Article Text

other Versions

PDF
A review of the clinical evidence related to early treatment of elevated LDL for cardiovascular primary prevention
  1. Kori Sauser1,
  2. Deborah A Levine2,3,
  3. Rodney A Hayward2,3
  1. 1Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
  3. 3Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital, Ann Arbor, Michigan, USA
  1. Correspondence to: Kori Sauser
    , Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA; ksauser{at}mgh.harvard.edu

Extract

Background The American College of Cardiology/American Heart Association updated cholesterol treatment guidelines dropped treatment recommendations based on elevated low-density lipoprotein (LDL) levels. Yet some experts cite the benefit of early statins in patients with elevated LDL for preventing atherosclerosis. We sought clinical evidence for this early LDL treatment hypothesis.

Methods and results A review of the clinical evidence examining the relationship between LDL reduction and outcomes (excluding LDL >190). We found three arguments proposed in the literature citing clinical evidence supporting the early LDL treatment hypothesis: (1), lower risk patients get relatively more primary prevention benefit from statins than higher risk patients, (2), statins demonstrate a legacy effect with prolonged risk reduction even after stopping treatment, and (3), genetic studies illustrate the benefit of lifelong LDL reduction for lowering CV risk. A review of the primary evidence found little clinical evidence supporting the first two arguments, but strong grade B+ evidence for the third. However, we found no evidence for or against whether intervening before 10-year risk exceeds 7.5-12.5% would result in substantial incremental net clinical benefit. If early intervention is practiced, evidence to date suggests that overall CV risk should be the primary indication.

Conclusions We found consistent grade B+ evidence that the effectiveness of LDL reduction on risk reduction will increase over time, however, we found no clinical evidence for or against whether starting before 10-year CV risk is 7.5–12.5% provides substantive additional net patient benefit, and grade A- evidence that elevated age-adjusted CV risk should be the primary indication for early treatment, but found no evidence for or against whether degree of LDL elevation should be a secondary factor. Additional clinical research is needed, especially with regard the long-term safety of statins and how long it takes for LDL reduction to reach full effectiveness.

  • CARDIOLOGY

Acknowledgments

The authors thank Elyse N Reamer, BS, University of Michigan, assisted with reference collection.

Statistics from Altmetric.com

Extract

Background The American College of Cardiology/American Heart Association updated cholesterol treatment guidelines dropped treatment recommendations based on elevated low-density lipoprotein (LDL) levels. Yet some experts cite the benefit of early statins in patients with elevated LDL for preventing atherosclerosis. We sought clinical evidence for this early LDL treatment hypothesis.

Methods and results A review of the clinical evidence examining the relationship between LDL reduction and outcomes (excluding LDL >190). We found three arguments proposed in the literature citing clinical evidence supporting the early LDL treatment hypothesis: (1), lower risk patients get relatively more primary prevention benefit from statins than higher risk patients, (2), statins demonstrate a legacy effect with prolonged risk reduction even after stopping treatment, and (3), genetic studies illustrate the benefit of lifelong LDL reduction for lowering CV risk. A review of the primary evidence found little clinical evidence supporting the first two arguments, but strong grade B+ evidence for the third. However, we found no evidence for or against whether intervening before 10-year risk exceeds 7.5-12.5% would result in substantial incremental net clinical benefit. If early intervention is practiced, evidence to date suggests that overall CV risk should be the primary indication.

Conclusions We found consistent grade B+ evidence that the effectiveness of LDL reduction on risk reduction will increase over time, however, we found no clinical evidence for or against whether starting before 10-year CV risk is 7.5–12.5% provides substantive additional net patient benefit, and grade A- evidence that elevated age-adjusted CV risk should be the primary indication for early treatment, but found no evidence for or against whether degree of LDL elevation should be a secondary factor. Additional clinical research is needed, especially with regard the long-term safety of statins and how long it takes for LDL reduction to reach full effectiveness.

Acknowledgments

The authors thank Elyse N Reamer, BS, University of Michigan, assisted with reference collection.

View Full Text

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles