What are the Canadian goals of therapy for hyperlipidemia?

Canadian Goals of Therapy for Hyperlipidemia

The Canadian Cardiovascular Society recommends an optimal LDL-C level of ≤2.0 mmol/L (approximately 77 mg/dL) as the primary treatment target, with non-HDL-C ≤2.6 mmol/L and apolipoprotein B ≤80 mg/dL as alternative targets supported by strong evidence. 1

Primary Treatment Target

• LDL-C remains the primary goal of therapy at ≤2.0 mmol/L 1
• This target is more aggressive than the U.S. NCEP ATP III goal of <100 mg/dL (2.6 mmol/L) for high-risk patients 1
• The Canadian guidelines use the GRADE system to evaluate evidence strength and quality 1

Alternative Treatment Targets

The Canadian approach uniquely recognizes alternative lipid markers with strong evidence:

• Non-HDL-C ≤2.6 mmol/L (strong recommendation, high-quality evidence) 1
• Apolipoprotein B ≤80 mg/dL (strong recommendation, high-quality evidence) 1
• These alternatives are particularly useful when triglycerides are elevated ≥200 mg/dL 1

Risk Stratification Approach

The Canadian guidelines stratify treatment intensity based on cardiovascular risk:

• Use the Framingham Risk Score (FRS) to estimate 10-year total ASCVD risk 1
• Double the FRS if family history of premature ASCVD exists in first-degree relatives (modified FRS) 1
• Patients are categorized as low-risk, intermediate-risk (FRS 5-19%), or high-risk 1

Secondary Risk Assessment

For intermediate-risk patients (FRS 5-19%), consider additional testing:

• Lipoprotein(a) levels 1
• High-sensitivity C-reactive protein 1
• Coronary calcium scoring 1
• Ankle-brachial index 1

Treatment Implementation

Statins are first-line pharmacological therapy for LDL-C lowering 1

The treatment algorithm follows this sequence:

1. Initiate lifestyle modifications (dietary changes focusing on saturated fat and cholesterol reduction, increased physical activity, weight loss) 1
2. Add statin therapy if lifestyle modifications fail to achieve targets 1
3. Consider combination therapy with fibrates for patients with low HDL (<40 mg/dL or 1.15 mmol/L) and triglycerides 150-500 mg/dL 1
4. Niacin can be added for HDL raising, though it may modestly affect glucose control at doses of 750-2000 mg/day 1

HDL and Triglyceride Goals

While LDL-C is primary, secondary targets include:

• Triglycerides <150 mg/dL (1.7 mmol/L) 1
• HDL cholesterol >40 mg/dL (1.15 mmol/L) 1
• For women, an HDL goal 10 mg/dL higher may be appropriate 1

Common Pitfalls

Real-world data from Alberta shows significant treatment gaps: only 65.9% of ASCVD patients receive lipid-lowering therapy, and among treated patients, 36.6% fail to achieve LDL-C <2.0 mmol/L or 50% reduction 2. This underscores the need for:

• Regular lipid monitoring (at least annually for high-risk patients) 1
• Aggressive titration of statin doses to achieve targets 2
• Consideration of combination therapy when monotherapy fails 1

Special Considerations

For patients with established cardiovascular disease or diabetes, these conditions are considered CHD risk equivalents requiring the most aggressive LDL-C lowering to <100 mg/dL (2.6 mmol/L) or the Canadian target of ≤2.0 mmol/L 1

When combining fibrates with statins, fenofibrate is preferred as it does not interfere with statin catabolism, minimizing myopathy risk 1