CMECardiovascular disease (CVD) remains the major cause of death worldwide. In modern medicine, atherosclerotic CVD and its ensuing complications provide a significant challenge to clinicians, from the level of primary care to subspecialty practice. The role of dyslipidaemia in the pathogenesis of atherosclerotic CVD has been extensively researched, and doctors across South Africa (SA) are often tasked with modifying this significant risk factor burden among a wide variety of population groups.When managing dyslipidaemia, it is clinically useful to separate hyperlipidaemia into two main categories, i.e. hypertriglyceridaemia and hypercholesterolaemia, particularly an increase in serum lowdensity lipoprotein (LDL) cholesterol concentrations. As discussed in this article, even though an elevated triglyceride (TG) level may result in an increased risk of CVD, the greatest effect of lowering markedly elevated serum TG (>10 mmol/L) is the reduction in the risk of developing acute pancreatitis, with a reduction of serum LDL cholesterol being a much more powerful predictor of risk reduction with regard to CVD morbidity and mortality. Management of predominant hypercholesterolaemia Statin therapyIf diet and lifestyle advice does not lower LDL cholesterol sufficiently, the 3-hydroxy 3-methylglutaryl co-enzyme A (HMG-CoA) reductase inhibitors or statins are the current mainstay of treatment of elevated LDL cholesterol. The most efficacious statins at their maximum dose can reduce LDL cholesterol by up to 50%. EzetimibeEzetimibe prevents intestinal absorption of cholesterol, and is currently the mainstay as a second-line agent in lowering LDL cholesterol. As per the European Society of Cardiology (ESC) guidelines, ezetimibe is recommended as an add-on therapy for patients on high-intensity statins, who require further LDL cholesterol reduction, or for patients who are statin intolerant. The IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT), [1] which showed a 2% absolute reduction in cardiovascular events compared with placebo over a 6-year follow-up period in patients on background statin therapy, has proven the benefit of the addition of ezetimibe to statin therapy in reducing cardiovascular events.While these medications have been used to excellent effect in lowering the rate of complications secondary to dyslipidaemia, there are still certain groups of the population for whom this combination is insufficient. The two major groups of patients who may require an additional or alternative approach to lipid-lowering therapy, are: (i) individuals with familial hypercholesterolaemia, which is highly prevalent in the Afrikaner, Jewish and Indian populations of SA, as they require a greater percentage reduction in LDL cholesterol to achieve acceptable LDL cholesterol target levels; and (ii) individuals experiencing side-effects from statin therapy, precluding the use of high-intensity statin therapy, i.e. statin-intolerant patients. New therapies for the treatment of hypercholesterolaemiaProprot...
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