Practice Guidelines for the Management of LDL-Related Risk
Managing risk related to low-density lipoprotein (LDL) is vital in therapy for patients at risk for atherosclerotic cardiovascular disease (ASCVD) events given its important etiologic role in atherogenesis. Despite decades of research showing reduction of ASCVD risk with multiple approaches to lowering of LDL cholesterol, there continue to be significant gaps in care with inadequate numbers of patients receiving standard of care lipid-lowering therapy. Confusion regarding implementation of the multiple published clinical practice guidelines has been identified as one contributor to suboptimal management of LDL-related risk. This review summarizes the current guidelines for reduction of LDL-related cardiovascular risk provided by a number of major professional societies, which have broad applicability to diverse populations worldwide. Statements have varied in the process and methodology of development of recommendations, the grading system for level and strength of evidence, the inclusion or exclusion of expert opinion, the suggested ASCVD risk assessment tool, the lipoproteins recommended for risk assessment, and the lipoprotein targets of therapy. The similarities and differences among important guidelines in the United States and internationally are discussed, with recommendations for future strategies to improve consistency in approaches to LDL-related ASCVD risk and to reduce gaps in implementation of evidence-based therapies.
Low-density lipoprotein (LDL) plays a significant role in the promotion, development, and progression of vascular atherosclerosis through a pathway that involves endothelial cell dysfunction, lipid oxidation and accumulation, foam cell formation, and inflammatory responses. Decades of clinical research have conclusively demonstrated that lowering of low-density lipoprotein cholesterol (LDL-C), whether by a low-saturated fat diet, partial ileal bypass surgery, or cholesterol-lowering medications, can significantly improve atherosclerotic cardiovascular disease (ASCVD) risk factors and reduce the risk of ASCVD events, including myocardial infarction, stroke, and coronary heart disease (CHD) death. Despite published clinical practice recommendations for the management of LDL-related cardiovascular risk, there are inadequate numbers of appropriate patients receiving standard of care lipid-lowering therapy. Numerous factors may contribute to gaps in care and confusion regarding implementation of appropriate guidelines for various patient populations may play a contributory role in suboptimal patient management.
In March 2013, the American College of Cardiology (ACC) Executive Committee approved a 3-year, multistakeholder quality initiative program, LDL: Address the Risk, to improve patient outcomes by increasing awareness of gaps in lipid management and the importance of managing LDL-related risk. One component of this program, the LDL: Address the Risk Think Tank, was convened on October 10, 2013, at the ACC's Heart House in Washington, DC. Participants in this conference included representatives of 17 medical specialty societies and other experts in cardiovascular disease risk reduction and lipidology. The purpose of this review is to summarize concerns regarding gaps in care related to implementation of the plethora and sometimes discordant clinical practice guidelines for the management of LDL-related risk, which were highlighted during the LDL: Address the Risk Think Tank. The discussion evaluates guidelines with broad applicability in large populations worldwide. We also highlight similarities and differences in the process and methodology for formulation of recommendations, the inclusion/exclusion of expert opinion and evidence from large randomized controlled trials (RCTs) and meta-analyses, the methodology for grading the strength and level of evidence, the recommended algorithms used for cardiovascular risk assessment, specific lipoprotein targets of therapy, and consideration of special patient populations.
Abstract and Introduction
Abstract
Managing risk related to low-density lipoprotein (LDL) is vital in therapy for patients at risk for atherosclerotic cardiovascular disease (ASCVD) events given its important etiologic role in atherogenesis. Despite decades of research showing reduction of ASCVD risk with multiple approaches to lowering of LDL cholesterol, there continue to be significant gaps in care with inadequate numbers of patients receiving standard of care lipid-lowering therapy. Confusion regarding implementation of the multiple published clinical practice guidelines has been identified as one contributor to suboptimal management of LDL-related risk. This review summarizes the current guidelines for reduction of LDL-related cardiovascular risk provided by a number of major professional societies, which have broad applicability to diverse populations worldwide. Statements have varied in the process and methodology of development of recommendations, the grading system for level and strength of evidence, the inclusion or exclusion of expert opinion, the suggested ASCVD risk assessment tool, the lipoproteins recommended for risk assessment, and the lipoprotein targets of therapy. The similarities and differences among important guidelines in the United States and internationally are discussed, with recommendations for future strategies to improve consistency in approaches to LDL-related ASCVD risk and to reduce gaps in implementation of evidence-based therapies.
Introduction
Low-density lipoprotein (LDL) plays a significant role in the promotion, development, and progression of vascular atherosclerosis through a pathway that involves endothelial cell dysfunction, lipid oxidation and accumulation, foam cell formation, and inflammatory responses. Decades of clinical research have conclusively demonstrated that lowering of low-density lipoprotein cholesterol (LDL-C), whether by a low-saturated fat diet, partial ileal bypass surgery, or cholesterol-lowering medications, can significantly improve atherosclerotic cardiovascular disease (ASCVD) risk factors and reduce the risk of ASCVD events, including myocardial infarction, stroke, and coronary heart disease (CHD) death. Despite published clinical practice recommendations for the management of LDL-related cardiovascular risk, there are inadequate numbers of appropriate patients receiving standard of care lipid-lowering therapy. Numerous factors may contribute to gaps in care and confusion regarding implementation of appropriate guidelines for various patient populations may play a contributory role in suboptimal patient management.
In March 2013, the American College of Cardiology (ACC) Executive Committee approved a 3-year, multistakeholder quality initiative program, LDL: Address the Risk, to improve patient outcomes by increasing awareness of gaps in lipid management and the importance of managing LDL-related risk. One component of this program, the LDL: Address the Risk Think Tank, was convened on October 10, 2013, at the ACC's Heart House in Washington, DC. Participants in this conference included representatives of 17 medical specialty societies and other experts in cardiovascular disease risk reduction and lipidology. The purpose of this review is to summarize concerns regarding gaps in care related to implementation of the plethora and sometimes discordant clinical practice guidelines for the management of LDL-related risk, which were highlighted during the LDL: Address the Risk Think Tank. The discussion evaluates guidelines with broad applicability in large populations worldwide. We also highlight similarities and differences in the process and methodology for formulation of recommendations, the inclusion/exclusion of expert opinion and evidence from large randomized controlled trials (RCTs) and meta-analyses, the methodology for grading the strength and level of evidence, the recommended algorithms used for cardiovascular risk assessment, specific lipoprotein targets of therapy, and consideration of special patient populations.
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