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Last Updated: 7/17/2015  

Lipid Disorders (Dyslipidemia)

  • For primary and secondary prevention, modulate whenever possible the major cardiovascular risk factors:

    • Increasing age

    • Smoking cigarettes

    • Hypertension

    • Diabetes mellitus and insulin resistance

    • Genetic factors that favor acceleration of atherosclerosis

    • Unfavorable lipoprotein profiles

  • Screen all men aged 35 years and older and women aged 45 years and older for lipid disorders.

  • Screen high-risk men and women beginning at age 20 years.

  • Pediatric guidelines recommend universal screening between the ages of 9 and 11 years.

  • In children with a parent who has premature ASCVD and dyslipidemia, screen as early as ages 1 to 4 years.

  • Recognize that the screening test is commonly nonfasting total cholesterol and HDLc levels, but a complete lipid profile would also detect potentially significant triglyceride disorders.

  • Confirm abnormalities in the nonfasting test with a 12-hour fasting lipid panel.

  • Use history to identify individuals who should be targeted for lipid treatment, and determine treatment thresholds and goals for therapy.

  • Calculate CV risk using updated risk calculators.

  • Classify patients with known CHD or a high-risk equivalent:

    • Very high risk: if the patient has CHD and uncontrolled major CV risk factors or a severe cholesterol lipid disorder suggesting high lifetime CHD risk

    • Intermediate risk: with features suggesting higher than expected short- and long-term CHD risk (e.g., atherosclerosis imaging studies, inflammatory or lipoprotein markers)

    • Low risk

  • Evaluate for diabetes.

  • Order a nonfasting lipid panel, and consider additional lab and other studies in select patients at moderate CV risk with either abnormal lipid profiles or unclear need for drug therapy, including:

    • Non-HDLc, apoB, or LDL-p: In individuals with elevated serum levels of triglyceride and/or low levels of HDLc, the calculated LDLc can be a poor indicator of true CV risk. In those individuals, the non-HDLc, apoB, or LDL-p may outperform LDLc for risk prediction, but because of the added expense of these measures, the non-HDLc is generally preferred.

    • Imaging for atherosclerosis: In moderate-risk individuals, consider using coronary artery calcium score by CT or carotid intima-media thickness by ultrasound to help stratify CV risk.

    • Tools such as hsCRP, lipoprotein-a, lipoprotein-associated phospholipase A2, and others may help stratify CV risk as well, but they tend to confirm rather than result in risk reclassification.

  • Rule out secondary causes of lipid disorders.

  • Initiate dietary therapy with a Mediterranean style diet, unless the patient has an overriding medical condition that warrants a different type of diet (e.g., hyperchylomicronemia responds better to a fat-restricted diet), and recommend exercise for all patients.

  • Obtain formal nutrition consultation for individuals with severe hypertriglyceridemia (hyperchylomicronemia).

  • Treat patients requiring drug therapy with statin drugs as the foundation for prevention of ASCVD. The strongest clinical trial evidence for reducing atherogenic lipoprotein levels comes from numerous trials with statin drugs.

  • Begin statin therapy in patients aged 21 years and older, based on CV risk:

    • In patients with known CV disease, provide a high-intensity statin unless contraindicated or not tolerated.

    • In patients with LDLc ≥190 mg/dL, provide a high-intensity statin unless contraindicated or not tolerated.

    • In patients aged 40 to 75 years with diabetes, but no known CV disease, provide moderate-intensity or high-intensity statin therapy.

    • Treat other patients according to the calculated risk for CV disease, providing a high-intensity statin to patients aged 40 to 75 years with at least a 10% calculated 10-year risk.

  • Use medications to lower triglycerides in patients with severe hypertriglyceridemia/hyperchylomicronemia who have not been able to reduce their triglyceride levels <500 mg/dL with lifestyle modification, to prevent pancreatitis. First-line treatment for marked triglyceride elevations should be with fibrates and/or high dose omega-3 fatty acids (fish oil).

  • Individualize therapy and consider combination drug therapy (e.g., statin plus nonstatin) in specific patients who do not achieve non-HDLc goals with maximum tolerated dose of statin drug, and who are at high enough risk to warrant additional pharmacotherapy. Select a non-statin based upon the treated lipid profile of the patient and expectations of response to the non-statin.

DOI: 10.7326/d176
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Thomas A. Pearson, MD, PhD, FACP is a consultant for Bristol-Myers Squibb, Bayer, J and J Merck, Merck/Schering Plough, Sanofi-Adventis, Forbes/Meditech, received honorarium from Abbott, AstraZeneca, Bayer, Bristol-Myers/Squibb, KOS, Pfizer, Merck/Schering Plough, Merck & Co., received grants from KOS, Merck & Co., Pfizer, Sanofi-Adventis. Laurie A. Kopin, EdD, MS, RN, ANP, FPCNA has nothing to disclose. Daniel Soffer, MD received program support for participation in clinical trials from Sanofi, Regeneron, Amgen, Pfizer, Astra-Zenenca, Novartis.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD, FACP; Richard Lynn, MD, FACP.

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