2013 ACC/AHA Lipid Guidelines: Mind the Gaps

The recently published 2013 ACC/AHA guidelines for the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk seem to have various implementation problems and have already initiated an intense debate. These guidelines identify 4 high-risk groups who could benefit from statins, patients with pre-existing atherosclerotic cardiovascular disease (CVD); people with familial (heterozygous) hypercholesterolemia, as evidenced by an LDL-cholesterol (LDL-C) of >190 mg/dl; diabetic patients aged 40-75; and people aged 40-75 with at least a 7.5% risk of developing CVD in the next decade, according to a formula described in the guidelines. In contrast to all other guidelines for the management of dyslipidemia, the 2013 ACC/AHA guidelines do not recommend specific LDL-C targets. Instead, they propose a 30-50% reduction in LDL-C administering high- or moderate-intensity statin therapy depending on the CVD risk. The problems of adopting these new guidelines are herein discussed

Dyslipidaemia of Obesity, Metabolic Syndrome and Type 2 Diabetes Mellitus: the Case for Residual Risk Reduction After Statin Treatment

Dyslipidaemia is frequently present in obesity, metabolic syndrome (MetS) and type 2 diabetes mellitus (T2DM). The predominant features of dyslipidaemia in these disorders include increased flux of free fatty acids (FFA), raised triglyceride (TG) and low high density lipoprotein cholesterol (HDL-C) levels, a predominance of small, dense (atherogenic) low density lipoprotein cholesterol (LDL) particles and raised apolipoprotein (apo) B values Posprandial hyperlipidaemia may also be present. Insulin resistance (IR) appears to play an important role in the pathogenesis of dyslipidaemia in obesity, MetS and T2DM. The cornerstone of treatment of this IR-related dyslipidaemia is lifestyle changes and in diabetic patients, tight glycaemic control. In addition to these measures, recent clinical trials showed benefit with statin treatment. Nevertheless, a substantial percentage of patients treated with statins still experience vascular events. This residual vascular risk needs to be addressed. This review summarizes the effects of hypolipidaemic drug combinations (including statins with cholesterol ester protein inhibitors, niacin, fibrates or fish oil, as well as fibrate-ezetimibe combination) on the residual vascular risk in patients with obesity, MetS or T2DM

Dyslipidemia Induced by Drugs Used for the Prevention and Treatment of Vascular Diseases

Dyslipidemia is a major vascular risk factor. Interestingly, several agents used for the prevention and treatment of vascular diseases have an adverse effect on the lipid profile. In addition, agents belonging to the same class (e.g. beta blockers) can have significantly different actions on lipid levels. We summarize the effects of drugs used for the prevention and treatment of vascular diseases on the lipid profile. These effects should be considered when selecting a specific agent, particularly in high-risk patients

Is there an additional benefit from coronary revascularization in diabetic patients with acute coronary syndromes or stable angina who are already on optimal medical treatment?

Cardiovascular disease (CVD) is common in patients with diabetes mellitus (DM) and related clinical outcomes are worse compared with non-diabetics. The optimal treatment in diabetic patients with coronary heart disease (CHD) is currently not established. We searched MEDLINE (1975-2010) using the key terms diabetes mellitus, coronary heart disease, revascularization, coronary artery bypass, angioplasty, coronary intervention and medical treatment. Most studies comparing different revascularization procedures in patients with CHD favoured coronary artery bypass graft (CABG) surgery in patients with DM. However, most of this evidence comes from subgroup analyses. Recent evidence suggests that advanced percutaneous coronary intervention (PCI) techniques along with best medical treatment may be non-inferior and more cost-effective compared with CABG. Treatment of vascular risk factors is a key option in terms of improving CVD outcomes in diabetic patients with CHD. The choice between medical therapy and revascularization warrants further assessment