Patient-Centered Management of Dyslipidemia: Part 2

Publication Date: December 1, 2015

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

...Chart 1. Nu...

The NLA Expert Panel supports a cardioprotecti...

...ective eating pattern should limit cholesterol int...

...here are individuals who are hyper-respon...

...e NLA Expert Panel recommends any of the f...

...s consumed as part of a healthy dietary patt...

...ated fat may be partially replaced w...

...loss of 5-10% body weight is generally recom...

...that contain a moderate quantity of carbo...

...sterols and stanols (~2 g/day) are recommend...

For patients with TG levels ≥150 mg/d...

...ents with TG levels ≥1000 mg/dL (and sel...

...osages of EPA + DHA for TG-lowering shoul...

...mary and secondary prevention of AS...

...with known ASCVD, suggestive, but not conclus...

...or patients with heart failure, 1 g/da...

...lic acid intake of 0.6–1.2% of energ...

...tion of at least three 1-oz. equivalent...

...umption of ≥ 4 servings/week (1 oz. per servi...

...ein foods are one source of plant protein, a...

...education/MNT by a registered dietitian nut...

...s from Baseline Lipoprotein Lipid Levels by Diet i...

...Predicted Effects of Macronutrient Replacem...


...Chart 2. E...

...ended minimal quantity of exercise for su...

...ce the effects on TG and HDL-C, and...

...exercise is also recommended to play a supp...


Management

...Managemen...

...General Management...


...Chart 3....

...should assess adherence to both lifestyle and at...

...idisciplinary health care team (such as th...

...i-faceted approach should be employed by cl...


...Chart 4. Team-Base...

...care teams for optimal lipid and ASCVD risk...

Health care team members should coordinate c...

...am-based collaborative care may be incorporated i...


Hypertriglyceridemia

...Hypertriglycer...

...tly, TG is not a specific target for therapy...


...4. Evaluation of Hypertriglyceridem...


...1. Clinical Algorithm for Screening and...


...utrition Therapy for Very High TG (≥500...


Children and Adolescents

...Children and Ad...

...SCVD events rarely occur in children, th...


...Chart 5...

...lipid screening of all children, regardless...

...hild or adolescent patient is screened an...

Children ≥2 years of age with the foll...

...hould be regularly screened for major risk fa...

...arget levels during treatment are a matte...

...reening and reverse cascade screening are recom...

...n alternate treatment goal for pediatric...

...lifestyle interventions, including increased physi...

...8 years of age are potential candidates f...

...s and bile acid sequestrants are pharm...

...ation should be given to measurement of pr...

...e effects with lipid-altering pharmac...

...Acceptable, Borderline-high, and High Plasm...

...7. Major Risk Factors and Conditions in Chil...

...yslipidemia Algorithm Targeting LDL-C from the 2...

...le 8. International Diabetes Federation’...


Special Populations

...Special Populat...

...SCVD risk is associated with geogr...


...Women's Heal...

...Chart 6. Women...

...eneral, women should be treated according to...

...-line cholesterol-lowering drug therapy, unle...

...tatin drug therapy with cholesterol absor...

...king statins may be at increased risk for cer...

...Chart 7. Pregn...

...ould be screened for dyslipidemia before pregnancy...

...ng lipid-lowering medications prior to...

...should be educated on the importance of p...

...otal-C and TG levels in women with normal...

...sterolemia during pregnancy and br...

...th FH may be treated with LDL apheresi...

...high TG (≥500 mg/dL) may be treated during p...

...h-risk condition for dyslipidemia, metabolic synd...

...pproach to risk stratification and atherog...

...agement of dyslipidemia in PCOS shou...

...e choice affects dyslipidemia. Combina...

...not be used for prevention or treatment of ASC...

...HT is an option for treatment of significant...

...e 9. Lipid Lowering Agents and Pregnancy Ca...

...10. Criteria for Diagnosis of...


...Older Patients...

...Chart 8. Older Pat...

...ntion strategies in patients 65–79 years of...

...or patients age ...

...y prevention in patients ≥80 years of age,...

...ors such as the C/AHA Pooled Cohort Risk...

Older, primary prevention patients who are s...

...rimary prevention patient is unable...

...AC scoring may be useful to further assess ris...

...intolerance is an issue, considerat...


...Ethnic Groups...

...Chart 9. Hispani...

...eneral, patients of Hispanic/Latino ethnicit...

...cians should be aware that Hispanics/Latinos i...

...s tend to have a greater prevalence o...

...Latinos have higher prevalence of type 2 di...

Some cardiovascular risk equations (e....

...Chart 10. Africa...

...As should be treated according to the...

...ans should be aware that AAs as a group are at in...

Because attributable ASCVD risk in AAs is less...

...incidence of metabolic syndrome than...

...race/ethnicity is included in the 2013...

...a) levels tend to be higher in AA pat...

...ld not withhold statin therapy from at ri...

...Chart 11...

In general, patients of SA ethnicity should be tr...

...d be aware that SAs (including individuals...

...escent in the United States have a greater p...

...sed prevalence of metabolic syndrome compared to...

...should be aware that risk assessment metho...

...he possibility of genetic variation in drug meta...

...e at increased risk for diabetes, vi...

...C...

...ld be aware that AIs/ANs have higher prevalence...

...eral, clinicians should screen for and man...

...cians should generally assess risk in AI/AN patie...


...Concurr...

...Chart...

...ns should be aware that patients with HIV are at...

...asting lipid panel should be obtained...

...ry prevention of ASCVD, HIV infectio...

...stratification is based on the NLA...

...non-HDL-C and LDL-C goals described in...

...00 mg/dL that is refractory to lifestyle modifi...

...tin therapy is first-line for elevated LDL-C and...

...1. Interactions Between ART and Statin...

...Chart 14. Patients w...

...nicians should be aware that patients with R...

...n between RA and ASCVD risk is independ...

...ary prevention of ASCVD, RA may be counted as an...

...cation is based on the NLA Recommendations for the...

...s should be vigilant in ensuring that RA patie...

...are generally the first-line treatment...

...t this time, atherogenic cholester...

...tient has had lipid levels checked d...

...RA Treatments with Manufacturer Pac...


Residual Risk After Statins and Lifestyle Modification

...Residual Risk Aft...

...rogressively more intensive lowerin...


...e 13. Significant Risk Indicators...


...Table...

...scription omega-3 fatty acids are firs...

...ith elevated TG (200–499 mg/dL) o...

...t at goal atherogenic cholesterol leve...

...in combination therapies to conside...

...vascular outcomes trials are completed wi...

...addition, PCSK9 inhibitora use may be consid...

...9 inhibitora use may also be considered in sele...

...bitor NOT recommended for childr...


...Combination Therapies (clinical trial...


...Statin Combination Therapy...