In Depth Cardiology: Primary Prevention Of Dyslipidemia - Role Of Non-Drug Therapy

Atherosclerotic cardiovascular disease (ASCVD) is one of the major causes of morbidity and mortality the world over. Major risk factors include total cholesterol, systolic blood pressure, diabetes and cigarette smoking. Every major risk factor deserves clinical attention. Underlying risk factors include atherogenic diets, obesity, physical sedentariness and genetic predisposition.

In issuing guideline organizations usually give importance to randomized clinical trials (RCTs) consequently giving pharmacological solutions more weightage. Drug therapy alone may not be the most relevant solution in primary prevention. Most investigators agree that atherosclerosis is mainly a lifestyle issue. International atherosclerosis society (ISA) position paper on Global Recommendations for The Management of Dyslipidemia full report rightly emphasizes the importance of non-drug primary preventive measures.

IAS Primary Prevention Recommendations

To reduce load of ASCVD world over, new onset disease must be dealt with effectively. Central emphasis of preventing ASCVD must be decreasing LDL-C and maintaining it low over the life span. The IAS guidelines include dietary factors to limit LDL raising lipids; high intake of fruits, vegetables and fiber; replace saturated fatty acids with unsaturated fatty acids; omega3 rich fish; and low sodium, high potassium diets. It also limits processed meats, sugar beverages, sweets, grain based desserts, bakery foods and alcohol intake; decrease total fat; rationalize total calories; obesity control; and complete cessation of tobacco. IAS favors using lifestyle interventions for unhealthy life habits. Drugs are reserved for higher risk patients.

Conclusion

Main target of primary prevention of dyslipidemia is reduction of atherogenic cholesterol. Secondary target is to decrease other risk factors. It is valid that ASCVD risk will be decreased by cholesterol lowering therapy in the presence of all other risk factors. Risk factors of non-lipid variety can fast track atherogenesis or prompt thrombotic events. IAS recommendations for cholesterol lowering therapy at different risk levels include Maximal Lifestyle Therapies (MLT) for each risk level. Cholesterol Lowering Drug (CLD) therapy is usually reserved for patients with moderately high or high risk level. This author agrees with IAS recommendations that in primary prevention trying to treat non lipid risk factors with LDL lowering alone will be insufficient. This will fail to achieve the benefits obtained by therapy directed at non-lipid risk factors.