What is the diagnosis and treatment for pure hypercholesterolemia (elevated cholesterol levels)?

From the Guidelines

Pure hypercholesterolemia should be treated with lifestyle modifications and medication, with a primary goal of reducing LDL cholesterol levels to below 100 mg/dL for most patients, or below 70 mg/dL for those with established cardiovascular disease, as recommended by the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. The diagnosis of pure hypercholesterolemia involves measuring LDL cholesterol levels, which should be used as the primary lipid analysis for screening, risk estimation, diagnosis, and management 1.

Key Recommendations

• Patients should adopt a heart-healthy diet low in saturated fats and cholesterol, engage in regular physical activity (at least 150 minutes of moderate exercise weekly), maintain a healthy weight, and avoid smoking.
• First-line medication therapy is usually a statin such as atorvastatin (starting at 10-20mg daily) or rosuvastatin (starting at 5-10mg daily) 1.
• If LDL targets aren't achieved with statins alone, ezetimibe 10mg daily may be added.
• For severe cases or those with familial hypercholesterolemia, PCSK9 inhibitors like evolocumab or alirocumab may be necessary.

Rationale

Treatment of pure hypercholesterolemia is essential to reduce the risk of cardiovascular disease, as elevated LDL cholesterol promotes atherosclerosis by depositing in arterial walls, leading to plaque formation and increased risk of heart attacks and strokes if left untreated 1.

Monitoring and Follow-up

Regular monitoring of lipid levels and liver function is essential to ensure the effectiveness and safety of treatment.

Additional Considerations

Lipoprotein(a) levels should be measured in patients at high risk of cardiovascular disease, and targeted levels should be below 50 mg/dL, as recommended by the European Society of Cardiology (ESC) guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosis and Treatment of Pure Hypercholesterolemia

The diagnosis and treatment of pure hypercholesterolemia, also known as elevated cholesterol levels, involve a combination of lifestyle modifications and pharmacologic therapy.

• The first line of treatment for hypercholesterolemia is diet, with patients encouraged to make simple and stepwise changes in their diets to lower elevated cholesterol levels 2.
• General dietary guidelines from the American Heart Association (AHA) Step-One Diet include limiting the amount of total fat to less than 30% of total calories, decreasing cholesterol intake to less than 300 mg/day, and adjusting caloric intake to levels required to attain or maintain ideal body weight 2.
• Lifestyle modifications, including diet, weight reduction, and increased physical activity, can help achieve target cholesterol levels, with the goal of reducing total cholesterol to <200 mg/dL and LDL-C<100 mg/dL 3.
• Medical intervention, such as pharmacologic therapy, should be reserved for those patients who have not reached this goal after 3 months of non-pharmacological approach 3.
• Statins and ezetimibe are still the basis of cholesterol-lowering therapy, with PCSK9 inhibitors used in patients at very high cardiovascular risk if, despite the maximum tolerated statin/ezetimibe therapy, an LDL-C reduction of more than 50 % would be needed to achieve the recommended LDL-C target 4.
• Alternative treatments to statins, such as ezetimibe, PCSK9 inhibitors, and bempedoic acid, have shown an excellent safety profile and may be considered for patients who are unable to tolerate effective doses or any dose of statins 5.

Lifestyle Modifications

Lifestyle modifications play a crucial role in the management of hypercholesterolemia, including:

• Dietary measures, such as limiting total fat and cholesterol intake, and adjusting caloric intake to attain or maintain ideal body weight 2, 6.
• Aerobic exercise, which can help reduce cholesterol levels and improve overall cardiovascular health 6.
• Weight reduction, which can help achieve target cholesterol levels and reduce the risk of coronary heart disease 3.

Pharmacologic Therapy

Pharmacologic therapy, including statins, ezetimibe, and PCSK9 inhibitors, can further decrease cholesterol levels and reduce the risk of coronary heart disease.

• Statins are well established as the first-line treatment to reduce low-density-lipoprotein cholesterol (LDL-C) and cardiovascular (CV) events 5.
• PCSK9 inhibitors are a new and safe option for lowering LDL cholesterol, particularly in patients at very high cardiovascular risk 4.
• Alternative treatments to statins, such as ezetimibe and bempedoic acid, have shown an excellent safety profile and may be considered for patients who are unable to tolerate effective doses or any dose of statins 5.