1. Section 6: Update on lipid treatment guidelines
LDL-C reduction with statins
Content Points:
Statins are the most potent lipid-lowering drugs currently available. The slide summarizes the current maximal approved dose for each statin and the LDL-C reduction that can be achieved at that dose, based on results of controlled clinical trials.41
As can be seen, these drugs produce reductions of 24% to 60%. The ability to achieve such large reductions in LDL-C has important implications for management strategies, as discussed in the following 3 slides.

2. Target LDL-C levels for initiating dietary therapy: Are they realistic?
Content Points:
The desirable LDL-C level is less than 130 mg/dL.42 For primary prevention, individuals with this desirable target level should be reevaluated in 5 years.
For patients without CHD, the desirable LDL-C levels are less than 160 mg/dL in those with no more than 1 other risk factor present, and less than 130 mg/dL in those with 2 or more other risk factors.
For those patients with established CHD, the target level for LDL-C is less than 100 mg/dL.
However, these guidelines were developed before the data supporting aggressive lipid lowering had emerged. In particular, the statin trials demonstrated major reductions in morbidity and mortality.

3. Target LDL-C levels for initiating drug therapy: Are they realistic?
Content Points:
The decision to initiate drug therapy is based on LDL-C levels and the presence of risk factors for coronary heart disease.42
For primary prevention in most persons without CHD, drug therapy is recommended when LDL-C is greater than 190 mg/dL in those with no more than 1 other CHD risk factor, and less than 160 mg/dL for those with 2 or more other risk factors.
The goal of therapy is to reduce LDL-C to less than 160 mg/dL in patients with less than 1 risk factor, and to less than 130 mg/dL in those with 2 or more risk factors.
For secondary prevention, the goal in patients with CHD is to lower their LDL-C levels to less than 100 mg/dL. Drug therapy is reasonable when LDL-C levels are greater than 130 mg/dL.
As discussed in the previous slide, these guidelines may need to be revisited based on new data that have emerged in support of aggressive lipid lowering with statins.

4. Treatment decisions based on LDL-C levels in adults with diabetes
Content Points:
The American Diabetes Association (ADA) has developed guidelines for the reduction of LDL-C levels. Such an approach is especially important for people who have type 2 diabetes and high LDL-C levels due to their substantially increased risk for CVD.43
The ADA guidelines are more aggressive than the NCEP guidelines.
According to the guidelines, pharmacologic therapy should be initiated at LDL-C levels greater than 100 mg/dL with a goal of reducing LDL-C to less than 100 mg/dL in all patients with diabetes and CHD, peripheral vascular disease (PVD) or clinical coronary vascular disease.

5. Risk factors for CAD: NCEP guidelines for adults
Content Points:
Risk factors that can interact with elevated LDL-C levels include age, family history of CVD, smoking, hypertension, HDL-C (levels < 35 mg/dL are a negative risk factor; levels > 60 mg/dL help reduce risk) and diabetes mellitus.42
Obesity is not listed as a risk factor because it operates through other risk factors (hypertension, hyperlipidemia, decreased HDL-C and diabetes mellitus).
Since physical activity of moderate intensity helps reduce CV risk, it should also be considered a target for intervention.

6. Dietary therapy for patients at risk for CAD
Content Points:
Dietary therapy is the cornerstone of the NCEP guidelines and drug therapy is intended as an adjunct to it.42
The primary aim of dietary therapy is to reduce CV risk by decreasing intake of saturated fats and cholesterol and by restoring appropriate calorie balance, while promoting good nutrition.
For patients not previously on dietary therapy, the Step I diet is recommended. However, the physician may choose to move directly to the Step II diet, based on a assessment of current eating habits.
If the goals of therapy are not achieved after 3 months on a Step I diet, the patient should move to a Step II diet.

7. Major classes of drugs to reduce lipids
Content Points:
There are 5 major types of lipid-lowering drugs discussed in the current NCEP guidelines.
They are bile acid sequestrants (resins), estrogen replacement therapy, fibric acid derivatives (fibrates), HMG-CoA reductase inhibitors (statins), and nicotinic acid (niacin).

8. Achieving NCEP goals for LDL-C
Content Points:
Studies have provided insights into the comparative efficacy of agents in achieving desired NCEP target goals for LDL-C.
Bertolini et al compared atorvastatin (10 mg/day) with pravastatin (20 mg/day) in 305 patients with hypercholesterolemia.44
Subjects had baseline LDL-C levels of greater than 160 mg/dL. If their LDL-C targets were not achieved by 16 weeks, the drug doses were doubled.
The chart at the left shows results at 16 weeks. Note the 35% reduction in LDL-C associated with atorvastatin therapy compared with 24% with pravastatin. In addition, 65% of patients treated with atorvastatin had achieved the LDL-C target of 130 mg/dL.

9. Achieving NCEP goals for LDL-C
Content Points:
This slide depicts results of a double-blind, placebo controlled, 52-week study comparing effects of atorvastatin (10 mg per day) and lovastatin (20 mg per day) in 1049 hypercholesterolemic patients.45
After 16 weeks, there was a 36% reduction in LDL-C with atorvastatin compared with 27% for lovastatin.
The chart at the right shows comparisons of the 2 agents in helping patients reach target goals for LDL-C. Seventy-four percent of patients on atorvastatin (vs 55% on lovastatin) reached target LDL-C goals.