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The landmark Scandinavian Simvastatin Survival Study (4S) published in 1994, may well be remembered as the study that finally put to rest many of the apprehensions and misconceptions regarding lipid-lowering therapy.
DUFFY AND MEREDITH 19961
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Dyslipidaemia is the presence of an abnormal lipid/lipoprotein profile in the serum and can be classified as:
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predominant hypertriglyceridaemia
predominant hypercholesterolaemia
mixed pattern with elevation of both cholesterol and triglyceride (TG)
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Modern epidemiological studies have established the facts that elevated plasma cholesterol causes pathological changes in the arterial wall leading to CAD, and that lipid-lowering through lifestyle factors or drug therapy results in reduction of coronary and cerebrovascular events with improved survival.
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A Cochrane systematic review2 of 18 large RCTs found high-quality evidence that statins reduce all-cause mortality and major vascular events. The number needed to treat (NNT) with statins varies markedly depending on the risk category the person falls into (see TABLE 78.1).
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As with other cardiovascular risk factors, focussing on any one measure (in this case, lipid profile) is only part of the whole-person approach to reducing risk.
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The main focus of treatment will be on primary dyslipidaemia but secondary causes (see TABLE 78.2) also need to be addressed. LDL-C is the lipid with the highest correlation with CHD and its level remains the primary target of lipid-modifying therapy. The statins are the first-line therapy for a raised level. Like total cholesterol measurement, LDL-C should not be used in isolation.
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4,5,6Major risk factors for CAD include:
Risk increases with increasing cholesterol levels
TG level >10 mmol/L increases risk of pancreatitis
Management depends on other cardiovascular risk factors
10% reduction of total cholesterol gives 20% reduction in CAD after 3 years
LDL-C reduction with statin therapy reduces heart attacks, stroke, the need for revascularisation and death
Screening is recommended 5 yearly from age 45 years (Aboriginal and Torres Strait Islander people from 35 years)
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5The following fasting tests are recommended in patients every 5 years, ...