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
Lifesty...
...art 1. Nutritional Recommendations...
...anel supports a cardioprotective ea...
...oprotective eating pattern should limit c...
...viduals who are hyper-responders t...
...NLA Expert Panel recommends any of...
...alcohol is consumed as part of a healthy dietary...
Dietary saturated fat may be partial...
...5-10% body weight is generally recommended for...
...s that contain a moderate quantity of carbohydra...
...ant sterols and stanols (~2 g/day) are r...
...with TG levels ≥150 mg/dL, lifes...
...with TG levels ≥1000 mg/dL (and select...
...ges of EPA + DHA for TG-lowering sho...
...d secondary prevention of ASCVD, consumi...
...ents with known ASCVD, suggestive, but not conclu...
...ients with heart failure, 1 g/day of EPA +...
...pha linonelic acid intake of 0.6–1....
...umption of at least three 1-oz. equivale...
...ion of ≥ 4 servings/week (1 oz. pe...
...protein foods are one source of plant pr...
...trition education/MNT by a registered...
...es from Baseline Lipoprotein Lipid Levels by D...
...3. Predicted Effects of Macronutrient...
...2. Exercise/Physical Activity Recommendat...
...mmended minimal quantity of exercise for...
...the effects on TG and HDL-C, and produce reduction...
...e exercise is also recommended to play a sup...
Management
Managem...
...al Management...
...t 3. Patient Adherence...
...vider should assess adherence to both lifestyle...
A multidisciplinary health care team (such as t...
...lti-faceted approach should be employed...
...Team-Based Collaborative Care...
...e teams for optimal lipid and ASCVD risk mana...
Health care team members should coordinate care s...
...sed collaborative care may be incorporate...
Hypertriglyceridemia
Hypertriglyceridem...
...Currently, TG is not a specific target for thera...
...luation of Hypertriglyceridemia...
...nical Algorithm for Screening and Manage...
...le 5. Nutrition Therapy for Very High TG (≥50...
Children and Adolescents
Children and Adole...
...gh ASCVD events rarely occur in children, t...
...art 5. Children and Adolesc...
...iversal lipid screening of all children, regar...
...adolescent patient is screened and has a fast...
...2 years of age with the following characteristics...
...d be regularly screened for major risk...
...ons on target levels during treatment are a matt...
...ing and reverse cascade screening are reco...
...alternate treatment goal for pediatric FH p...
...er lifestyle interventions, includin...
...8 years of age are potential candidat...
...and bile acid sequestrants are ph...
...sideration should be given to measurem...
...effects with lipid-altering pharmac...
...cceptable, Borderline-high, and High Plasma L...
...e 7. Major Risk Factors and Conditi...
...slipidemia Algorithm Targeting LDL-C fr...
...e 8. International Diabetes Federa...
Special Populations
...pecial Populations...
...ASCVD risk is associated with geograph...
...en's Health...
...Women's Health...
...eral, women should be treated according to the N...
...-line cholesterol-lowering drug the...
...-statin drug therapy with cholesterol absorpti...
...ing statins may be at increased risk...
...Pregnancy to Menopause...
...en should be screened for dyslipidemia befor...
...or women taking lipid-lowering medic...
...e educated on the importance of pregna...
...TG levels in women with normal pre...
...ercholesterolemia during pregnancy and b...
...FH may be treated with LDL apheresis during...
...ery high TG (≥500 mg/dL) may be treated durin...
...a high-risk condition for dyslipidemia, metabol...
...ach to risk stratification and atherogen...
...management of dyslipidemia in PCOS should focus...
...aceptive choice affects dyslipidemia....
...ex HT should not be used for prevention or tre...
Menopausal sex HT is an option for trea...
...able 9. Lipid Lowering Agents and Pregnancy C...
...10. Criteria for Diagnosis of...
...r Patients
...8. Older Patient...
...ary prevention strategies in patients 65...
...or patients age ≥65 t...
...secondary prevention in patients ≥80 years of...
...rs such as the C/AHA Pooled Cohort Risk calcul...
..., primary prevention patients who are sta...
...he older primary prevention patient is unable...
...ay be useful to further assess risk in older...
...tolerance is an issue, consideration should be...
Ethnic Groups
...hart 9. Hispanics/Lat...
...ents of Hispanic/Latino ethnicity should be t...
...d be aware that Hispanics/Latinos in th...
...Latinos tend to have a greater prevalence of hi...
...os have higher prevalence of type 2 diabetes...
...lar risk equations (e.g., Framingham equa...
...rt 10. African Americans (AAs)...
...s should be treated according to the...
...should be aware that AAs as a group are at...
...ributable ASCVD risk in AAs is less dr...
...lower incidence of metabolic syndrome than NHW...
...ace/ethnicity is included in the 2013 C/AHA Pooled...
...p(a) levels tend to be higher in AA patients, meas...
...uld not withhold statin therapy from at...
Chart 11. South Asian...
...patients of SA ethnicity should be treated a...
...hould be aware that SAs (including in...
...ts of SA descent in the United States have...
...ave increased prevalence of metaboli...
...ould be aware that risk assessment methods may un...
...possibility of genetic variation in drug...
...are at increased risk for diabetes,...
...rican Indians/Alaska Natives (AIs/ANs)...
...d be aware that AIs/ANs have highe...
...inicians should screen for and manage dyslipidemi...
...nicians should generally assess risk...
...rrent Conditions...
...13. HIV-Infected Persons...
...ould be aware that patients with HIV are at incre...
...ting lipid panel should be obtained...
...vention of ASCVD, HIV infection may...
...isk stratification is based on the NLA Reco...
...d LDL-C goals described in the NLA Part 1...
...500 mg/dL that is refractory to lifestyle mod...
...s first-line for elevated LDL-C and non-...
...11. Interactions Between ART and Sta...
...hart 14. Patients with Rheumatoid Art...
...ns should be aware that patients with RA are at...
...between RA and ASCVD risk is independent of the ri...
...ry prevention of ASCVD, RA may be counted...
...sk stratification is based on the NLA Re...
...cians should be vigilant in ensuring that R...
...are generally the first-line treatment for...
..., atherogenic cholesterol treatment...
If an RA patient has had lipid levels c...
...12. RA Treatments with Manufacturer Package Inse...
Residual Risk After Statins and Lifestyle Modification
...idual Risk After Statins and Lifestyle...
Progressively more intensive lo...
...Significant Risk IndicatorsHaving trou...
...e 14. Recommendat...
...es and prescription omega-3 fatty acids are first-...
...ients with elevated TG (200–499 mg/dL...
...t at goal atherogenic cholesterol levels on...
...mended statin combination therapies to consid...
...ascular outcomes trials are completed with PC...
In addition, PCSK9 inhibitora use may be...
...itora use may also be considered in se...
...PCSK9 inhibitor NOT recommended for children....
...atin Combination Therapies (clinical trial r...
...Statin Combination Therapy...