The National Lipid Association Issues New Recommendations for Patient-Centered Management of Cholesterol

The NLA expert panel’s consensus emphasizes that non-HDL-C is a better primary target for modification than LDL-C, and is now considered as a co-target with LDL-C.

The main conclusions of the NLA panel include:

1. An elevated level of cholesterol carried by circulating apolipoprotein (apo) B-containing lipoproteins (non–HDL-C and LDL-C, termed atherogenic cholesterol) is a root cause of atherosclerosis, the key underlying process contributing to most clinical arteriosclerotic cardiovascular disease (ASCVD) events.

2. Reducing elevated levels of these atherogenic cholesterol particles will lower ASCVD risk in proportion to the extent that atherogenic cholesterol is reduced. This benefit is presumed to be a result from atherogenic cholesterol lowering through multiple modalities, including lifestyle and drug therapies.

3. The intensity of risk-reduction therapy should generally be adjusted to the patient’s absolute risk for an ASCVD event.

4. Atherosclerosis is a process that often begins early in life and progresses for decades before resulting in a clinical ASCVD event. Therefore, both intermediate-term and long-term/lifetime risk should be considered when assessing the potential benefits and hazards of risk-reduction therapies.

5. For patients in whom lipid-lowering drug therapy is indicated, statin treatment is the primary modality for reducing ASCVD risk.

6. Non-lipid ASCVD risk factors should also be managed appropriately, particularly high blood pressure, cigarette smoking and diabetes mellitus.

Many approaches that safely lower blood cholesterol—including improved dietary and exercise habits and several medications—have been shown to reduce cardiovascular risk in higher-risk individuals. While statin medications in specific doses have the most supportive evidence, clinical judgment should be used to determine the best approach for each patient. Also, the panel recommends that consideration be given to use of combination therapy to statins with lipid-altering agents that further lower non-HDL-C and LDL-C to achieve goal levels of atherogenic cholesterol in high risk patients.