Updated guidelines for the management of dyslipidemia and the prevention of cardiovascular disease in adults by pharmacists

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TL;DR

This article summarizes the 2021 Canadian Cardiovascular Society dyslipidemia guidelines tailored for pharmacists, emphasizing statins as first-line therapy and introducing thresholds for therapy intensification instead of fixed targets. Key updates include lifetime measurement of lipoprotein(a), preference for non-HDL-C and apolipoprotein B over LDL-C, and new evidence supporting PCSK9 inhibitors and icosapent ethyl while advising against omega-3 supplements. The guidelines reinforce pharmacist-led screening, risk assessment, and shared decision-making to improve cardiovascular outcomes.

Full summary

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**Background:** Cardiovascular disease (CVD) is the second leading cause of death in Canada, and pharmacist-led dyslipidemia management has been shown to improve patient outcomes. This article presents an update of the 2021 Canadian Cardiovascular Society (CCS) Dyslipidemia Guidelines, tailored for pharmacists, highlighting key changes from the 2016 version.

**Methods:** The authors reviewed the 2021 CCS Dyslipidemia Guidelines and summarized recommendations relevant to pharmacists, including screening, risk assessment, treatment initiation, therapy intensification, and lifestyle modifications. The article incorporates evidence from major clinical trials such as FOURIER, ODYSSEY OUTCOMES, REDUCE-IT, ASCEND, VITAL, and STRENGTH.

**Key Results:** - **Screening:** All individuals ≥40 years and those with risk factors (e.g., diabetes, hypertension, smoking, family history, CKD, inflammatory diseases, HIV, COPD, pregnancy complications) should be screened. New recommendations include measuring lipoprotein(a) once in a lifetime and preferring non-HDL-C and apolipoprotein B over LDL-C, especially when triglycerides >1.5 mmol/L. - **Risk Assessment:** For primary prevention, use the modified Framingham Risk Score or Cardiovascular Life Expectancy Model. Statin-indicated conditions (e.g., LDL-C ≥5 mmol/L, familial hypercholesterolemia, diabetes, CKD, ASCVD) automatically confer high risk. - **Treatment Initiation:** Statins remain first-line. For primary prevention, statin therapy is recommended in all high-risk (10-year FRS ≥20%) and intermediate-risk (FRS 10%-19.9%) patients with LDL-C ≥3.5 mmol/L, non-HDL-C ≥4.2 mmol/L, or ApoB ≥1.05 g/L. Low-risk patients generally do not require statins, with exceptions. - **Therapy Intensification:** Instead of fixed targets, thresholds are used. For ASCVD patients, consider adding ezetimibe and/or PCSK9 inhibitor if LDL-C ≥1.8 mmol/L, ApoB ≥0.7 g/L, or non-HDL-C ≥2.4 mmol/L. Icosapent ethyl (IPE) is recommended for ASCVD patients with triglycerides 1.5-5.6 mmol/L on maximally tolerated statin. Omega-3 polyunsaturated fatty acids are not recommended for cardiovascular risk reduction. - **Key Trial Data:** - FOURIER (evolocumab): NNT 67 for composite cardiovascular outcomes, median follow-up 2.2 years. - ODYSSEY OUTCOMES (alirocumab): NNT 63 for composite outcomes, median follow-up 2.8 years. - REDUCE-IT (IPE): NNT 21 for composite outcome, NNT 112 for cardiovascular death, median follow-up 4.9 years. - ASCEND, VITAL, STRENGTH: No significant cardiovascular benefit with omega-3 PUFAs. - **Lifestyle:** Emphasize tobacco cessation, limited alcohol (risk increases with ≥7 drinks/week), Mediterranean diet, and 150 minutes/week of moderate-to-vigorous aerobic activity plus muscle-strengthening activities.

**Clinical Implications:** Pharmacists should actively screen, assess cardiovascular risk, initiate and intensify statin therapy using thresholds, and consider nonstatin options (ezetimibe, PCSK9 inhibitors, IPE) when indicated. They should avoid recommending omega-3 supplements and engage patients in shared decision-making. These guidelines support pharmacist-led dyslipidemia management to reduce cardiovascular disease burden.