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4. Overview of the Management of Dyslipidemia in Secondary Prevention

Health behaviour interventions

We continue to recommend health behaviour interventions to optimize CV health in all patients with a previous ASCVD event (refer to the Health behaviour interventions in the section on Overview of the Management of Dyslipidemia in Primary Prevention). In secondary prevention, limiting sedentary behaviour can be additive to regular physical activity with respect to the reduction of ASCVD events. A certified exercise physiologist might be of value to provide advice and follow-up. Cardiac rehabilitation has been clearly shown to be of benefit in this patient population and remains a cornerstone of management.[19] Relevant recommendations from the previous dyslipidemia guidelines that remain unchanged are provided in Supplemental Appendix S5.

New areas of focus

Several areas were reviewed by our group that directly affect the care and management of patients with previous ASCVD events and have led to new or updated recommendations, specifically: (1) the role of nonstatin therapies to reduce ASCVD events; (2) the most appropriate lipid/lipoprotein threshold for the intensification of therapy in the management of dyslipidemia; and (3) the lack of CV benefit of omega-3 fatty acids from dietary sources or other formulations/supplements.

Figure 1. Treatment approach for primary prevention patients (without a statin-indicated condition*). Statin-indicated conditions consist of all docu- mented ASCVD conditions, as well as other high-risk primary prevention conditions in the absence of ASCVD, such as most patients with diabetes, those with chronic kidney disease, and those with an LDL-C ≥ 5.0 mmol/L. Screening should be repeated every 5 years for men and women aged 40-75 years using the modified FRS or Cardiovascular Life Expectancy Model (CLEM) to guide therapy to reduce major CV events. A risk assess- ment might also be completed whenever a patient’s expected risk status changes. ApoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; AU, Agatston units; BAS, bile acid sequestrant; CAC, coronary artery calcium; CAD, coronary artery disease; CV, cardiovascular; FHx, fam- ily history; HDL-C, high-density lipoprotein cholesterol; hsCRP, high-sensitivity C-reactive protein; HTN, hypertension; FRS, Framingham Risk Score; IFG, impaired fasting glucose; LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein(a); mins, minutes; Rx, treatment; yrs, years. * Calculate risk using the FRS.
Figure 2. Treatment approach for patients with a statin-indicated condition. ABI, ankle-brachial index; ACR, albumin to creatinine; ApoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; PCSK9, proprotein convertase subtilisin/kexin type 9; Rx, treatment; TIA, transient ischemic attack.

References

  1. Stone J, ed. Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention: Translating Knowledge Into Action. 3rd Ed Winnipeg: Canadian Association of Cardiac Rehabilitation;2009.

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