Hypercholesterolaemia - practical information for non-specialists

Abstract

Hypercholesterolaemia is amongst the most common conditions encountered in the medical profession. It remains one of the key modifiable cardiovascular risk factors and there have been recent advances in the risk stratification methods and treatment options available. In this review, we provide a background into hypercholesterolaemia for non-specialists and consider the merits of the different risk assessment tools available. We also provide detailed considerations as to: i) when to start treatment, ii) what targets to aim for and iii) the role of low density lipoprotein cholesterol.

Keywords: cardiovascualr risk; hypercholesterolaemia; lipid disorders; low density lipoprotein cholesterol; practical recommendations.

Figure 1

Lipoprotein metabolism ABCA1 – ATP-binding cassette transporter A1, HDL – high density lipoprotein, LDL – low density lipoprotein, TG – triglycerides, SRB1 – scavenger receptor class B type 1, VLDL – very low density lipoprotein.

Figure 2

Association between cardiovascular risk reduction and absolute reduction in low density lipoprotein cholesterol in major randomised control trials [67, 75, 81, 82, 85]. Adapted from Soran et al. [75] (where full list of additional individual trial references can be found). There is a consistent reduction in cardiovascular risk of about one-fifth for every 1 mmol/l (38 mg/dl) reduction in LDL-C CVD – cardiovascular disease, LDL-C – low density lipoprotein cholesterol. OSLER – Open Label Study of Long Term Evaluation Against LDL-C, GREACE – Greek Atorvastatin and Coronary Heart Disease Evaluation, ODYSSEY – Efficacy and Safety of Alirocumab in Reducing Lipids and Cardiovascular Events, FOURIER – Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk, TNT – Treating to New Targets, SHARP – Study of Heart and Renal Protection, PROVE-IT – Pravastatin or Atorvastatin Evaluation and Infection Therapy, IDEAL – Incremental Decrease in End Points Through Aggressive Lipid Lowering, A–Z – Aggrasat-Zocar Phase, REVEAL – Randomized Evaluation of the Effects of Anacetrapib through Lipid Modification, IMPROVE – Improved Reduction of Outcomes: Vytorin Efficacy International Trial, SEARCH – Study of Effectiveness of Additional Reductions in Cholesterol and Homocysteine.

Figure 3

Summary of 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (modified according [57])

Figure 4

Summary of Joint British Societies’ guideline 3 (modified according [35])

Figure 5

Summary of European Atherosclerosis Society guideline 2016 (modified according [34])

Figure 6

Statins and their LDL cholesterol-lowering potency (Handrean Soran & Paul Durrington 2008)