Management of dyslipidemia

The 2 principal approaches to management of dyslipidemias are lifestyle intervention and lipid-modifying drug therapy. Recent revisions to the American Heart Association's dietary guidelines for reducing cardiovascular disease emphasize an overall healthy eating pattern and maintenance of appropriate body weight, together with achieving a desirable blood pressure and a desirable lipoprotein profile. New National Cholesterol Education Program treatment guidelines include a scoring system for calculating coronary heart disease (CHD) risk that is adapted from the Framingham Heart Study, as well as a category of CHD risk equivalents (e.g., diabetes) that will encourage more aggressive therapeutic intervention for individuals at high short-term risk for CHD, even in the absence of clinically evident coronary disease. Classes of lipid-modifying drugs include bile acid sequestrants (resins), fibrates, and statins, with each class exerting different effects on the lipid profile. Nicotinic acid (niacin) is also an approved lipid-modifying agent. The armamentarium for treating lipid disorders and atherosclerosis now includes statins that can decrease low-density lipoprotein (LDL) cholesterol levels by up to 55%, as well as a resin with improved tolerability. In patients with high levels of LDL cholesterol and triglycerides, together with low concentrations of high-density lipoprotein cholesterol, combination therapy may be effective. Moreover, researchers are currently investigating the development of drugs directed at molecular targets, including cholesterol esterification and accumulation in macrophage foam cells (e.g., inhibiting acyl-coenzyme A: cholesterol acyltransferase), degradation of atherosclerotic plaque (e.g., decreasing the expression of matrix metalloproteinases), and reverse cholesterol transport (e.g., stimulating ATP-binding cassette transporter A1).