What is the primary goal of therapy in a patient with hyperlipidemia?

From the Guidelines

The primary goal of therapy in a patient with hyperlipidemia is to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) by lowering lipid levels, particularly low-density lipoprotein cholesterol (LDL-C), with a recommended LDL-C goal of < 1.8 mmol/L (70 mg/dL) or a reduction of at least 50% if the baseline LDL-C is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL) for patients at very high CV risk, as stated in the 2016 ESC/EAS guidelines 1. The treatment approach typically begins with lifestyle modifications, including a heart-healthy diet, regular physical activity, weight management, smoking cessation, and limited alcohol consumption.

• Key lifestyle modifications include:
  • A diet low in saturated fats
  • Regular physical activity
  • Weight management
  • Smoking cessation
  • Limited alcohol consumption If lifestyle changes are insufficient, medication therapy is indicated, with statins being the first-line pharmacological treatment, as recommended by the 2024 International Lipid Expert Panel (ILEP) position paper 1.
• Common statins include:
  • Atorvastatin (10-80 mg daily)
  • Rosuvastatin (5-40 mg daily)
  • Simvastatin (10-40 mg daily) For patients who cannot tolerate statins or who need additional LDL-C lowering, ezetimibe (10 mg daily), PCSK9 inhibitors (evolocumab or alirocumab), or bile acid sequestrants may be added, as suggested by the 2024 ILEP position paper 1. Treatment intensity should be tailored to the patient's ASCVD risk, with more aggressive therapy for those with established cardiovascular disease or multiple risk factors, as emphasized in the 2016 ESC/EAS guidelines 1 and the 2024 ILEP position paper 1. Regular monitoring of lipid levels and potential medication side effects is essential to ensure the effectiveness and safety of the treatment, as recommended by the 2007 American Heart Association and American Diabetes Association scientific statement 1. Lowering LDL-C is emphasized because it directly contributes to plaque formation in arteries, and reducing these levels has been consistently shown to decrease cardiovascular events and mortality, as stated in the 2024 ILEP position paper 1.

From the FDA Drug Label

Ezetimibe Tablet reduces total-C, LDL-C, Apo B, and non-HDL-C in patients with hyperlipidemia. The primary goal of therapy in a patient with hyperlipidemia is to reduce total-C, LDL-C, Apo B, and non-HDL-C.

• The goal is to achieve maximal to near maximal response, which is generally achieved within 2 weeks and maintained during chronic therapy.
• This is based on the clinical studies that showed ezetimibe tablet significantly lowered total-C, LDL-C, Apo B, and non-HDL-C compared to placebo 2.

From the Research

Primary Goal of Therapy in Hyperlipidemia

The primary goal of therapy in a patient with hyperlipidemia is to reduce the risk of cardiovascular events by managing lipid levels.

• Lowering low-density lipoprotein cholesterol (LDL-C) levels with statins remains the primary goal of therapy, as stated in the study 3.
• For secondary prevention patients, those with coronary heart disease (CHD) or CHD risk equivalents, intensive LDL-C lowering is recommended 3.
• However, some studies suggest that LDL particle number (LDL-P) should be considered a primary goal of therapy due to its stronger association with cardiovascular risk, especially in high cardiometabolic risk patients 4.

Treatment Approaches

Different treatment approaches may be used to achieve the primary goal of therapy, including:

• Statin monotherapy, which may not be sufficient for high-risk patients 3.
• Combination therapy with other agents, such as fibrates, niacin, or long-chain omega-3 fatty acids, which may be effective in reducing triglyceride levels and cardiovascular risk 5.
• Novel medications, such as PCSK9 inhibitors, which can lower LDL-C levels by 50%-60% above that achieved by statin therapy alone 6.

Importance of Goal Attainment

Achieving treatment goals for lipid-lowering is crucial in reducing the risk of cardiovascular events, as failure to reach treatment goals translates into a higher risk of cardiovascular events 7.