Chapter 32: Dyslipidemia

Update Summary

July, 2023

The following sections, tables, and figures were updated:

• The chapter has been revised in several sections to reflect the results of the CLEAR-OUTCOMES study, which provides evidence regarding the potential role of bempedoic acid in the prevention of cardiovascular events. Revisions include updates to the following sections:

  • General Approach to Treatment

  • Table 32-3 Select Landmark Clinical Trials

  • Adenosine Triphosphate-Citrate Lyase Inhibitors

• A new paragraph was added to the “Dietary Supplements” section reflecting the results of the SPORT trial which compared rosuvastatin to six commonly used dietary supplements.

• Updates were made throughout the chapter to change PCSK9 inhibitors to the preferred terminology PCSK9 monoclonal antibody (PCSK9 mAb), including Figure 32-7.

• Revisions are done to Figure 32-8 clarifying the approach to treatment of hypertriglyceridemia.

• Information is added about the nocebo effect and how to mitigate it in the “HMG-CoA Reductase Inhibitors” (Statins) section.

• The REPRIEVE study provides new evidence regarding the benefits of statin therapy in patients with human immunodeficiency virus (HIV) infection; updates were made to the “Patients with Chronic Inflammatory Disorders and HIV” section.

KEY CONCEPTS

• Lipid abnormalities increase the risk of atherosclerotic cardiovascular disease (ASCVD), which includes ischemic coronary heart disease, ischemic stroke, and peripheral arterial disease.

• Low-density-lipoprotein cholesterol (LDL-C) is the primary target to reduce the risk of ASCVD events.

• Genetic abnormalities and environmental factors are involved in the development of dyslipidemia.

• Therapeutic lifestyle change is the first-line therapy for any lipoprotein disorder.

• If therapeutic lifestyle changes are insufficient, lipid-lowering agents should be chosen based on which lipid is at an undesirable level and the degree to which it is expected to increase the risk of ASCVD.

• Statins are the drug of choice for dyslipidemia because they significantly lower LDL-C and the risk of ASCVD events and are generally well tolerated.

• If statin monotherapy is insufficient, patients may be treated with evidence-based combination therapy but should be monitored closely for drug-drug interactions.

• Reducing total cholesterol and LDL-C reduces CHD and total mortality.

• Lipid-lowering therapies that reduce ASCVD event rates are cost-effective.

• Several novel medications, including antisense oligonucleotide inhibitors of apoB, microsomal triglyceride transport protein inhibitors, adenosine triphosphate-citrate lyase (ACL) inhibitors, and proprotein convertase subtilisin/kexin type 9 (PCSK9) modulating therapies, can be used as add-on therapy or in lieu of statin therapy in select high-risk patients.

BEYOND THE BOOK

Watch these YouTube videos to learn about cholesterol basics as well as the physiology of lipoprotein cholesterol and metabolism:

• Cholesterol Good and Bad (https://tinyurl.com/yx6a5ufj) by the US National Library of Medicine

• Physiology of Lipoprotein Cholesterol (https://tinyurl.com/hcy239y) by Armando Hasudungan

• Physiology of Lipoprotein Metabolism (https://tinyurl.com/pwo856o) by National ...