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. Nutritiona...

...NLA Expert Panel supports a cardiopro...

...rdioprotective eating pattern should...

...re are individuals who are hyper-respo...

...Panel recommends any of the following health...

...l is consumed as part of a healthy d...

...saturated fat may be partially repl...

...of 5-10% body weight is generally reco...

Eating patterns that contain a moder...

...erols and stanols (~2 g/day) are recommended f...

...th TG levels ≥150 mg/dL, lifestyle therap...

...patients with TG levels ≥1000 mg/d...

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

...d secondary prevention of ASCVD, con...

...th known ASCVD, suggestive, but not co...

...r patients with heart failure, 1 g...

...onelic acid intake of 0.6–1.2% of energy i...

...on of at least three 1-oz. equivalent servin...

...tion of ≥ 4 servings/week (1 oz. per se...

...in foods are one source of plant protein, amo...

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

...2. Changes from Baseline Lipoprotein Lipid Levels...

...e 3. Predicted Effects of Macronutri...


...Chart 2....

...commended minimal quantity of exercise for suppo...

...ance the effects on TG and HDL-C, and produce redu...

...rcise is also recommended to play a su...


Management

...Management...

...General...


...Chart 3. P...

...provider should assess adherence to both lifestyl...

...nary health care team (such as the patient’...

The multi-faceted approach should be empl...


...Chart 4. T...

...alth care teams for optimal lipid and ASCVD ri...

...re team members should coordinate c...

...collaborative care may be incorpora...


Hypertriglyceridemia

...Hypertriglyc...

...rrently, TG is not a specific targ...


...4. Evaluation of Hypertriglyceride...


...gure 1. Clinical Algorithm for Scre...


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


Children and Adolescents

...Childr...

...though ASCVD events rarely occur in ch...


...Chart 5. Chil...

...screening of all children, regardless of general...

...adolescent patient is screened and has a fa...

...ren ≥2 years of age with the following ch...

...en should be regularly screened for major risk fac...

...on target levels during treatment a...

...scade screening and reverse cascade scr...

...lternate treatment goal for pediatri...

...iet and other lifestyle interventions, includ...

...≥8 years of age are potential candid...

...tins and bile acid sequestrants are...

...sideration should be given to measurement...

...tential side effects with lipid-altering p...

...cceptable, Borderline-high, and High...

...Risk Factors and Conditions in Children and...

...ure 2. Dyslipidemia Algorithm Targeting L...

...ternational Diabetes Federation’s Definition o...


Special Populations

...Special Popula...

...ASCVD risk is associated with geog...


Women&...

...Chart 6. Women...

...ral, women should be treated according t...

...sterol-lowering drug therapy, unless contrai...

...drug therapy with cholesterol absorpt...

...omen taking statins may be at increased r...

...Chart 7. Pregnancy to Me...

...ld be screened for dyslipidemia before pregna...

...n taking lipid-lowering medications prior to pr...

...en should be educated on the importance of pregn...

...C and TG levels in women with normal preg...

...emia during pregnancy and breast feeding,...

...y be treated with LDL apheresis during pregnancy...

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

...h-risk condition for dyslipidemia, m...

...risk stratification and atherogenic cholesterol t...

...rapeutic management of dyslipidemia in PCO...

...ceptive choice affects dyslipidemia. Comb...

...ex HT should not be used for preventi...

...l sex HT is an option for treatmen...

...d Lowering Agents and Pregnancy CategoriesaH...

Table 10. Criteria for Diagno...


...Old...

Chart 8....

...ry prevention strategies in patients 65–79 ye...

...ients age ≥65 to...

...r secondary prevention in patients ...

...rs such as the C/AHA Pooled Cohort Risk calculat...

...rimary prevention patients who are statin-e...

If the older primary prevention pa...

...ng may be useful to further assess risk in old...

...tin intolerance is an issue, consideration shou...


...Ethn...

...Chart 9. Hispanic...

...ents of Hispanic/Latino ethnicity should be tr...

...nicians should be aware that Hispanics/Latino...

...cs/Latinos tend to have a greater prevalenc...

...os have higher prevalence of type 2 diabetes m...

...diovascular risk equations (e.g., Framingham...

...Chart 10. Afri...

...eral, AAs should be treated according to th...

...s should be aware that AAs as a group are at incr...

...ributable ASCVD risk in AAs is less driven b...

...r incidence of metabolic syndrome than NHW...

...cause AA race/ethnicity is included in t...

...cause Lp(a) levels tend to be higher in AA...

...cians should not withhold statin therapy from at r...

Chart...

...general, patients of SA ethnicity should be tre...

...should be aware that SAs (including indivi...

...tients of SA descent in the United States h...

...ave increased prevalence of metabolic syndrome com...

...hould be aware that risk assessment met...

...he possibility of genetic variatio...

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

...Char...

...ians should be aware that AIs/ANs have h...

..., clinicians should screen for and manage dysl...

...ould generally assess risk in AI/AN patients...


...C...

...Chart 13. HIV-Infected Per...

...d be aware that patients with HIV are at...

...fasting lipid panel should be obtained in all...

...y prevention of ASCVD, HIV infection may be c...

...ratification is based on the NLA Recommendations f...

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

...500 mg/dL that is refractory to lifestyle m...

...erapy is first-line for elevated LDL-C an...

...11. Interactions Between ART and StatinsaHav...

...Chart...

...ould be aware that patients with RA are at incr...

...ociation between RA and ASCVD risk...

...ary prevention of ASCVD, RA may be...

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

...ld be vigilant in ensuring that RA patients are...

...erally the first-line treatment for dyslipidemi...

...time, atherogenic cholesterol treatm...

...RA patient has had lipid levels che...

...able 12. RA Treatments with Manufac...


Residual Risk After Statins and Lifestyle Modification

...Residual Risk After Sta...

...vely more intensive lowering of low-d...


...nificant Risk IndicatorsHaving trouble v...


...tes and prescription omega-3 fatty...

...with elevated TG (200–499 mg/dL) on ma...

...ts not at goal atherogenic cholesterol levels on...

Recommended statin combination thera...

Until cardiovascular outcomes tria...

..., PCSK9 inhibitora use may be considered for...

...ra use may also be considered in sel...

a PCSK9 inhibitor NOT recommended for chi...


...in Combination Therapies (clinical tr...


...atin Combination Therapy...