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|Objective||To investigate the extent of residual dyslipidemia in US adults|
|Study design||Cross-sectional survey|
This analysis included data from 2,509 adults aged ≥18 years in the US National Health and Nutrition Examination Survey (NHANES) 2009-2010. In total, 1,129 (41.8%) had hyperlipidemia on the basis of current treatment guidelines for low-density lipoprotein cholesterol (LDL-C), of whom 484 (mean age 60.1 ± 14.9 years, 52% men) were treated with lipid-modifying therapy.
Table 1. LDL-C and non-HDL-C goals (mg/dL)1
Hyperlipidemia was defined as an elevated LDL-C level or evidence of ongoing treatment for elevated cholesterol (any prescription for statins, bile acid sequestrants, fibrates, cholesterol absorption inhibitors, niacin or omega 3-fatty acids). Global CVD risk estimation was based on the Framingham risk score. Subjects were also categorised according to the presence of metabolic syndrome, diabetes, CKD and CVD.
The proportion of subjects achieving lipid goals is summarised in Table 2. Overall, only 36.5% of treated subjects achieved all lipid goals. Most treated subjects were receiving statin monotherapy (82%), with only a minority receiving combination therapy (8.1%) or other treatment as monotherapy (9.5%). One in five treated subjects had residual atherogenic dyslipidemia (Figure 1).
Table 2. Lipid characteristics of subjects with hyperlipidemia
Figure 1. Proportion of lipid abnormalities in treated subjects
|Author's conclusion||Despite widely available treatments for dyslipidemia, many patients remain at suboptimal lipid levels, indicating the need for greater adherence to lifestyle and medical therapies to address these gaps in the management of dyslipidemia.|
Despite modern pharmacotherapy, a substantial proportion of patients have residual dyslipidemia. A particular concern is the high proportion of treated patients with elevated triglycerides and low HDL-C – i.e. atherogenic dyslipidemia. In this study, about one in three patients had elevated triglycerides and/or low HDL-C, and one in five had both lipid abnormalities. Given that this dyslipidemic profile is recognised as a key driver of atherogenic risk, especially in individuals with cardiometabolic disease,2,3 there is clearly much to be done to improve clinical management.
It is acknowledged that this study has limitations, due to its cross-sectional design and methodology. For example, treatment information was based on prescribed medication containers, and there is no information relating to doses, or over-the-counter treatments, including functional foods. Treatment adherence and clinical inertia are also recognised as a contributing factor in failure to achieve lipid targets,4 although this was not investigated in this study.
Even taking these limitations into account, this study highlights the extent of undertreatment of dyslipidemia in patients with and without cardiovascular disease. Based on these data, it is estimated that 5.8 million individuals in the US have elevated triglycerides and 4.6 million have low HDL-C, despite lipid-modifying therapy. The burden of undertreatment of atherogenic dyslipidemia may be even higher in certain regions, such as Asia and the Middle East, where rapidly developing economies are key drivers of escalating rates of sedentary lifestyle, obesity, metabolic syndrome and type 2 diabetes,5,6 all of which are characterised by a high prevalence of atherogenic dyslipidemia.2
Given that almost all treated individuals were on a statin (~90%), it is clear that statin therapy, although effective in lowering LDL-C concentration, is insufficient for managing atherogenic dyslipidemia, supported by evidence from major prospective studies.7 This is also a key message of the Residual Risk Reduction Initiative,8 as discussed in recent videos on this website. Thus, there are significant opportunities for improved lipid management of atherogenic dyslipidemia beyond lifestyle changes, by combination of a statin with existing therapies such as fibrates, or a number of novel treatments, such as selective peroxisome proliferator-activated receptor alpha modulators (SPPARMa) or proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody therapy, as highlighted in previous reports on this site. These treatments offer the possibility to reduce the high residual cardiovascular risk that persists in individuals with atherogenic dyslipidemia that is not addressed by statins.
1. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on