Current Treatment of Dyslipidemia: A New Paradigm for Statin Drug Use and the Need for Additional Therapies

Coronary heart disease (CHD) is the leading cause of death in most countries, with the high prevalence currently driven by dual epidemics of obesity and diabetes. Statin drugs, the most effective, evidence-based agents to prevent and treat this disease, have a central role in management and are advised in all published guidelines. The 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol and assessment guidelines ('new ACC/AHA guidelines') emphasized global cardiovascular (CV) risk reduction as opposed to targeting low-density lipoprotein-cholesterol (LDL-C) levels, stressed the use of statins in two dose intensities, utilized a new risk calculator using pooled cohort equations, and lowered the risk cutoff for initiation of statin therapy. Although there were major strengths of the new ACC/AHA guidelines, substantial controversy followed their release, particulars of which are discussed in this review. They were generally regarded as improvements in an ongoing transition using evidenced-based data for maximum patient benefit. Several guidelines, other than the ACC/AHA guidelines, currently provide practitioners with choices, some depending on practice locations. Cholesterol control with statin drugs is used in all paradigms. However, some patients respond inadequately, approximately 15 % are intolerant, and other factors prevent attaining cholesterol goals in as many as 40 % of patients. Even after treatment, substantial residual risk for ongoing major events remains. Another readily available modality that can rival statin drugs in effectiveness is vast improvement in diet and lifestyle within the general population; however, despite great effort, existing programs to implement such changes have failed. Hence, despite unrivaled success, there is great need for additional drugs to prevent and treat CHD, whether as monotherapy or in combination with statin drugs. New American guidelines do not discuss or recommend any nonstatin drugs for CHD, and the US FDA has moved away from approving drugs based solely on changes in surrogates in the absence of clinical outcomes trials. Both have significantly altered the realities of developing pharmacotherapies and cardiology practice.