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

...ifestyl...

...ritional Recommendations...

...NLA Expert Panel supports a cardioprotect...

...rotective eating pattern should limit cholestero...

...individuals who are hyper-responders to dietary...

...xpert Panel recommends any of the follow...

...consumed as part of a healthy dietary pat...

...ary saturated fat may be partially re...

...oss of 5-10% body weight is generally recommended...

...s that contain a moderate quantity of carboh...

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

...ith TG levels ≥150 mg/dL, lifesty...

...th TG levels ≥1000 mg/dL (and selected p...

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

...primary and secondary prevention of ASCVD, consum...

...atients with known ASCVD, suggestive, bu...

...with heart failure, 1 g/day of EPA + DHA...

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

...mption of at least three 1-oz. equival...

...nsumption of ≥ 4 servings/week (1 oz. per...

...oy protein foods are one source of plant...

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

...le 2. Changes from Baseline Lipoprotein...

...ed Effects of Macronutrient Replacemen...


...rt 2. Exercise/Physical Activity Recommenda...

...minimal quantity of exercise for supporting cardi...

...enhance the effects on TG and HDL-C...

...sistance exercise is also recommended to play...


Management

...agement...

...ral Management...


Chart 3. Patient Adherence

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

...multidisciplinary health care tea...

...multi-faceted approach should be employed...


...am-Based Collaborative Care

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

...team members should coordinate care s...

Team-based collaborative care may be in...


Hypertriglyceridemia

...riglyceridemia...

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


Table 4. Evaluation of Hypertriglyceridemia...


Figure 1. Clinical Algorithm for Screeni...


...ition Therapy for Very High TG (≥500 mg/...


Children and Adolescents

...dren and Adolescen...

...Although ASCVD events rarely occur in c...


...t 5. Children and Adolescent...

Universal lipid screening of all children,...

...a child or adolescent patient is screened an...

...years of age with the following characte...

...dren should be regularly screened for m...

Decisions on target levels during trea...

...ening and reverse cascade screening...

...treatment goal for pediatric FH patients in who...

...lifestyle interventions, including incre...

...n ≥8 years of age are potential ca...

...atins and bile acid sequestrants are pharma...

...should be given to measurement of pretr...

...side effects with lipid-altering pharmaco...

...6. Acceptable, Borderline-high, an...

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

...pidemia Algorithm Targeting LDL-C f...

...International Diabetes Federation’s Defini...


Special Populations

Special Populations

...Increased ASCVD risk is associated with geo...


...en's Health

...art 6. Women's H...

...women should be treated according to...

...ne cholesterol-lowering drug thera...

...rug therapy with cholesterol absorption inhi...

Women taking statins may be at increased...

...7. Pregnancy to Menopause

...men should be screened for dyslipid...

For women taking lipid-lowering medications...

...should be educated on the importance...

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

...erolemia during pregnancy and breas...

...may be treated with LDL apheresis durin...

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

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

...to risk stratification and atheroge...

Therapeutic management of dyslipide...

...ceptive choice affects dyslipidemia. Com...

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

...ex HT is an option for treatment of signi...

...9. Lipid Lowering Agents and Preg...

...iteria for Diagnosis of PCOS...


...lder Patien...

...art 8. Older Patient...

...imary prevention strategies in patients 65...

...tients age ≥65 to...

...ondary prevention in patients ≥80 years...

...tors such as the C/AHA Pooled Cohort...

...er, primary prevention patients who are s...

...the older primary prevention patient is unable to...

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

...statin intolerance is an issue, consideration...


Ethnic Gr...

...t 9. Hispanics/Latinos...

...general, patients of Hispanic/Latino ethni...

...ians should be aware that Hispanics...

...nics/Latinos tend to have a greater prevalence...

...tinos have higher prevalence of type 2 d...

Some cardiovascular risk equations...

...0. African Americans (AAs)...

In general, AAs should be treated accordi...

...inicians should be aware that AAs as a...

...attributable ASCVD risk in AAs is le...

...ve a lower incidence of metabolic sy...

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

...vels tend to be higher in AA patients, meas...

...should not withhold statin therapy from...

Chart 11. South Asians...

...eral, patients of SA ethnicity should be trea...

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

...of SA descent in the United States have a greater...

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

...icians should be aware that risk assessment...

...ssibility of genetic variation in drug metabolis...

...are at increased risk for diabetes...

...can Indians/Alaska Natives (AIs/ANs...

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

...inicians should screen for and manage dy...

...hould generally assess risk in AI/AN...


...ncurrent Condition...

...HIV-Infected Persons...

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

...g lipid panel should be obtained in all newly ide...

...evention of ASCVD, HIV infection may be counted a...

...isk stratification is based on the NLA Recommend...

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

...00 mg/dL that is refractory to lifesty...

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

...le 11. Interactions Between ART and Statins...

...hart 14. Patients with Rheumatoid Arthritis...

...ians should be aware that patients wit...

...ion between RA and ASCVD risk is independent of t...

...r primary prevention of ASCVD, RA may be counted...

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

Clinicians should be vigilant in ensuring...

...ins are generally the first-line treatmen...

...s time, atherogenic cholesterol treat...

...f an RA patient has had lipid levels checked dur...

...Treatments with Manufacturer Package...


Residual Risk After Statins and Lifestyle Modification

...k After Statins and Lifestyle Modification...

...ly more intensive lowering of low-density li...


...ble 13. Significant Risk IndicatorsH...


...14. Recommendations...

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

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

...at goal atherogenic cholesterol levels on ma...

...tatin combination therapies to consid...

...vascular outcomes trials are completed...

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

...nhibitora use may also be considered in selected...

...ibitor NOT recommended for children....


...atin Combination Therapies (clinical trial res...


...atin Combination Therapy...