What is the non-HDL (non-high-density lipoprotein) cholesterol treatment threshold and how do QRISK (Quantitative Risk Assessment) or ADVASC (Atherosclerotic Cardiovascular Disease) scores guide treatment decisions?

From the Guidelines

The non-HDL cholesterol treatment threshold is 30 mg/dL higher than the corresponding LDL-C target, and QRISK or ADVASC scores guide treatment decisions by estimating a person's 10-year risk of developing cardiovascular disease. For individuals with high cardiovascular risk, the target non-HDL level is typically <100 mg/dL, which is 30 mg/dL higher than the LDL-C target of <70 mg/dL 1. The QRISK and ADVASC scores are used to estimate a person's 10-year risk of developing cardiovascular disease, with scores above 10% or 7.5% indicating high risk and guiding treatment decisions towards statin therapy 1. Some key points to consider when determining treatment thresholds include:

• Non-HDL cholesterol is a secondary target for therapy when LDL-C goals have been achieved, especially in individuals with high triglyceride levels 1
• The target non-HDL-C level for each risk category is 30 mg/dL higher than the corresponding LDL-C target, representing the normal contribution of VLDL-C to the non-HDL-C concentration 1
• Measurement of non-HDL-C is particularly useful in individuals with high triglyceride levels and makes treatment of triglyceride disorders less confusing 1
• Non-HDL-C is an independent predictor of cardiovascular events 1 Treatment typically begins with moderate-intensity statins, and for very high-risk patients, high-intensity statins are recommended, with additional therapies considered if target levels are not reached 1. Risk assessment should be repeated regularly to guide ongoing treatment decisions. Non-HDL cholesterol is preferred over LDL as it captures all atherogenic lipoproteins, providing a more comprehensive assessment of cardiovascular risk 1.

From the Research

Non-HDL Cholesterol Treatment Threshold

• The treatment threshold for non-HDL cholesterol is not strictly defined, but studies suggest that it should be considered in conjunction with absolute cardiovascular risk and LDL cholesterol reduction achievable with statin treatment 2.
• Non-HDL cholesterol is calculated as total cholesterol minus HDL cholesterol and is considered a reliable goal for dyslipidemia management, as it encompasses all plasma lipoproteins except HDL 3.
• A study found that non-HDL cholesterol is an independent risk factor for cardiovascular disease and can identify residual risk of atherosclerotic cardiovascular disease in patients with well-controlled LDL cholesterol 4.

Role of QRISK and ADVASC Scores

• QRISK and ADVASC scores are used to estimate the absolute risk of cardiovascular disease, but there is limited evidence on their specific role in determining treatment thresholds for non-HDL cholesterol.
• However, studies suggest that these scores can be used in conjunction with non-HDL cholesterol levels to guide treatment decisions, as they provide a more comprehensive assessment of cardiovascular risk 2, 3.
• For example, a study found that non-HDL cholesterol can be used to identify patients at high residual risk of cardiovascular events, even if they have well-controlled LDL cholesterol, and that this information can be used to inform treatment decisions 4.

Treatment Decisions

• Treatment decisions for non-HDL cholesterol should be based on a comprehensive assessment of cardiovascular risk, including absolute risk, LDL cholesterol reduction achievable with statin treatment, and non-HDL cholesterol levels 2, 3.
• Statin therapy is recommended for patients with high cardiovascular risk, and non-HDL cholesterol can be used as a secondary target to reduce residual cardiovascular risk 5, 4.
• Delaying statin therapy can increase the risk of cardiovascular events, and timely lipid-lowering is important for high-risk patient populations, such as those with diabetes 6.