Top 10 Takeaways from the 2021 CCS Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults, as referenced in the article “Sweeping dyslipidemia guidelines urge improved screening, new medications, and lifestyle counselling. But, hold the fish-oil supplements.”
- Screen patients for lipoprotein (a), a biomarker that is a risk factor for heart disease and stroke. Because Lp(a) is genetically determined, this blood test needs to be done once in a lifetime. Lp(a) measurement is particularly useful in the further risk assessment of apparently healthy individuals.
- Pregnancy-related complications (hypertension, gestational diabetes, pre-eclampsia, and pre-term birth) are associated with “accelerated aging” of the blood vessels and an elevated risk of developing cardiovascular disease. Screen and counsel women who have had these complications, about the importance of returning to a normal weight, eating well, exercising, and controlling their blood pressure.
- Consider the use of effective newer non-statin medications, including injectables, to treat people who don’t achieve optimal control with statins. Guidelines identify two classes of LDL-lowering drugs: ezetimibe, a cholesterol-absorption inhibitor, and the PCSK9 inhibitors, which are the newer injectable drugs. Clinicians need to be able to identify who would benefit from these add-on therapies so they can advocate for their patients.
- For the first time, the Dyslipidemia Guidelines use thresholds, rather than targets, for intensifying therapies. If patients are unable to achieve a certain threshold level with initial statin therapy, the addition of newer therapies is recommended.
- Patients with other forms of vascular disease should be treated with statins. Conditions include chronic kidney disease (even mild), peripheral arterial disease, and aortic abdominal aneurysm. Patients may benefit from additional lipid-lowering therapy if their LDL remains above 1.8 mmol/L while on a statin. These patients almost always have concomitant cardiovascular disease.
- Promote lifestyle management hand-in-hand with drug therapy. Rather than a stepped approach (encouraging patients to lose weight, exercise and improve their diet before prescribing a statin), recommend these approaches be prescribed simultaneously, especially for middle-aged patients with at least one risk factor (obesity, high BP, family history, etc).
- Use the lipid biomarkers non-HDL and ApoB as alternatives to LDL for predicting cardiovascular risk, particularly in individuals with high triglycerides. These measurements can be done on non-fasting samples and are considered the best lipid markers of cardiovascular risk.
- Discuss with your patients that over-the-counter omega-3 supplements are ineffective in lipid management and not recommended. Dietary sources are better (such as fish and walnuts). Only one prescription form of a purified fish oil (icosapent ethyl) has proven effective in a select group of patients.
- Lifestyle changes, including weight loss and at least 150 minutes of exercise/week, are very important. Portion control, reduced intake of refined carbohydrates, saturated fats and cholesterol, and following a Mediterranean or DASH diet are recommended. Ketogenic diets are not recommended because they are high in saturated fat and cholesterol. Encourage your patients to do exercises they enjoy, especially walking.
- Take note of important tweaks to the Guidelines, including changes in reference values for non-HDL and ApoB to adequately represent the same percentile equivalent as LDL. There is clarification of earlier Guidelines about the small and select group of people who would benefit from coronary calcium scoring to determine the level of calcium deposit in the coronary arteries.
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