JCL roundtable: Lipid treatment targets.

This Roundtable discussion concerns atherogenic risk markers and treatment targets used by clinical lipidologists in daily practice. Our purpose is to understand the risk marker framework that supports and enables the new ACC/AHA/Multisociety Cholesterol Guidelines. Some biomarkers are highly associated with atherogenic risk but fail to qualify as treatment targets. Prominent examples are high-density lipoprotein cholesterol, for which targeted treatment has failed to reduce cardiovascular risk, and lipoprotein(a), which currently lacks a highly effective mode of treatment. As a consequence, guidelines have focused consistently on low-density lipoprotein cholesterol (LDL-C) and more recently on non-high-density lipoprotein cholesterol. We discuss a new calculation for LDL-C that shows greater accuracy than the commonly performed Friedewald calculation. LDL-C treatment goals have renewed prominence in the 2018 Guidelines. Thresholds for treatment initiation or intensification inherently establish goals of reducing atherogenic cholesterol levels below the thresholds. Treatment goals may be absolute, such as less than 70 mg/dL for LDL-C in very high-risk secondary prevention or relative, such as 50% or greater reduction of LDL-C. The timeframe of treatment is another consideration because milder treatment started earlier may sometimes be preferred over stronger treatment given late in the course of atherosclerotic progression. Advanced lipid testing and vascular imaging, particularly coronary artery calcium, also have their place in risk assessment to guide clinical lipid practice.

Hypertriglyceridemia: A review of the evidence.

Elevated triglycerides are independently associated with increased atherosclerotic cardiovascular disease risk. Hypertriglyceridemia is often a polygenic condition that can be affected by numerous interventions. Primary care NPs are well positioned to appropriately evaluate and manage hypertriglyceridemia, improving overall health outcomes.

Relationship among low cholesterol levels, depressive symptoms, aggression, hostility, and cynicism.

BACKGROUND: Treatment guidelines for lipids have become increasingly more aggressive. However, naturally low or therapeutically reduced cholesterol levels may be associated with adverse psychological health symptoms, including depression, aggression, and hostility. OBJECTIVE: To examine relationships between low total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol levels and measures of psychosocial status among middle-aged adults. METHODS: A total of 1995 subjects enrolled in the Heart Strategies Concentrating on Risk Evaluation study with data on TC, LDL cholesterol, and self-reported ratings of psychological health were evaluated. To quantify ratings of depression, aggression, cynicism, and hostility, psychological measures included the Center for Epidemiologic Studies Depression Scale (CES-D) and Cook-Medley Hostility Inventory. RESULTS: Of 1995 participants, 25.1% were taking a lipid-lowering agent at baseline. Mean CES-D scores were similar between participants with low (<150 mg/dL) versus greater (≥150 mg/dL) TC and low (<100 mg/dL) versus higher (≥100 mg/dL) LDL cholesterol. However, among 22 participants with LDL cholesterol <70 mg/dL, the prevalence of clinically significant depressive symptomatology (CES-D score ≥16) was 31.8% compared with 12.1% in the remaining cohort (P = .005). In multivariable analysis, low LDL cholesterol (<100 mg/dL) was associated with cynicism (partial r = -0.14, P = .02) and hostility (partial r = -0.18, P = .004), but only in the subgroup of white subjects currently taking lipid-lowering medications. Low LDL cholesterol (versus non-low) was associated with greater aggression scores but only among participants currently taking psychiatric medications (3.4 ± 1.7 vs 2.8 ± 1.5, P = .02). CONCLUSIONS: Our data indicate mixed evidence for independent relationships between low total and LDL cholesterol levels and impaired psychological health.

Heterozygous familial hypercholesterolemia case study.

PURPOSE: To examine a case of heterozygous familial hypercholesterolemia (HeFH) in a primary care setting and to review the epidemiology, pathophysiology, etiology, and treatment guidelines to reduce the mortality related to this disease process. DATA SOURCES: Findings from the history, physical exam, and laboratory results of a young French Canadian male presenting to a primary care office. Evidence-based literature search included Ovid MEDLINE, PubMed, National Lipid Association, and e-medicine website. CONCLUSIONS: Familial hypercholesterolemia is a serious and common genetic disorder that results in premature atherosclerosis. Early screening, detection, and treatment are vital in order to reduce the associated morbidity and mortality. IMPLICATIONS FOR PRACTICE: Clinicians need to understand hypercholesterolemia and the atherogenic process. Physical exam and laboratory findings are key to the early identification and intervention for children and adults at risk for early cardiovascular disease.