Hyperlipidemia (HLD) or Dyslipidemia: Screening, Treatment, and Prevention

Clinic A/P, adults, Clinic A/P, Peds

H&P + Dx
Exercise? Diet? FHx of premature CAD?
Risk factors for ASCVD?
Known ASCVD in pt?
BMI? xanthoma? xanthelasma?
Carotid bruits?
Screening recs.
Labs: Lipid panel (non-fasting). Baseline LFTs (CMP) and CK.
Repeat the lipid panel to confirm HLD.
TSH, A1C, CMP, U/A to r/o secondary causes of hyperlipidemia, as needed.
Consider labs to r/o key risk factors for ASCVD.
Treatment
LSC:  exercise, diet, and weight loss (if indicated).
1st-line drug: Statin
Pts with known ASCVD should receive high-intensity statins regardless of LDL unless they fall into special categories (e.g., older age) or do not tolerate high-intensity statins, in which case moderate-intensity statins are appropriate.
Tx all pts with no known ASCVD w/ statins if total LDL ≥ 190 or 10-year ASCVD risk is ≥ 10%. Start mod-dose statin on pts w/10-year ASCVD risk ≥ 10 % and high-intensity in pts w/ risk >20%.
If very high LDL-C (≥ 190 mg/dL), evaluate for familial HLD + start high-intensity Statin.
2nd-line drugs: If LDL-C is still high despite high-intensity or maximal statin therapy, add Ezetimibe as the second drug.  Other LDL-lowering drugs include bile acid sequestrants and PCSK9 inhibitors.
Monitoring
Check AST & ALT before starting statins (i.e. baseline). No need to recheck CK and LFTs unless pt has symptoms.
Check LDL-C  in 1 to 3mo after starting tx w/ either LSC (alone), with LSC + Statins, or when adjusting Statin dose. Then q6-12 mo after tx goal is reached.
– A good response is to tx is and LDL-C drop of 35 to 50%. If a good response is not achieved, eval for compliance. If compliance good but not adequate tx (e.g. if 10-yr risk still > 20%), increase to high-intensity statin.
Referring
Refer to cardiology if coronary artery calcium (CAC) measurements needed as when risk level and tx decisions less certain.
Refer to cardiology when fibrates are needed for elevated TGs. Some advise not to combine fibrates with statins.
Refer when a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor needs to be considered for patients at very high risk.
Refer pts w/ genetic condition that causes very high LDL-C.

—//END//—

Hyperlipidemia Links & Pearls

  • Secondary Prevention of ASCVD, algorithm.
  • Cholesterol – Primary Prevention Algorithm.
  • LDL-C is what you target to Rx HLD.
  • Don’t use Niacin – “Prescription niacin (nicotinic acid, vitamin B3) does not reduce myocardial infarctions, strokes, or overall mortality when used for primary or secondary prevention” (SOR A) – AFP. 2018 Apr 1;97(7):436-437
  • For pts with no known ASCVD event, statin tx is based on the patient’s 10-year risk of an ASCVD event rather than treating specific lipid levels except for severe HLD ( LDL ≥ 190). The ACC and AHA recommend tx w/ moderate- to high-intensity statins if the risk is ≥ 7.5%, whereas the USPSTF and NICE recommend tx if the risk is ≥ 10%.
  • Moderate and High-Intensity Statin Therapy.
  • LDL Cholesterol Calculation and High Triglycerides.
  • ASCVD Risk Calculator from MDCalc.com.For use in adults without known ASCVD.
  • ASCVD Risk Calculator from the ACC.
  • The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians (Grade B).
  • 10-year risk estimates are based on ACC/AHA Pooled Cohort Equation.
  • Kaiser Permanente 2018 guidelines, recommends “screening with a non-fasting lipid panel for both men and women between ages 40 and 75 at a minimum of every 5 years.” They say, “Non-fasting lipid panel is now the preferred cholesterol test.”
  • Equivalent Doses for Statins.
  • Total cholesterol (TC) = LDL + HDL + VLDL. Where VLDL ≅ TG/5. The formula is valid if TG <400 mg/dL. If TG > 400 mg/dL, you have to measure the LDL directly, rather than calculating it.
  • Statins are HMG-CoA reductase inhibitors.
  • Rx statins, regardless of LDL, for pts w/ CHD risk equivalents or 10 yr ASCVD risk >20%.
  • Statins decrease cardiac & overall mortality in pts with or without ASCVD.
  • Statin benefits and functions.
  • “Triglyceride-lowering drugs are fibrates and niacin; they have a mild LDL-lowering action, but RCTs do not support their use as add-on drugs to statin therapy See algorithm.” 2018 AHA/ACC guidelines.
  • Bile Sequestrants (Cholestyramine, Colestipol, or Colesevelam).
  • Cholesterol classification.
  • ATP III Quick Reference Guide.
  • The 2018 AHA/ACC Cholesterol Guidelines.

Abbreviations
LSC = Lifestyle Changes;

“Triglycerides are considered to have atherogenic properties. • HDL is considered a protective lipoprotein because it contributes to reverse cholesterol transport. • Small, dense LDL is considered more atherogenic than large, buoyant LDL because it is more prone to oxidation and can trigger inflammatory processes.” WHO

 

References / Resources

J Am Coll Cardiol. 2018 Nov 3. pii: S0735-1097(18)39033-8. https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625 (New AHA/ACC Cholesterol guidelines for 2018)

Click to access ascvd-primary.pdf

https://www.aafp.org/news/health-of-the-public/20181128ahaacccholesterol.html

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000638

https://www.aafp.org/afp/2017/0115/p78.html

Gaddi A, Cicero AF, Odoo FO, Poli AA, Paoletti R; Atherosclerosis and Metabolic Diseases Study Group. Practical guidelines for familial combined hyperlipidemia diagnosis: an up-date. Vasc Health Risk Manag. 2007;3(6):877–886.

Am Fam Physician. 2018 Apr 1;97(7):436-437. https://www.aafp.org/afp/2018/0401/p436.html

print