Aktuelle lipidologische Therapie zur Prävention kardiovaskulärer Erkrankungen – Treat To Target

Die zielwertgerechte Therapie des Fettstoffwechsels ist ein unverzichtbarer Baustein bei der kardiovaskulären Prävention. Patienten mit hohem Risiko sollten ein LDL-Cholesterin von unter 100 mg/dl (2,6 mmol/l), mit sehr hohem Risiko eines von unter 70 mg/dl (1,8 mmol/l) erreichen. Eine Alternative gerade bei Patienten mit Diabetes ist das Non-HDL-Cholesterin, das 30 mg/dl (0,7 mmol/l) höher als das LDL-Cholesterin liegen darf. Wenn irgend möglich, sollten Statine eingesetzt werden, diese bilden die Grundlage der Therapie. Wenn Statine in der höchsten sinnvollen oder verträglichen Dosierung nicht ausreichen, ist eine Kombination oder Monotherapie mit dem Cholesterin-Resorptionsinhibitor Ezetimib indiziert. Optional bei hohen Triglyzeriden und diabetischer Mikroangiopathie sind Fibrate. Bei Progress kardiovaskulärer Erkrankungen unter maximaler Therapie können Inhibitoren der Proproteinkonvertase Subtilisin / Kexin Typ 9 (PCSK9) eingesetzt werden. Letzte Option ist bei entsprechender Indikation die Initiierung einer LDL-Apherese.

Target aimed treatment of LDL-cholesterol is a central element of cardiovascular prevention. High-risk patients should achieve an LDL-cholesterol below 100 mg/dl (2,6 mmol/l); those being at very high risk of less than 70 mg/dl (1,8 mmol/l). An alternative lipid target especially for patients with diabetes is Non-HDL cholesterol with an aim being 30 mg/dl (0,7 mmol/l) higher than that of LDL cholesterol. If at all possible, statins should be used, which form the therapeutic basis. In cases where statins are not sufficient even in the highest acceptable or tolerable dosage, use of the cholesterol absorption inhibitor ezetimibe is indicated. Optionally, in patients with high triglycerides and diabetic microangiopathy, are fibrates. If a progress of cardiovascular disease despite maximal LDL lowering therapy is observed, inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9) may be used. Last option is to initiate LDL-apheresis, when indicated.

Key words

Prevention - cardiovascular disease - cholesterol - LDL-cholesterol - Non-HDL-cholesterol

• Literatur

• 1 Gregg EW, Li Y, Wang J et al. Changes in diabetes-related complications in the United States, 1990-2010. NEJM 2014; 370: 1514-1523
• 2 4-S-Trialists. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383-1389
• 3 Stone NJ, Robinson JG, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129: 1-45
• 4 Catapano AL, Reiner Z, De Backer G et al. ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis 2011; 217 (Suppl. 01) 1-44
• 5 Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174 000 participants in 27 randomised trials. Lancet 2015; 385: 1397-1405
• 6 Nicholls SJ, Tuzcu EM, Sipahi I et al. Statins, high-density lipoprotein cholesterol, and regression of coronary atherosclerosis. JAMA 2007; 297: 499-508
• 7 Cannon CP, Blazing MA, Giugliano RP et al. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. NEJM 2015; 372: 2387-2397
• 8 Navarese EP, Kolodziejczak M, Schulze V et al. Effects of Proprotein Convertase Subtilisin/Kexin Type 9 Antibodies in Adults With Hypercholesterolemia: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163: 40-51
• 9 Robinson JG, Wang S, Smith BJ et al. Meta-analysis of the relationship between non-high-density lipoprotein cholesterol reduction and coronary heart disease risk. J Am Coll Cardiol 2009; 53: 316-322
• 10 American Diabetes Association. Standards of medical care in diabetes-2012. Diabetes Care 2012; 35 (Suppl. 01) 11-63
• 11 Wolfram G, Bechthold A, Boeing H et al. Evidence-Based Guideline of the German Nutrition Society: Fat Intake and Prevention of Selected Nutrition-Related Diseases. Ann Nutr Metab 2015; 67: 141-204
• 12 Estruch R, Ros E, Martinez-Gonzalez MA. Mediterranean diet for primary prevention of cardiovascular disease. NEJM 2013; 369: 676-677
• 13 Weng TC, Yang YH, Lin SJ et al. A systematic review and meta-analysis on the therapeutic equivalence of statins. J Clin Pharm Ther 2010; 35: 139-151
• 14 Stroes ES, Thompson PD, Corsini A et al. Statin-associated muscle symptoms: impact on statin therapy-European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management. Eur Heart J 2015; 36: 1012-1022
• 15 Sattar N, Preiss D, Murray HM et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010; 375: 735-742
• 16 Ginsberg HN, Elam MB, Lovato LC et al. Effects of combination lipid therapy in type 2 diabetes mellitus. NEJM 2010; 362: 1563-1574
• 17 Rajamani K, Colman PG, Li LP et al. Effect of fenofibrate on amputation events in people with type 2 diabetes mellitus (FIELD study): a prespecified analysis of a randomised controlled trial. Lancet 2009; 373: 1780-1788