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(CPG) for the Management of Dyslipidemia for Cardiovascular

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(CPG) for the Management of Dyslipidemia for Cardiovascular VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF DYSLIPIDEMIA FOR CARDIOVASCULAR RISK REDUCTION Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical trial and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent Department of Veterans Affairs nor TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 4.0 – 2020 VA/DoD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction Prepared by: The Management of Dyslipidemia for Cardiovascular Risk Reduction Work Group With support from: The Office of Quality and Patient Safety, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 4.0 – 2020 Based on evidence reviewed through May 16, 2019 June 2020 Page 2 of 127 VA/DoD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction Table of Contents I. Introduction ..................................................................................................................................... 5 II. Dyslipidemia is Defined by Risk for Cardiovascular Disease .............................................................. 5 III. About this Clinical Practice Guideline ............................................................................................... 6 A. Methods ............................................................................................................................................... 6 a. Grading Recommendations ......................................................................................................... 7 b. Reconciling 2014 Clinical Practice Guideline Recommendations ............................................... 8 c. Peer Review Process .................................................................................................................... 9 B. Summary of Patient Focus Group Methods and Findings .................................................................. 9 C. Conflicts of Interest ........................................................................................................................... 10 D. Scope of this Clinical Practice Guideline ........................................................................................... 10 a. Populations Included in this Guideline ...................................................................................... 10 b. Populations Excluded from this Guideline ................................................................................ 10 E. Patient-centered Care ....................................................................................................................... 11 F. Highlighted Features of this Clinical Practice Guideline ................................................................... 11 a. Methodology.............................................................................................................................. 11 b. Treatment Intensity Instead of Lipid Targets ............................................................................ 11 G. Shared Decision Making .................................................................................................................... 12 H. Implementation ................................................................................................................................. 12 IV. Guideline Work Group ................................................................................................................... 13 V. Algorithm ...................................................................................................................................... 14 Algorithm: Management of Dyslipidemia for Cardiovascular Risk Reduction......................................... 15 VI. Recommendations ......................................................................................................................... 17 A. Screening and Assessment of Cardiovascular Risk ........................................................................... 19 B. Pharmacotherapy, Supplements, and Nutraceuticals ...................................................................... 25 a. Primary Prevention .................................................................................................................... 25 b. Secondary Prevention ................................................................................................................ 32 c. Other Medications, Supplements, and Nutraceuticals ............................................................. 39 d. Monitoring and Adherence ....................................................................................................... 47 C. Lifestyle Interventions ....................................................................................................................... 52 VII. Knowledge Gaps and Recommended Research .............................................................................. 56 A. Comparison of Medical Therapies in Primary and Secondary Prevention ...................................... 56 a. Primary Prevention .................................................................................................................... 56 b. Secondary Prevention ................................................................................................................ 57 June 2020 Page 3 of 127 VA/DoD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction B. Effectiveness of Non-statin Monotherapy for Primary Prevention ................................................. 57 C. Safety of Newer Therapies ................................................................................................................ 57 D. Stratifying Primary Prevention Benefits by Patient Risk Estimates ................................................. 57 E. Prospective Studies to Improve Statin Adherence ........................................................................... 57 F. Prospective Comparative Study of Risk Prediction Strategies ......................................................... 58 G. Prospective Comparison of Risk Calculators in Varied Populations ................................................ 58 H. Pragmatic, Evidence-based Dietary Studies ..................................................................................... 58 I. Comparative Studies of Cardiac Rehabilitation Programs ............................................................... 58 Appendix A: Evidence Review Methodology ....................................................................................... 59 A. Developing the Key Questions .......................................................................................................... 59 B. Conducting the Systematic Evidence Review ................................................................................... 65 C. Convening the Face-to-face Meeting ................................................................................................ 71 D. Grading Recommendations ............................................................................................................... 71 E. Recommendation Categorization ..................................................................................................... 75 F. Drafting and Submitting the Final Clinical Practice Guideline.......................................................... 76 Appendix B: Cardiovascular Disease Risk Calculators .......................................................................... 78 Appendix C: Pharmacotherapy ........................................................................................................... 79 Appendix D: Patient Education on the Mediterranean Diet ................................................................ 81 Appendix E: Patient Focus Group Methods and Findings .................................................................... 82 A. Methods ............................................................................................................................................. 82 B. Patient Focus Group
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