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Last Updated: 8/4/2014  

Lipid Disorders (Dyslipidemia)

Screening
  • Screen high-risk adults, all men aged 35 or older, and women aged 45 or older for lipid disorders by checking either a fasting lipid profile or total cholesterol and HDL. Screen low-risk adults every 5 years.

Diagnosis
  • Use history to identify individuals who should be targeted for lipid treatment, determine treatment thresholds and goals for therapy, and classify patients as:

    • CHD or CHD high risk equivalent, and consider very high risk if the patient also has uncontrolled major CV risk factors

    • 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

    • Severe lipid (cholesterol) disorder, suggesting high lifetime CHD risk

  • Check a fasting lipid profile to diagnose lipid disorders.

  • Evaluate for diabetes.

  • Calculate CV risk using updated pooled cohort equation or alternative risk tools.

  • 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:

    • Imaging for atherosclerosis (coronary artery calcium score by CT or carotid intima-media thickness by ultrasound) to help stratify CV risk in moderate-risk individuals

    • Tools such as high-sensitivity C-reactive protein, lipoprotein-(a), lipoprotein phospholipase A2, and others

  • Rule out secondary causes of lipid disorders.

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

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

  • Treat patients requiring drug therapy with statin drugs as the foundation for prevention of atherosclerotic CV disease.

  • Begin statin therapy based on patients' CV risk:

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

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

    • In patients aged 40 to 75 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 and 75 with at least a 10% calculated 10-year risk.

  • Use medications to lower triglycerides in patients with severe hypertriglyceridemia/hyperchylomicronemia to prevent pancreatitis, 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.

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.
Authors 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 no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Daniel Soffer, MD received a one-time consulting fee from Aegerion, grant funding from Sanofi/Regeneron, and an educational grant from Roche Genentech.

The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, FACP, Editor.

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