Strategies for optimizing lipid management.

The currently recommended low-density lipoprotein cholesterol (LDL-C) goal of < 100 mg/dL in high-risk patients is a reasonable target of lipid-lowering therapy. Indeed, recent studies have suggested that the optimal level of LDL-C level may be < 70 mg/dL. However, there is considerable evidence that lipid measures other than LDL-C may be more accurate predictors of cardiovascular risk and thus may be useful in addition to LDL-C in guiding treatment to reduce cardiovascular risk. Non-high-density lipoprotein cholesterol (non-HDL-C) provides a measure of all atherogenic, apolipoprotein (apo) B-containing lipoproteins and can be calculated from a standard lipid panel. Baseline non-HDL-C level has been found to be superior to LDL-C level in predicting cardiovascular risk. Currently, non-HDL-C is recommended as a secondary target of lipid-lowering therapy in patients with elevated triglycerides. Apo B may also be useful in risk assessment and determining optimal therapy; apo B level and apo B/apo A-I ratio on 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor ("statin") therapy have been found to be strong predictors of risk of acute vascular events. Available data indicate that optimal apo B levels may not be achieved even with what has been considered intensive lipid-lowering therapy. Identification of optimal lipid targets and increased efforts to achieve those targets may help reduce the cardiovascular risk that remains despite lipid-lowering therapy that is currently considered adequate or even aggressive.