p.56 抽出テキスト

............................................................................................................................................................................. 13 Strategies to encourage adoption of healthy lifestyle changes and adherence to lipidmodifying therapies

Helping patients to change to healthier lifestyle habits is most effectively achieved through formal programmes of preventive care, possibly because of the intensive follow-up and multidisciplinary expertise they provide.608 However, in everyday care, adherence to both healthy lifestyle changes and medication regimens is a challenge to patients and professionals. A comprehensive patient- and family-centred approach located in one healthcare setting is recommended rather than addressing single risk factors with more than one intervention in different locations. Box 10 includes some useful techniques when counselling patients for behavioural change.

A comprehensive approach to improving adherence to medication is described in the Supplementary Data document.

14 Key messages

(1) Cholesterol and risk. Prospective studies, randomized trials, and Mendelian randomization studies have all shown that raised LDL-C is a cause of ASCVD. Throughout the range of LDL-C levels, ‘lower is better’ with no lower threshold, at least down to 1 mmol/L. Lowering LDL-C may yield worthwhile benefits in patients with average or below average LDL-C who are already receiving LDL-C-lowering treatment. The proportional reduction in ASCVD risk achieved by lowering LDL-C (e.g. with a statin, ezetimibe, or PCSK9-inhibitor) depends on the absolute reduction in LDL-C, with each 1 mmol/L reduction corresponding to a reduction of about one-fifth in ASCVD. (2) PCSK-9 inhibitors. Large trials have shown that PCSK9 inhibitors further reduce ASCVD risk when given on top of statin-based therapy and their use may need to be restricted to those at the highest risk for ASCVD. (3) Use of cardiac imaging for risk stratification. CAC score assessment with CT may be helpful in reaching decisions about treatment in people who are at moderate risk of ASCVD. Obtaining such a score may assist in discussions about treatment strategies in patients where the LDL-C goal is not achieved with lifestyle intervention alone and there is a question of whether to institute LDL-C-lowering treatment. Assessment of arterial (carotid or femoral) plaque burden on ultrasonography may also be informative in these circumstances. (4) Use of ApoB in risk stratification. ApoB may be a better measure of an individual’s exposure to pro atherogenic lipoproteins, and hence its use may be particularly helpful for risk assessment in people where measurement of LDL-C underestimates this burden, such as those with high TG, DM, obesity, or very low LDL-C. (5) Use of Lp(a) in risk stratification. A one-off measurement of Lp(a) may help to identify people with very high inherited Lp(a) levels who may have a substantial lifetime risk of ASCVD. A high Lp(a) plasma level may also be helpful in further risk stratification of patients at high risk of ASCVD, in patients with a family history of premature CVD, and to determine treatment strategies in people whose estimated risk is on the border of risk categories. (6) Intensification of treatment goals. It is important to ensure that treatment of the highest-risk patients achieves the largest LDL-C reduction possible. These Guidelines aim to support this by setting both a minimum percentage LDL-C reduction (50%) and an absolute LDL-C treatment goal of <1.4 mmol/L (<55 mg/ dL) for very-high-risk patients, and <1.8 mmol/L (<70 mg/dL) for high-risk patients. It is recommended that FH patients with ASCVD or who have another major risk factor are treated as very-high-risk, and those with no prior ASCVD or other risk factors as high-risk. (7) Treatment of patients with recent ACS. New randomized trials support a strategy of intensification of LDL-C-lowering therapy in very-high-risk patients with ACS (MI or unstable angina). If the specified LDL-C treatment goal is not achieved after 46 weeks with the highest tolerated statin dose and ezetimibe, it is appropriate to add a PCSK9 inhibitor. (8) Safety of low LDL cholesterol concentrations. To date there are no known adverse effects of very low LDL-C concentrations [e.g. <1 mmol/L (40 mg/dL)]. (9) Management of statin ‘intolerance’. While statins rarely cause serious muscle damage (myopathy, or rhabdomyolysis in the most severe cases), there is much public concern that statins may commonly cause less serious muscle symptoms. Such statin ‘intolerance’ is frequently encountered by practitioners and may be difficult to manage. However, placebo-controlled randomized trials have shown very clearly that true statin intolerance is rare, and that it is generally possible to institute some form of statin therapy (e.g. by changing the statin or reducing the dose) in the overwhelming majority of patients at risk of ASCVD. (10) Statin treatment for older people. A meta-analysis of randomized trials has shown that the effects of statin therapy are determined by the absolute reduction in LDL-C as well as the baseline ASCVD risk, and are independent of all known risk factors, including age. Statin therapy in older people should therefore be considered according to the estimated level of risk and baseline

Box 10 Methods for enhancing adherence to lifestyle changes

1. Explore motivation and identify ambivalence. Weigh pros and cons for change, assess and build self-efficacy and confidence, and avoid circular discussion.

2 Offer support, and establish an alliance with the patient and his/her

family.

3 Involve the partner, other household members, or caregiver who may

be influential in the lifestyle of the patient. 4. Use the OARS method (Open-ended questions, Affirmation, Reflective listening, Summarising when discussing behaviour changes (www.smartrecovery.org/wp-content/uploads/2017/03/UsingMIinSR.pdf). 5. Tailor advice to an individual patient’s culture, habits, and situation. 6. Use SMART goal setting (negotiate goals for change that are Specific, Measurable, Achievable, Realistic, and Timely). Follow-up on goals and record progress on a shared record. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026