Treatment goals and key points of lipid regulation for dyslipidemia in special populations

How to treat lipid-lowering disorders in patients with metabolic syndrome?

As mentioned earlier, metabolic syndrome is a clinical syndrome characterized by obesity, hyperglycemia (impaired glucose regulation or diabetes), hypertension, and dyslipidemia [hypertriose and/or hypoHDL-C]. A key feature is the presence of interconnected metabolic risk factors in the same patient. These factors directly promote the development of ASCVD and increase the risk of type 2 diabetes.

The main goals of preventing and treating metabolic syndrome are to prevent ASCVD and type 2 diabetes. For those with existing ASCVD, prevention of recurrent cardiovascular events is crucial. Aggressive and sustained lifestyle interventions are essential for achieving treatment goals. In principle, lifestyle therapy should be initiated first. If the goals cannot be achieved, appropriate drug therapy should be used to target each component.

The treatment goals for lipid metabolism disorders in metabolic syndrome are LDL-C < 2.6 mmol/L (100 mg/dL), TG < 1.7 mmol/L (150 mg/dL), and HDL-C ≥ 1.0 mmol/L (40 mg/dL).

How should lipid-lowering therapy be administered to stroke patients?

For patients with non-cardiac ischemic stroke or transient ischemic attack (TIA), regardless of whether there is other evidence of atherosclerosis, long-term statin therapy is recommended to reduce the risk of recurrent stroke and cardiovascular events.

For patients with ischemic stroke or TIA caused by atherosclerotic stenosis of large intracranial arteries (stenosis rate 70%–99%), the recommended target value is LDL-C < 1.8 mmol/L (70 mg/dL). Long-term statin therapy is generally safe. For patients with a history of cerebral hemorrhage, non-cardiac ischemic stroke, or TIA, the risks and benefits should be weighed before the appropriate use of statins.

How should lipid-lowering therapy be used in patients with chronic kidney disease?

Chronic kidney disease (CKD) is often accompanied by abnormal lipid metabolism and promotes the development of asthenic-associated cardiovascular disease (ASCVD). Statin therapy is recommended for CKD patients, provided it is well-tolerated. Treatment goals: For mild to moderate CKD, LDL-C <2.6 mmol/L, non-HDL-C <3.4 mmol/L; for severe CKD, CKD with hypertension, or diabetes, LDL-C <1.8 mmol/L, non-HDL-C <2.6 mmol/L. Moderate-intensity statin therapy is recommended, with the possibility of combining it with cholesterol absorption inhibitors. For patients with end-stage renal disease (ESRD) and those on hemodialysis, the risks and benefits of cholesterol-lowering therapy should be carefully assessed, and individualized drug selection and LDL-C targets are recommended.

Patients with chronic kidney disease (CKD) are at high risk of statin-induced myopathy, especially when renal function is progressively declining or glomerular filtration rate (GFR) is <30 ml/(min·1.73²). The risk of myopathy is closely related to statin dosage, and high-dose use should be avoided. When moderate-intensity statin therapy fails to achieve target LDL-C, ezetimibe is recommended for combination therapy. Fibrates can increase creatinine levels; in patients with moderate to severe CKD, combination therapy with statins may increase the risk of myopathy.