A Synopsis of AFP's "Pharmacologic Treatment of Hyperlipidemia "

Pharmacologic Treatment of Hyperlipidemia 
ALLEN R. LAST, MD, MPH, University of Wisconsin Fox Valley Family Medicine Residency Program, Appleton, Wisconsin, JONATHAN D. FERENCE, PharmD, Wilkes University Nesbitt College of Pharmacy and Nursing, Wilkes-Barre, Pennsylvania, JULIANNE FALLERONI, DO, MPH, University of Wisconsin Fox Valley Family Medicine Residency Program, Appleton, Wisconsin
http://www.aafp.org/afp/2011/0901/p551.pdf
Am Fam Physician. 2011 Sep 1;84(5):551-558.

     Hyperlipidemia is seen in over half of all patients with cardiovascular disease. Lowering cholesterol is an important part of primary and secondary prevention in CVD patients. LDL is the primary target of cholesterol lowering therapy.  The "treat-to-target approach" (ATP III) uses the risk factors to determine the LDL goal. A "fixed-dose approach" uses risk factors to determine treatment with the same treatment goal. Neither approach was proven to be better, but the ATP III guidelines, which have a more aggressive strategy for higher risk patients, is more commonly followed. 
    Primary prevention is treating patients before the disease occurs (in this case, before an MI). Statins are the most widely used medication and the most commonly prescribed for hyperlipidemia. The results are conflicting and can be skewed (see the JUPITER study). Regardless, statins are the treatment of choice for primary prevention of cardiovascular events as well as in patients with a history of CVD and acute coronary syndrome.
     Low HDL levels and high triglycerides are other lipid abnormalities. Fibrates have been shown to normalize these values. The have not, however, shown a mortality benefit, and may increase risk. Niacin can raise HDL levels, but has not shown to reduce mortality in primary prevention. Bile acid-binding resins may reduce LDL levels, but not all-cause mortality. Omega 3 fatty acids have poor results as well. 
     Secondary prevention is defined as treating patients to halt or slow disease progression. Statins are recommended in all patients with a history of CVD or CVD equivalent, regardless of of cholesterol levels. Lower doses of statins should be used in patients with CVD and higher doses reserved for patients with ACS. Fibrates reduced the risk of subsequent coronary events, but it does not reduce overall mortality. Niacin does not reduce overall mortality risk, but may improve disease-oriented outcomes when combined with a statin. Bile acid binders and omega 3's do not help either. 
    In cerebrovascular disease, statins can reduce the risk of recurrent strokes, but will not reduce all cause mortality. It will cause a small increase in hemorrhagic stroke. Statins will not reduce mortality in patients with peripheral arterial disease, but it will increase the patients maximal walking distance.