Hypercholesterinämie – Wen, wann, wie behandeln?

Was ist neu?

LDL-Cholesterin und Arteriosklerose In den letzten Jahren haben klinisch wissenschaftliche Daten zu LDL-Cholesterin und Arteriosklerose zu immer niedrigeren LDL-Cholesterin-Zielwerten und zur Ausweitung der Indikation für eine medikamentöse Lipidtherapie auf immer größere Bevölkerungs- bzw. Patientengruppen geführt.

Kardiovaskuläres Risiko und Therapieziele Bei der Einschätzung des kardiovaskulären Risikos von Patienten werden neben z.B. vorbestehender kardiovaskulärer Erkrankung, familiärer Hypercholesterinämie und Typ-II-Diabetes auch Typ-I-Diabetes, diabetische Folgeerkrankungen, Niereninsuffizienz und subklinische Arteriosklerose berücksichtigt.

Lipidologische Therapie zur kardiovaskulären Risikoreduktion Zur Berechnung des kardiovaskulären Risikos in der Primärprävention wurden die Kalkulatoren SCORE2 und SCORE-OP neu entwickelt. Eine diätetische Intervention gehört an den Anfang jeder lipidsenkenden Therapie. Bempedoinsäure und Inclisiran stellen neue medikamentöse Therapieoptionen dar.

Therapeutisches Vorgehen Nach der Anamnese erfolgt die Zielwertsetzung und die stufenweise Aufdosierung eines Statins. Nach 6–12 Wochen wird diese Therapie ggf. mit einem ACL-Inhibitor kombiniert, um die Wirkung zu verstärken.

Abstract

In recent years, clinical scientific data on LDL cholesterol and atherosclerosis has led to lowering of LDL-C targets and the expansion of the indication for lipid drug therapy to larger populations or patients. The calculators SCORE2 and SCORE-OP were newly developed to calculate the cardiovascular risk in primary prevention. When assessing the cardiovascular risk of patients, in addition to e.g., pre-existing cardiovascular disease, familial hypercholesterolaemia and type II diabetes, type I diabetes, diabetic complications, renal insufficiency and subclinical arteriosclerosis are also considered. Statins are the basic therapy for hypercholesterolemia. Alternative medication are ACL inhibitors e.g., Bempedoic acid and Inclisiran which represent new drug therapy options for statin intolerance. Nevertheless, a dietary intervention belongs at the beginning of every lipid-lowering therapy.

Schlüsselwörter

Hypercholesterinämie - LDL-Cholesterin - kardiovaskuläres Risiko - SCORE2 - Ernährung

Keywords

hypercholesterolaemia - LDL cholesterol - cardiovascular risk - SCORE2 - nutrition

• Literatur

• 1 Anitschkow N. Über Veränderungen der Kaninchenaorta bei experimenteller Cholesteatose. Beitr Pathol Anat 1913; 56: 379-404
• 2 Grundy SM, Cleeman JI, Merz CN. et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110: 227-239
• 3 Teslovich TM, Musunuru K, Smith AV. et al. Biological, clinical and population relevance of 95 loci for blood lipids. Nature 2010; 466: 707-713
• 4 Ference BA, Majeed F, Penumetcha R. et al. Effect of naturally random allocation to lower low-density lipoprotein cholesterol on the risk of coronary heart disease mediated by polymorphisms in NPC1L1, HMGCR, or both: a 2 × 2 factorial Mendelian randomization study. Journal of the American College of Cardiology 2015; 65: 1552-1561
• 5 Buchwald H, Varco RL, Matts JP. et al. Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia. Report of the Program on the Surgical Control of the Hyperlipidemias (POSCH). N Engl J Med 1990; 323: 946-955
• 6 Nordestgaard BG, Chapman MJ, Humphries SE. et al. Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease: Consensus Statement of the European Atherosclerosis Society. Eur Heart J 2013; 34 (45) 3478-90a
• 7 Boekholdt SM, Arsenault BJ, Mora S. et al. Association of LDL cholesterol, non-HDL cholesterol, and apolipoprotein B levels with risk of cardiovascular events among patients treated with statins: a meta-analysis. JAMA 2012; 307: 1302-1309
• 8 Mach F, Baigent C, Catapano AL. et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2019; 41: 111-188
• 9 SCORE2 working group and ESC Cardiovascular risk collaboration. SCORE2 risk prediction algorithms: new models to estimate 10-year risk of cardiovascular disease in Europe. Eur Heart J 2021; 42: 2439-2454
• 10 Tsujita K, Sugiyama S, Sumida H. et al. Impact of Dual Lipid-Lowering Strategy With Ezetimibe and Atorvastatin on Coronary Plaque Regression in Patients With Percutaneous Coronary Intervention: The Multicenter Randomized Controlled PRECISE-IVUS Trial. J Am Coll Cardiol 2015; 66: 495-507
• 11 Nicholls SJ, Puri R, Anderson T. et al. Effect of Evolocumab on Progression of Coronary Disease in Statin-Treated Patients: The GLAGOV Randomized Clinical Trial. JAMA 2016; 316: 2373-2384
• 12 Allan GM, Nouri F, Korownyk C. et al. Agreement among cardiovascular disease risk calculators. Circulation 2013; 127: 1948-1956
• 13 SCORE2-OP working group and ESC Cardiovascular risk collaboration. SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions. Eur Heart J 2021; 42: 2455-2467
• 14 Visseren FLJ, Mach F, Smulders YM. et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021; 42: 3227-3337
• 15 Estruch R, Ros E, Martinez-Gonzalez MA. Mediterranean diet for primary prevention of cardiovascular disease. N Engl J Med 2013; 369: 676-677
• 16 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
• 17 Collins R, Reith C, Emberson J. et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 388: 2532-2561
• 18 Sturzebecher PE, Schumann F, Kassner U. et al. Statin intolerance and statin-associated muscular pain. Herz 2022; 47: 204-211
• 19 Cannon CP, Blazing MA, Giugliano RP. et al. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. N Engl J Med 2015; 372: 2387-2397
• 20 Nissen SE, Lincoff AM, Brennan D. et al. Bempedoic Acid and Cardiovascular Outcomes in Statin-Intolerant Patients. N Engl J Med 2023; 388: 1353-1364
• 21 Sabatine MS, Giugliano RP, Keech AC. et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. N Engl J Med 2017; 377: 787-788
• 22 McCullough PA, Ballantyne CM, Sanganalmath SK. et al. Efficacy and Safety of Alirocumab in High-Risk Patients With Clinical Atherosclerotic Cardiovascular Disease and/or Heterozygous Familial Hypercholesterolemia (from 5 Placebo-Controlled ODYSSEY Trials). Am J Cardiol 2018; 121: 940-948
• 23 Chandra Ghosh G, Bandyopadhyay D, Ghosh RK. et al. Effectiveness and Safety of Inclisiran, A Novel Long-Acting RNA Therapeutic Inhibitor of Proprotein Convertase Subtilisin/Kexin 9. Am J Cardiol 2018; 122: 1272-1277