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VA/Department of Defense guideline supports elimination of lipid targets
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The United States Department of Veterans Affairs and the U.S. Department of Defense approved a joint clinical practice guideline for management of dyslipidemia for CVD risk reduction in adults.
Consistent with the cholesterol guideline released by the American College of Cardiology and the American Heart Association, the guideline supports the elimination of lipid targets.
Moderate fixed-dose statin therapy endorsed
John R. Downs, MD, co-chair of the VA/Department of Defense Evidence-Based Practice Work Group, the task force that developed the guideline, and colleagues wrote that they reviewed literature through February 2014 — a more recent timeline than that used for the ACC/AHA guideline — and did not find any evidence supporting the use of LDL or non-HDL levels as treatment targets.
“However, clear evidence shows that moderate fixed-dose statin monotherapy improves total mortality and results in fewer CVD events,” they wrote.
The committee also recommended against liberal use of C-reactive protein and coronary artery calcium testing as additions to conventional risk factors. “Evidence is insufficient to recommend for or against either of these tests in patients at any level of risk for CVD,” they wrote.
While using these tests may make sense in some intermediate-risk patients for whom there is uncertainty or indifference about treatment, “such testing should be a shared decision with the patient, and the rationale for the test should be clear before it is used,” the authors wrote. “Routine use of these tests is not recommended because of the lack of evidence that testing improves patient outcomes, the costs of testing and [CAC] testing exposes patients to potentially harmful radiation.”
Decisions about whether to begin statin therapy should be made following a calculation of 10-year risk for CVD and a discussion with the patient about whether the potential benefits of the medication outweigh its potential harms, Downs, from the medicine service at South Texas Veterans Health Care System, San Antonio, and colleagues wrote.
Risk stratification key
The committee concluded that for patients with a 10-year CVD risk of 12% or greater, the benefits of CVD risk reduction “substantially outweigh the risks,” and treatment with a moderate-dose statin is strongly recommended.
For patients at a 10-year CVD risk of 6% to 12%, the decision to initiate statin therapy should be made on an individual basis, because the evidence for these patients is more limited and risk calculators tend to overestimate risk, they wrote.
There is no evidence of benefit for those at a 10-year CVD risk of less than 6%, they wrote.
For secondary prevention, there is strong evidence that it is beneficial to initiate statin therapy at a moderate dose, and to titrate to a higher dose where appropriate, the panel wrote.
Evidence for the greater efficacy of a high-dose statin compared to a moderate-dose one is inconsistent, and observed benefits have been limited to a reduction in nonfatal events. However, adverse events occur more frequently with high-dose statins, so “if high-dose statins are considered, clinicians and patients should carefully consider the known added harms and small additional benefits of such therapy and limit high-dose statins to patients at the greatest risk for CVD.”
A fasting lipid profile is not necessary, because “lipid measures are necessary to enable risk calculation based only on measures of total cholesterol and HDL levels, and the small variance in LDL level is unlikely to affect classification of risk or therapeutic decisions,” the panel wrote. “Thus, a nonfasting lipid profile provides acceptably accurate measures for risk calculation.”
In addition, except when adherence is an issue or when high-dose statin use causes concerns about very low LDL levels, the work group recommended against routine monitoring of lipid levels upon initiation of a statin, because statin efficacy is based on target dose rather than lipid levels. – by Erik Swain
Disclosure: The members of the VA/Department of Defense Evidence-Based Practice Work Group report no relevant financial disclosures.
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