VA, DOD dyslipidemia guideline focuses on doses, tests, prevention, healthy lifestyle

A dyslipidemia guideline from the Department of Veterans Affairs and Department of Defense provided recommendations on statin dosing, tests for predicting CVD risk, primary and secondary CVD prevention, nutrition and exercise.

CVD is the leading cause of death in the United States, and by 2035, its economic burden could top $1 trillion, data suggest. Although statin use could reduce that burden, its uptake is hindered by patient nonadherence and intolerance and high discontinuation rates, according to James T. Reston, PhD, MPH, senior associate director at the ECRI Institute, and colleagues. They said this “critically important issue requires clinician awareness and ongoing clinical attention to achieve optimal health outcomes.”

In a systematic review, Reston and colleagues analyzed 141 studies and six publications that evaluated interventions for improving statin tolerance and adherence. Based the available evidence, Patrick G. O'Malley, MD, MPH, an associate dean of clinical affairs at Uniformed Services University of the Health Sciences, and another set of authors developed a guideline of 27 recommendations, including the seven that follow as “most relevant for practice”:

• Stain users should not exceed the moderate level of dosing that is consistent with the medication’s clinical trials.
• Coronary artery calcium, high-sensitivity C-reactive protein, ankle-brachial index and apolipoprotein tests should only be conducted after patient-physician discussions that include the uncertain benefits, known harms and reason for testing.
• Moderate-dose statin therapy should “still [be] emphasized” for the primary prevention of CVD.
• Moderate statin doses should be recommended for CVD secondary prevention, with dose intensification based on a patient’s CVD risk.
• Individuals do not need to fast before laboratory tests.
• Individuals should be encouraged to engage in physical activity of “any intensity or duration” for the primary CVD prevention, whereas a “structured, exercise-based rehabilitation program” is recommended for secondary CVD prevention in patients with a history of CVD.
• Individuals should follow a Mediterranean diet for primary and secondary CVD prevention; eschew supplements for the sole purpose of reducing higher than normal CVD risks; avoid niacin and adding fibrates to statin therapy for primary or secondary CVD prevention; and limit icosapent ethyl consumption to those seeking secondary prevention of CVD.

In a related editorial, Alison L. Bailey, MD, FACC, an affiliated associate professor of cardiology at the University of Tennessee, and Charles L. Campbell, MD, a cardiologist at Piedmont Heart Institute in Atlanta, wrote that the guideline would “probably result in greater outcomes.”

However, they said the VA/DOD guideline differs from other society recommendations, “most notably in the approach to risk reduction in the secondary prevention arena.” Baily and Campbell explained that the other guidelines recommend high-intensity statin therapy vs. moderate-intensity therapy and, being less concerned about potential adverse events associated with the drugs.

The authors suggested that the VA/DOD guideline “probably leaves a portion of the VA/DOD population undertreated and may prove confusing to clinicians looking to reduce both CVD mortality and morbidity in patients with established CVD or multiple CVD risk factors and conditions.”

References

• Bailey AL, et al. Ann Intern Med. 2020;doi:10.7326/M20-6125.
• Reston JT, et al. Ann Intern Med. 2020;doi:10.7326/M20-4680.