Treating dyslipidemia: something more than giving statins

Mortality due to cardiovascular diseases has dropped significantly in the last 30 years,¹ not least thanks to the treatment of dyslipidaemia. Low-density lipoprotein cholesterol (LDL-C) is an aetiological agent of arteriosclerosis, stimulating inflammatory phenomena and cell proliferation in the vascular wall.² Cholesterol-lowering drugs reduce the rates of vascular events due to their action on LDL-C concentrations. There is very robust evidence, extensively explored by the Cholesterol Treatment Trialist Collaboration (CTTC), that shows that the reduction in the risk of vascular diseases associated with the use of statins is mediated by the absolute decrease in LDL-C.³ In addition, a decrease in LDL mediated by other drugs such as ezetimibe or PCSK9 inhibitors, or even by non-pharmacological means such as diet or surgery, gives rise to the same fall in risk for every reduced unit of cholesterol.⁴ This association between decreased Ldl-C and decreased risk has been confirmed by Mendelian randomisation studies.⁵

All this evidence indicates that Ldl-C should be the treatment goal of lipid-lowering treatment, looking beyond the use of statins alone. The guidelines published in 2013 by the American College of Cardiology and the American Heart Association on the management of hypercholesterolaemia for cardiovascular prevention have been the driving force behind the almost exclusive use of statins to reduce cardiovascular risk, recommending the administration of potent statins at the highest doses in high-risk subjects, practically irrespective of their effect on Ldl-C.⁶ The publication of the results of the improve-it, fourier and Odyssey Studies,^7–9 Together With The Rest Of The Parallel Evidence Mentioned, Highlights The Need For A Change Of Treatment Focus Towards The Concept Of Prescribing High-Intensity treatment of hypercholesterolaemia.¹⁰

The sad reality is that these therapies are not used, patients with high cardiovascular risk are undertreated and the attainment percentage of treatment goals remains unacceptably low.¹¹

Whilst there are a number of different causes that could be attributed to poor therapeutic performance, the most significant seems to be undertreatment. According to recent data from the DYSIS study, the dosage of statins is low even in patients who have suffered vascular events, equivalent to 35 mg a day of simvastatin.¹²

The study published in this issue of the Clínica e investigación enArteriosclerosis ¹³confirms that prior treatment planning is associated with a significant increase in the attainment of treatment goals. When starting a lipid-lowering therapy, the doctor needs to ask him or herself what the treatment goal of the patient being treated is. Once this has been established, the distance between the patient's current status and the treatment goal to be attained should be measured, and then a treatment with sufficient strength to attain this goal should be chosen. With this strategy, the use of combination therapy, that is, hypercholesterolaemia treatment beyond high doses of statins, can be considered. Doctors should consider their patient's situation and decide whether intermediate doses of statins combined with ezetimibe, which are usually better tolerated and generally more effective, could improve the patient's adherence and the treatment's effectiveness.

Simple tools such as the desktop treatment planning table assessed in the aforementioned article,¹³ of which there are updated versions,¹⁴ or digital tools incorporated into electronic medical records, such as those developed by Zamora et al.,¹⁵ could increase treatment success rates in a medical area that we know contributes to improving the length and quality of life of our fellow citizens.

Conflicts of interest

The authors declare that they have no conflicts of interest.