Cholesterol Management and Risk Reduction - Current Guidelines and Barriers to Goal Attainment

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Asia Pacific Cardiology - Volume 2 Issue 1;2008:2(1):16-20

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Cardiovascular disease (CVD), a major cause of morbidity and mortality worldwide, is predicted to result in 20 million deaths by 2015.1–4 Coronary heart disease (CHD) is the most common clinical manifestation of CVD.5,6 A major, modifiable risk factor for CVD is hypercholesterolaemia, particularly elevated low-density lipoprotein cholesterol (LDL-C).7–13 Clinical trials with angiographic end-points have consistently shown that lowering cholesterol levels slows the progression of atherosclerotic lesions and reduces end-points such as myocardial infarction and sudden death.14–16
Various epidemiological studies have correlated the intake of specific types of fat with plasma cholesterol levels and, consequently, CHD incidence.17 However, intervention studies have shown that dietary modification can reduce cholesterol levels only by about 10%.18–20 Accordingly, the management of hypercholesterolaemia is often a step-wise approach incorporating lifestyle modification with eventual pharmacotherapy. Several drug classes are available for reducing plasma cholesterol levels, including early agents such as bile acid sequestrants, fibrates and nicotinic acid.21 These first-generation antilipid agents are associated with mild efficacy or poor tolerance as a result of adverse effects.22 The introduction of the statins represented a major advance in lipid-lowering therapy.23
The statins inhibit 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, which is responsible for mediating the feedback suppression of cholesterol biosynthesis,24 and have become the mainstay for the treatment of elevated plasma cholesterol levels because of their efficacy in reducing LDL-C, as well as their excellent tolerability and safety.23 The benefits of statin therapy have been established in several landmark clinical trials and include reduced morbidity and mortality from CHD, decreased progression of atherosclerosis, regression of atherosclerotic lesions and decreased coronary artery revascularisation.25–30 This article will review the current guidelines for cholesterol management and cardiovascular risk reduction. It will also focus on the treatment gap that exists between what the guidelines recommend and what is actually seen in clinical practice, and will discuss the barriers responsible for this gap.

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