Treating to goal: new strategies for initiating and optimizing lipid-lowering therapy in patients with atherosclerosis

Abstract

The National Cholesterol Education Program (NCEP) guidelines prepared by the Adult Treatment Panel (ATP) provide clinicians with recommendations for the clinical management of abnormal blood cholesterol to reduce the risk of cardiovascular events. The recently updated NCEP guidelines have included a number of key amendments such as the recognition of low high-density lipoprotein cholesterol (HDL-C) as a risk factor for cardiovascular disease, while maintaining the focus of treatment on lowering low-density lipoprotein cholesterol (LDL-C) levels. Several agents can be used to modify the lipid profile in-line with the NCEP ATP-III recommendations, but hydroxymethyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) remain the most effective and best-tolerated drugs for lowering LDL-C. The optimal time to initiate drug therapy had been in question, although recent studies suggest in-hospital initiation following admission with cardiovascular disease reduces the risk of recurrent events and improves long-term patient compliance. Inpatient physicians and nurses therefore play a pivotal role in influencing not only short-term management needs, but also the long-term recovery of their patients. This role should not be underestimated, as recent surveys have highlighted a significant problem of undertreatment in patients with documented atherosclerosis with regards to lipid-lowering and other cardioprotective therapy. Although reversing patient under-treatment will require clinicians to address a variety of issues, systematic in-hospital initiation of currently available lipid-lowering therapies in patients with atherosclerotic vascular disease is likely to have major benefits, reducing the occurrence of cardiovascular events and saving lives. Several statins, cholesterol absorption inhibitors, novel metabolic inhibitors, and combinations of agents are currently in clinical development and it is hoped that these will also assist clinicians in the important task of getting patients to recommended LDL-C and HDL-C levels.