[Hyperlipidemia: therapeutic principles in clinical practice]

Clinical prognosis of coronary heart disease is not only determined by the degree of stenosis, but rather by the structure and probability that so-called vulnerable plaques rupture. Therefore, the global risk of an individual should be considered to recommend specific LDL cholesterol levels in plasma as therapeutic goals. For a coronary 10-year risk > 20% the LDL-cholesterol level in plasma should be < 100 mg/dl, if the risk is between 10-20% an LDL cholesterol level < 130 mg/dl, an individual with only one additional risk factor and most probably a risk < 10% an LDL cholesterol level < 160 mg/dl is recommended. Recently, the committee for practical guidelines of the European Cardiology Society has recommended to consider not only the coronary but also the total risk of cardiovascular mortality. To reach the recommended therapeutic target levels of LDL cholesterol, nonpharmacologic measures should be taken and different classes of drugs are available. Several pharmacologic therapeutics are available like bileacid sequestrants, nicotinic acid and its derivatives, fibrates, cholesterol synthesis inhibitors and the selective inhibitor of intestinal cholesterol absorption. The selective inhibition of cholesterol absorption by ezetimibe is a novel principle of drug action. Ezetimibe selectively inhibits intestinal absorption of free cholesterol and phytosterols. On the basis of this specific novel pharmacologic principle of drug action, ezetimibe is useful in the combination therapy with statins and can lower LDL cholesterol levels in patients with homozygous familial hypercholesterolemia and elevated plasma levels of sitosterol and campesterol in patients with sitosterolemia.