Coronary heart disease secondary prevention lipid management

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

2011 AHA/ACCF Guidelines for Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease (DO NOT EDIT) [1]

Lipid Management (DO NOT EDIT) [1]

Goal: Treatment with statin therapy; use statin therapy to achieve an LDL-C of <100 mg/dL; for very high risk* patients an LDL-C <70 mg/dL is reasonable; if triglycerides are ≥200 mg/dL, non–HDL-C should be <130 mg/dL, whereas non–HDL-C <100 mg/dL for very high risk patients is reasonable.
Class I
"1. A lipid profile in all patients should be established, and for hospitalized patients, lipid-lowering therapy as recommended below should be initiated before discharge. [2] (Level of Evidence: B)"
"2. Lifestyle modifications including daily physical activity and weight management are strongly recommended for all patients. [3][4] (Level of Evidence: B)"
"3. Dietary therapy for all patients should include reduced intake of saturated fats (to <7% of total calories), transfatty acids (to <1% of total calories), and cholesterol (to <200 mg/d). [5][6][7][8][4] (Level of Evidence: B)"
"4. In addition to therapeutic lifestyle changes, statin therapy should be prescribed in the absence of contraindications or documented adverse effects. [9][10][11][12][4] (Level of Evidence: A)"
"5. An adequate dose of statin should be used that reduces LDL-C to <100 mg/dL AND achieves at least a 30% lowering of LDL-C. [9][10][11][12][4] (Level of Evidence: C)"
"6. Patients who have triglycerides ≥200 mg/dL should be treated with statins to lower non–HDL-C to <130 mg/dL. [9][10][11][13] (Level of Evidence: B)"
"7. Patients who have triglycerides >500 mg/dL should be started on fibrate therapy in addition to statin therapy to prevent acute pancreatitis. (Level of Evidence: C)"
Class IIa
"1. If treatment with a statin (including trials of higher-dose statins and higher-potency statins does not achieve the goal selected for a patient, intensification of LDL-C-lowering drug therapy with a bile acid sequestrant‡ or niacin§ is reasonable. [14][15][16] (Level of Evidence: B)"
"2. For patients who do not tolerate statins, LDL-C–lowering therapy with bile acid sequestrants‡ and/or niacin§ is reasonable. [17][18] (Level of Evidence: B)"
"3. It is reasonable to treat very high-risk* patients with statin therapy to lower LDL-C to <70 mg/dL. [10][11][12][19][20][19] (Level of Evidence: C)"
"4. In patients who are at very high risk* and who have triglycerides ≥200 mg/dL, a non–HDL-C goal of <100 mg/dL is reasonable. [9][10][11][13] (Level of Evidence: B)"
Class IIb
"1. The use of ezetimibe may be considered for patients who do not tolerate or achieve target LDL-C with statins, bile acid sequestrants‡ , and/or niacin§. (Level of Evidence:C) "
"2. For patients who continue to have an elevated non–HDL-C while on adequate statin therapy , niacin§ or fibrate∥ therapy [15][21] (Level of Evidence:B) or fish oil (Level of Evidence:C) may be reasonable. "
"3. For all patients, it may be reasonable to recommend omega-3 fatty acids from fish¶ or fish oil capsules (1 g/d) for cardiovascular disease risk reduction. [22][23][24] (Level of Evidence:B) "
* Presence of established CVD plus (1) multiple major risk factors (especially diabetes), (2) severe and poorly controlled risk factors (especially continued cigarette smoking), (3) multiple risk factors of the metabolic syndrome (especially high triglycerides ≥200 mg/dL plus non–HDL-C ≥130 mg/dL with low HDL-C <40 mg/dL), and (4) patients with ACSs.
† Non–HDL-C is equal to total cholesterol minus HDL-C.
‡ The use of bile acid sequestrants is relatively contraindicated when triglycerides are ≥200 mg/dL and is contraindicated when triglycerides are ≥500 mg/dL.
§ Dietary supplement niacin must not be used as a substitute for prescription niacin.
∥ The combination of high-dose statin plus fibrate (especially gemfibrozil) can increase risk for severe myopathy. Statin doses should be kept relatively low with this combination.
¶ Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.


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