Lipid-lowering treatment for secondary prevention

NICE states with respect to secondary prevention (1):

• lipid-modification therapy should be offered and should not be delayed by management of modifiable risk factors. Blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include:
  • smoking status
  • alcohol consumption
  • blood pressure
  • body mass index or other measure of obesity
  • fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available)
  • fasting blood glucose
  • renal function
  • liver function (transaminases)
  • thyroid-stimulating hormone (TSH) if dyslipidaemia is present
• if a person has acute coronary syndrome, statin treatment should not be delayed until lipid levels are available. A fasting lipid sample should be taken about 3 months after the start of treatment

The landmark trials regarding the use of statins in secondary prevention are the 4S (Scandinavian Simvastatin Survival Study), the CARE (Cholesterol And Recurrent Events) trial and the LIPID (Long-term Intervention with Pravastatin in Ischaemic Heart Disease).

• these trials revealed that reduction of total serum cholesterol and low-density lipoprotein (LDL) cholesterol in the region of 25-35% using statin therapy led to a reduction in coronary heart disease (CHD) mortality by approximately the same degree
• the trial evidence was that patients with unstable angina benefited to the same degree as to those post-myocardial infarction

NICE suggests (1):

• start statin treatment in people with CVD with atorvastatin 80 mg. Use a lower dose of atorvastatin if any of the following apply:
  • potential drug interactions
  • high risk of adverse effects
  • patient preference
• Target
  • for secondary prevention of CVD, aim for low-density lipoprotein (LDL) cholesterol levels of 2.0 mmol per litre or less, or non-HDL cholesterol levels of 2.6 mmol per litre or less

Notes:

• do not offer nicotinic acid analogues, bile sequestrants or omega-3 fatty acid preparations for secondary prevention of CVD
• do not routinely use fibrates for secondary prevention of CVD
• combination therapy for preventing CVD
  • do not offer the combination of a bile acid sequestrant (anion exchange resin), fibrate, nicotinic acid or omega-3 fatty acid compound with a statin for the primary or secondary prevention of CVD
• ezetimibe for secondary prevention
  • people with primary hypercholesterolaemia should be considered for ezetimibe treatment in line with NICE guidance - see linked item

Reference:

1. NICE (December 2023). Lipid modification - Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease.