Title: Earlier Intervention in the Management of Hypercholesterolemia: What Are We Waiting For?
Date Posted: August 9, 2010
Authors: Steinberg D.
Citation: J Am Coll Cardiol 2010;56:627-629.
Study Question:
Should we be treating hypercholesterolemia earlier in life?
Should we be treating some patients’ hypercholesterolemia earlier than currently indicated? Clinicians rely on Adult Treatment Panel (ATP) guidelines to assist in determining if and when to start treating hypercholesterolemia with medications—mainly statins. The ATP guidelines use Framingham risk scores to determine a 10-year risk. These scores provide a method for determining risk level, which in turn assists clinicians to identify target goals for low-density lipoprotein (LDL) levels and use of pharmacologic therapy. The author points out that younger patients often have 10-year risk levels, which suggest interventions are not recommended. However, the lifetime risk for cardiovascular (CV) events is often much higher than the calculated 10-year risk. The hypothesis of this article being treatment at an earlier age would translate into years of lower LDL levels, which would significantly reduce CV disease (CVD) events. As the author correctly points out, a randomized study to examine this premise is not feasible. In looking at the literature related to the PCSK9 gene, a lifetime low LDL level (28% lower) suggests a benefit of an 88% drop in coronary heart disease risk. Given this observation, perhaps several decades of LDL levels would translate into significant reductions in CVD events. However, all drugs carry some degree of risk, and the long-term use of statins is not clear.
So do we place more weight on the lifetime risk for CVD and aggressively treat lipids at a younger age than currently recommended, or do we proceed with caution given the unknown risk of long-term pharmacologic intervention? Dr. Steinberg proposes that the benefits outweigh the risks for many people.
Perspective:
Most clinicians and patients would agree that more years of controlled risk factors are optimal for decreasing risk for CVD. All clinicians should celebrate each decade in which cardiac risk factors remain absent in patients. The balance between pharmacologic treatment for long-term lipid control versus potential adverse effects of such therapy is not clear. Use of more novel risk factors such as C-reactive protein and coronary artery calcium can assist in determining who would benefit the most from more aggressive therapies. Clinicians need to outline the current understanding of guidelines for risk factor management as well as more recent knowledge on the lifetime risk for CVD events. Each patient is ultimately the one who decides what is best for him/her.
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