Abstract
Since 2014, guidelines for the management of lipid disorders to reduce cardiovascular
(CV) events have been updated in the United States, the United Kingdom, Europe, and
Canada. Some of these guidelines are almost entirely evidence-based whereas others
are a mix of evidence and expert opinion. Guidelines differ on such simple questions
as to whether blood samples should be fasting or nonfasting, and whether low-density
lipoprotein cholesterol (LDL-C) or another lipid parameter should be the primary focus
of treatment. Different risk assessment tools are recommended by different guidelines.
Lifetime risk is highlighted in some guidelines, with the suggestion that earlier
treatment will reduce lifetime risk in younger people even when short-term risk is
low. Some guidelines have numerical treatment targets that differ according to level
of risk, while others eschew targets but recommend statins at high or moderate intensity
to reduce LDL-C by ≥ 50% or 30%-50%, respectively. Statins are the backbone of therapy
in all guidelines. Ezetimibe produced a 6.4% relative risk reduction in the only large
clinical outcomes trial in which it was tested, and is recommended for high-risk patients
with an inadequate response to statins, despite the high number needed to treat to
prevent 1 CV event. Proprotein convertase subtilisin/kexin 9 inhibitors lack outcome
data to support their use, but are approved for patients with familial hypercholesterolemia
or clinical atherosclerotic CV disease who require additional LDL-C lowering beyond
statins. All these new guidelines are aimed at improving the problem of undertreatment
of high-risk groups, leading to better outcomes for these patients.
Résumé
Depuis 2014, les États-Unis, le Royaume-Uni, l’Europe et le Canada ont procédé à l’actualisation
des lignes directrices sur la prise en charge des anomalies lipidiques pour réduire
les événements cardiovasculaires (CV). Certaines de ces lignes directrices sont presque
entièrement fondées sur les données probantes, tandis que les autres constituent une
combinaison de données probantes et d’opinions d’experts. Les lignes directrices diffèrent
sur de simples questions quant à savoir si les échantillons de sang devraient être
prélevés à jeun ou non à jeun, et si l’objectif principal du traitement devrait porter
sur le cholestérol à lipoprotéines de faible densité (cholestérol LDL) ou sur un autre
paramètre du bilan lipidique. Les diverses lignes directrices recommandent différents
outils d’évaluation des risques. Certaines lignes directrices mettent en relief les
risques à vie, et suggèrent qu’un traitement plus précoce les réduira chez les personnes
plus jeunes même lorsque les risques à court terme sont faibles. Certaines lignes
directrices ont des cibles numériques de traitement qui diffèrent selon le niveau
de risque, tandis que d’autres évitent les cibles, mais recommandent un traitement
par statines d’intensité élevée ou modérée pour réduire respectivement le cholestérol
LDL de ≥ 50 % ou de 30 % à 50 %. Les statines sont le pilier de traitement de toutes
les lignes directrices. L’ézétimibe entraînait une réduction du risque relatif de
6,4 % dans la seule grande étude sur les résultats cliniques au cours de laquelle
il était testé, et est recommandé chez les patients exposés à un risque élevé qui
ont une réponse inadéquate aux statines, en dépit du nombre élevé de sujets à traiter
pour empêcher 1 événement CV. Les inhibiteurs de la proprotéine convertase subtilisine/kexine
de type 9 manquent de données sur les résultats cliniques pour soutenir leur utilisation,
mais sont approuvés chez les patients atteints d’une hypercholestérolémie familiale
ou d’une maladie CV athérosclérotique clinique qui nécessitent un hypocholestérolémiant
pour abaisser le cholestérol LDL en plus des statines. Toutes ces nouvelles lignes
directrices visent l’amélioration du problème de l’insuffisance de traitement des
groupes exposés à un risque élevé afin d’entraîner de meilleurs résultats cliniques
chez ces patients.
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Article info
Publication history
Published online: October 24, 2016
Accepted:
October 13,
2016
Received:
September 13,
2016
Footnotes
See page 348 for disclosure information.
Identification
Copyright
© 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
