From the Guidelines
Statins are the first-line agent in the treatment of hyperlipidemia (elevated lipid levels).
Key Points
- The primary goal of treatment is to lower LDL-C levels, with a target of <1.4 mmol/L (55 mg/dL) or a reduction of at least 50% from baseline in patients with established ASCVD 1.
- Statin therapy is recommended as the first-choice lipid-lowering treatment in patients with high LDL-C levels, regardless of their cardiovascular risk profile 1.
- High-intensity statin treatment, such as atorvastatin ≥40 mg or rosuvastatin ≥20 mg daily, reduces LDL-C levels by 45%–50% on average 1.
- Ezetimibe should be used as second-line therapy when the treatment goal is not achieved with maximally tolerated statin therapy, or as first-line therapy in the case of intolerance to any statin regimen 1.
- In patients at very high CV risk, with persistent high LDL-C despite treatment with maximal tolerated statin dose, in combination with ezetimibe, or in patients with statin intolerance, a PCSK9 inhibitor is recommended 1.
Rationale
The use of statins as first-line therapy is supported by numerous studies, including a landmark meta-analysis involving patients with and without ASCVD, which showed that statin treatment reduces the risk of major vascular events by 22%, all-cause mortality by 10%, and mortality due to coronary heart disease by 20% per 1.0 mmol/L of achieved reduction in LDL-C levels 1. Additionally, the 2019 ESC/EAS Guidelines for the management of dyslipidaemias and the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice recommend statin therapy as the first-line treatment for patients with elevated lipid levels 1.
From the Research
First-Line Treatment for Hyperlipidemia
The first-line agent in the treatment of hyperlipidemia is statins, which decrease low-density lipoprotein cholesterol (LDL-C) by 30-50% and proportionally reduce cardiovascular events 2. Statins are the mainstay treatment for hyperlipidemia and are recommended as the first-line treatment for primary prevention in patients with high risk of cardiovascular disease 3, 4.
Key Points
- Statins are the first-line option for the management of hypercholesterolemia in a large percentage of patients 4.
- Statins should be given at the appropriate dose and considering the differences in lipid-lowering potency across the different medications 4.
- High-intensity statin therapy is recommended as the first-line treatment in secondary prevention to achieve less than 70 mg/dL of LDL-C levels 3.
- The addition of ezetimibe is recommended if LDL-C levels remain elevated with maximal statins 3, 5.
Treatment Approach
The approach to determining the appropriate treatment options has undergone important changes, with guidelines recommending treatment decisions based on the intensity of response associated with various statins 6. The basis of treating hyperlipidemia remains diet, physical exercise, and weight reduction, with statins as the first-line drug treatment 5.