recommendations.

Some of the recommendations from the panel highlight areas that included:

screening and classification of lipoprotein lipid levels in adults older than 20 years;
targets for intervention in dyslipidemia management;
atherosclerotic cardiovascular disease (ASCVD) risk assessment and treatment goals based on risk category; and
lifestyle and drug therapies intended to reduce morbidity and mortality associated with dyslipidemia.

However, the panel also had to develop a second set of recommendations to expand on the first part to include areas where clinicians may desire additional guidance, particularly where the evidence base is less robust or is lacking results from randomized controlled trials on clinical ASCVD events to guide clinical decisions.

Content areas that were identified for inclusion in the second part of recommendations included:

groups with special considerations that cover the life span from children to seniors and from pregnancy to menopause; and
ethnic groups such as Hispanics/Latinos, African-Americans, South Asians and American Indians/Alaska Natives.

Part 1:

After reviewing the evidence-based randomized controlled trials, the panel made several conclusions that included:

An elevated level of cholesterol carried by circulating apolipoprotein B-containing lipoproteins is a root cause of atherosclerosis, the key underlying process contributing to most clinical ASCVD events.
Reducing elevated levels of atherogenic cholesterol will lower ASCVD risk in proportion to the extent that atherogenic cholesterol is reduced. This benefit is presumed to result from atherogenic cholesterol lowering through multiple modalities, including lifestyle and drug therapies.
For patients in whom lipid-lowering drug therapy is indicated, statin treatment is the primary modality for reducing ASCVD risk.

In the first part of the recommendations, the panel wrote that its consensus view was that treatment goals, which have been used historically by health care providers for the past 25 years or so, continue to be useful as a systematic means to ensure that the aggressiveness of therapy to lower atherogenic cholesterol is matched to absolute risk for an event.

Additionally, the view is that using treatment goals, compared with prescribing moderate- to high-intensity statins without treatment targets, will not result in undertreatment as was suggested in the American College of Cardiology (ACC)/American Heart Association (AHA) 2013 dyslipidemia recommendations, the panel wrote.

Metabolic syndrome

The panel noted that metabolic syndrome is recognized as a multiplex risk factor for both ASCVD and type 2 diabetes, and the predictive value of metabolic syndrome for type 2 diabetes risk, although substantial, is less than that shown for diabetes-specific risk equations.

Increased adiposity and insulin resistance appear to be central pathophysiological features of this cluster of interrelated metabolic and hemodynamic disturbances, including elevations in blood pressure (BP), triglycerides and glucose, as well as depressed high-density lipoprotein cholesterol (HDL-C), according to the panel.

Metabolic syndrome also likely reflects ASCVD risk secondary to indicators that are often not measured clinically, including increased oxidation, inflammation, endothelial dysfunction and thrombogenicity.

Some of the panel members were in favor of recommending that a diagnosis of metabolic syndrome be considered for reclassification of an individual into a higher risk category. However, because of the overlap between certain ASCVD risk factors and metabolic syndrome criteria, the panel did not agree that the metabolic syndrome should be labeled a high-risk condition at this time.

The main value of identifying the presence of the metabolic syndrome, according to the panel, is to recognize individuals with a high potential to benefit from lifestyle therapies, particularly weight loss if overweight or obese, and increased physical activity.

Part 2:

The panel wrote that lifestyle therapies are central to dyslipidemia management and should be advised for all patients, regardless of whether drug therapy is also prescribed.

As highlighted in the first part of recommendations from the NLA, a trial of lifestyle therapies should be attempted before use of drug therapy for most patients.

Exceptions include patients at very high or high risk for whom clinicians may wish to simultaneously begin lifestyle and drug therapies.

Lifestyle therapies

Limited evidence is available from randomized clinical trials to assess the effects of lifestyle therapies on ASCVD event risk, the panel wrote. However, evidence from epidemiologic studies consistently supports a strong relationship between circulating levels of atherogenic cholesterol and ASCVD event risk.

The panel recommended lifestyle therapies as an integral component of treatment plans for the management of dyslipidemia and ASCVD event risk reduction at all risk level. For lowering levels of atherogenic cholesterol, the main features include a cardioprotective dietary pattern low in cholesterol-raising fatty acids (< 7% of energy from saturated fatty acids and minimal intake of trans unsaturated fatty acids) and dietary cholesterol (< 200 mg per day), as well as regular physical activity (≥ 150 minutes per week of moderate or higher intensity activity).

Dietary adjuncts, including plant sterols/stanols and viscous fibers, may be used to enhance the reductions in atherogenic cholesterol.

Energy restriction and further increases in physical activity were recommended by the panel for patients with overweight or obesity for whom weight loss and additional reductions in atherogenic cholesterol levels are desired.

Jacobson TA, et al. J Clin Lipidol. 2015:doi:10.1016/j.jacl.2015.02.003.

National Lipid Association issues recommendations for dyslipidemia management