Patient-Centered Management of Dyslipidemia: Part 2
Key Points
Key Points
- An elevated level of cholesterol carried by circulating apolipoprotein (APO) B containing lipoproteins (non-high-density lipoprotein cholesterol [non-HDL -C] and low-density lipoprotein cholesterol [LDL-C], termed atherogenic cholesterol) is a root cause of atherosclerosis, the key underlying process contributing to most clinical atherosclerotic cardiovascular disease (ASCVD) events.
- Reducing elevated levels of atherogenic cholesterol will lower ASCVD risk in proportion to the extent that atherogenic cholesterol is reduced.
- The intensity of risk-reduction therapy should generally be adjusted to the patient’s absolute risk for an ASCVD event (see Table 1).
- Atherosclerosis is a process that often begins early in life and progresses for decades before resulting in a clinical ASCVD event. Therefore, both intermediate-term and long-term/lifetime risk should be considered when assessing the potential benefits and hazards of risk-reduction therapies.
- For patients in whom lipid-lowering drug therapy is indicated, statin treatment is the primary modality for reducing ASCVD risk.
- Treatment goals and periodic monitoring of atherogenic cholesterol levels (non-HDLC and LDL-C) are important tools in the implementation of a successful treatment strategy. These aid the clinician in assessing the adequacy of treatment and facilitate active participation by the patient through feedback and reinforcement of the beneficial effects of lifestyle and pharmaceutical therapies.
- Non-lipid ASCVD risk factors should also be managed appropriately, particularly high blood pressure, cigarette smoking, and diabetes mellitus.
- NLA Dyslipidemia – Part II represents a continuation of NLAa Dyslipidemia – Part I providing patient-centered, evidence-graded recommendations for the management of specific aspects of dyslipidemia.
a Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 1. Lipid 2014; 8:473–88.
Table 1. Criteria for ASCVD Risk Assessment, Treatment Goals for Atherogenic Cholesterol, and Levels at Which to Consider Drug Therapy
Lifestyle
...festyl...
...tritional Recommendations...
...Panel supports a cardioprotective eating...
...tective eating pattern should limit chole...
There are individuals who are hyper-respon...
...Expert Panel recommends any of the follo...
...consumed as part of a healthy dietary pattern,...
...ietary saturated fat may be partially repl...
...ht loss of 5-10% body weight is generally re...
...g patterns that contain a moderate quantity of ca...
...d stanols (~2 g/day) are recommended f...
...with TG levels ≥150 mg/dL, lifest...
For patients with TG levels ≥1000...
...dosages of EPA + DHA for TG-lowering should be...
...d secondary prevention of ASCVD, co...
...th known ASCVD, suggestive, but not concl...
...ts with heart failure, 1 g/day of EPA + DHA is r...
...linonelic acid intake of 0.6–1.2% o...
...ption of at least three 1-oz. equivalent serving...
Consumption of ≥ 4 servings/week (1 oz....
...protein foods are one source of plant protei...
...tion/MNT by a registered dietitian nutritio...
...able 2. Changes from Baseline Lipoprotein Lipid L...
...3. Predicted Effects of Macronutrient...
...Exercise/Physical Activity Recommendati...
...mmended minimal quantity of exercise for support...
...nce the effects on TG and HDL-C, and...
...ercise is also recommended to play...
Management
...nagement...
...neral Manageme...
.... Patient Adherence...
...vider should assess adherence to both lifestyle an...
...iplinary health care team (such as th...
...lti-faceted approach should be employed by...
...m-Based Collaborative Care...
...h care teams for optimal lipid and...
...lth care team members should coordinate...
...m-based collaborative care may be inco...
Hypertriglyceridemia
...ypertriglycerid...
Currently, TG is not a specific target...
.... Evaluation of Hypertriglyceridemia Me...
...Clinical Algorithm for Screening and Manage...
...on Therapy for Very High TG (≥500 mg/dL)/Ch...
Children and Adolescents
...en and Adolescents...
...h ASCVD events rarely occur in children, the...
...rt 5. Children and Adolescents...
...l lipid screening of all children, regardl...
...d or adolescent patient is screened...
...ldren ≥2 years of age with the following charact...
...ldren should be regularly screened for...
...arget levels during treatment are a...
...ning and reverse cascade screening are...
...lternate treatment goal for pediatric FH p...
...d other lifestyle interventions, includin...
...dren ≥8 years of age are potenti...
...nd bile acid sequestrants are pharmacologi...
...deration should be given to measur...
...effects with lipid-altering pharmacotherapy sho...
.... Acceptable, Borderline-high, and Hi...
...ble 7. Major Risk Factors and Conditions in Child...
...igure 2. Dyslipidemia Algorithm Targeting L...
...International Diabetes Federation’...
Special Populations
Special Populatio...
...SCVD risk is associated with geograph...
...#39;s Health...
...Women's Healt...
...women should be treated according to the NLA R...
...cholesterol-lowering drug therapy, un...
...atin drug therapy with cholesterol absorp...
...king statins may be at increased risk...
...Pregnancy to Menopause...
...d be screened for dyslipidemia before pre...
...taking lipid-lowering medications prior t...
...men should be educated on the importance of preg...
...and TG levels in women with normal pregnancies...
...percholesterolemia during pregnancy and...
...y be treated with LDL apheresis during pregnanc...
...TG (≥500 mg/dL) may be treated d...
...high-risk condition for dyslipidemia, metab...
...pproach to risk stratification and atherogenic...
Therapeutic management of dyslipidemia in...
Contraceptive choice affects dyslipidemia....
...d not be used for prevention or treat...
...sex HT is an option for treatment of signific...
...e 9. Lipid Lowering Agents and Pre...
...teria for Diagnosis of PCOS...
Older Patient...
...t 8. Older Patie...
...prevention strategies in patients 65...
...or patients age ≥65 to...
...ndary prevention in patients ≥80 years of...
...rs such as the C/AHA Pooled Cohort Risk...
...rimary prevention patients who are stat...
If the older primary prevention pati...
...C scoring may be useful to further assess risk...
...rance is an issue, consideration shoul...
Ethnic Grou...
...art 9. Hispanics/Lat...
...ents of Hispanic/Latino ethnicity sh...
...ians should be aware that Hispanics/Latino...
Hispanics/Latinos tend to have a great...
...inos have higher prevalence of typ...
Some cardiovascular risk equations (e.g., Fra...
...hart 10. African Americans (...
...n general, AAs should be treated according to the...
...nicians should be aware that AAs as a group are at...
...ecause attributable ASCVD risk in AAs is less d...
...ave a lower incidence of metabolic syndrome t...
...AA race/ethnicity is included in the 20...
...vels tend to be higher in AA patients...
...s should not withhold statin therapy from a...
...11. South Asians (SAs)...
...tients of SA ethnicity should be treated accordin...
...ould be aware that SAs (including individuals...
Patients of SA descent in the United States have...
SAs have increased prevalence of metabo...
Clinicians should be aware that risk assess...
...ue to the possibility of genetic variation in drug...
...As are at increased risk for diabetes, vigilan...
...art 12. American Indians/Alaska Natives...
...linicians should be aware that AIs/ANs...
...nicians should screen for and mana...
...hould generally assess risk in AI/AN patients usin...
...ncurrent Conditions...
...t 13. HIV-Infected Pers...
...should be aware that patients with HIV are at...
...d panel should be obtained in all newly ide...
...primary prevention of ASCVD, HIV in...
...ation is based on the NLA Recommendations for the...
...HDL-C and LDL-C goals described in the NLA Par...
...¥500 mg/dL that is refractory to lifestyle m...
...therapy is first-line for elevated LD...
...1. Interactions Between ART and St...
...Patients with Rheumatoid Arthritis (RA)
Clinicians should be aware that patients with RA a...
...ation between RA and ASCVD risk is independent of...
...y prevention of ASCVD, RA may be counted as...
...atification is based on the NLA Recomme...
...ians should be vigilant in ensuring th...
...erally the first-line treatment for dyslipi...
...time, atherogenic cholesterol tre...
...nt has had lipid levels checked during an...
...able 12. RA Treatments with Manufacturer...
Residual Risk After Statins and Lifestyle Modification
...isk After Statins and Lifestyle Modification...
...ssively more intensive lowering of low-densi...
...gnificant Risk IndicatorsHaving tro...
...le 14. Recommendations...
...es and prescription omega-3 fatty aci...
...tients with elevated TG (200–499 m...
...nts not at goal atherogenic cholestero...
...mmended statin combination therapies...
...ascular outcomes trials are completed...
...ddition, PCSK9 inhibitora use may b...
...tora use may also be considered in sel...
...CSK9 inhibitor NOT recommended for ch...
.... Statin Combination Therapies (clinical trial...
...Statin Combination Ther...