We read with interest Vila À et al. titled “Observational study of patients from a Lipid Unit on lipid-modifying therapy for primary and secondary prevention: ULFI Study”1 highlighting that factors associated with therapeutic lipid lowering success were the presence of arteriosclerotic cardiovascular disease, the intensity of lipid-lowering treatment (LLT), diabetes mellitus, and low to moderate alcohol consumption but we have to consider that low adherence to LLT is one of the main reasons beyond the failure in achieving the recommended lipid targets in several patients. The ULFI study is in agree with the SANTORINI study2 who reported that a considerable proportion of subjects at high and very high cardiovascular risk fail to reach the LDL-cholesterol goals established by the guidelines (<70 and <55mg/dL, respectively) although prescribing attitudes changed over time, with a rising, trend toward more aggressive LLT interventions. Recently, ESC indications3 highlighting the importance of periodic reassessment of chronic cardiovascular therapy especially after a lengthy period of treatment. However, between the several discussed cardiovascular medications, some further considerations need to be made regarding the LLT:
- i)
Niacin treatment, although able to increase HDL cholesterol levels especially in familial hypoalphalipoproteinemia, increase the frequency of serious adverse events with an unfavorable risk/benefit ration and the fish oil supplementation (<1g/day) has an irrelevant therapeutic effect although a very high daily dose is not recommended, especially in patients with heart disease, due to the risk of atrial fibrillation.4
- ii)
Statin-associated muscle symptoms (SAMS) are a major determinant of poor treatment adherence and/or statin discontinuation but this condition can benefit from coenzyme Q10 supplementation especially when CPK values are high before start statin therapy.5 Moreover, SAMS could be the opportunity to identify, through vitamin D dosage, states of vitamin deficiency in order to start specific therapy.
- iii)
Among patients with atherosclerotic cardiovascular disease (ASCVD), hypertriglyceridemia is common, and is associated with higher ASCVD risk across a range of TG.6 Lowering triglycerides with fibrates reduces the risk of cardiovascular events by the same amount as LDL-C-lowering therapies when measured per unit change of non-HDL-C. Combinations of statins with gemfibrozil may enhance the risk for myopathy but this risk seems to be small using fenofibrate and routinary monitoring CPK.7
- iv)
Simvastatin has a good safety profile, especially in chronic kidney disease,8 and adding ezetimibe allowed an LDL-cholesterol reduction great then 50% in a large number of high cardiovascular risk subjects.
All strategies, according to the operative international lipid expert panel indication and with protocol to valorized the therapeutic adherence,1,9 have a role to improve the LLT effectiveness don’t forget, in the era of “new” lipid-lowering drugs, cornerstone data regarding “old” LLT.
Funding sourcesNo financial support was received.
Author approvalAll authors have seen and approved the study submitted.
No part of the submitted work has been published or is under consideration for publication elsewhere.
Authors’ contributionFS and BDP: contributed to conception or design, drafted and critically revised the manuscript. All authors read and approved the final version of the manuscript.
NotesData have not been presented at any congress.
Consent for publicationThe patient signed the informed consent from form for anonymous medical data usage in our paper.
Conflict of interestNo conflict of interest for each author.
None.