Management of hyperlipidemia: goals for the prevention of atherosclerosis

The goals of treatment for patients with hyperlipoproteinemia are to reduce plasma concentrations of known atherogenic lipoproteins, thereby exerting a favorable effect upon lipid deposition in the arterial wall and, less commonly, to prevent the adverse sequelae of hyperchylomicronemia in patients with severe hypertriglyceridemia. Diet is the cornerstone of the therapy after the exclusion of secondary factors; the decision to begin drug therapy should be made only after an adequate trial of diet has failed to achieve satisfactory concentrations of plasma lipids and lipoproteins. For patients without evidence of atherosclerosis the goals is to reduce the plasma concentrations of low density lipoproteins to below 160 mg/dl (4.2 mM/L); for those individuals with atherosclerosis or the concurrent presence of two risk factors, a lower level of LDL is desirable (less than 130 mg/dl; 3.4 mM/L). For regression to occur the LDL level may need to be below 100 mg/dl (2.6 mM/L). The bile acid sequestrants (cholestyramine and colestipol), nicotinic acid, fenofibrate, and inhibitors of HMG CoA reductase (e.g., lovastatin or simvastatin) are the most effective drugs for use in patients with primary hypercholesterolemia and these agents reduce plasma concentrations of total and LDL cholesterol by 15-45%. For those patients with concurrent hypertriglyceridemia, nicotinic acid, lovastatin or simvastatin, or fenofibrate are the preferred drugs for initial use. Fibric acid derivatives (e.g., clofibrate, gemfibrozil, bezafibrate, or fenofibrate) are all effective in the therapy of patients with type III hyperlipoproteinemia, as is nicotinic acid or lovastatin.(ABSTRACT TRUNCATED AT 250 WORDS)