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
...estyle...
...1. Nutritional Recommendations...
...anel supports a cardioprotective e...
...cardioprotective eating pattern should limit chole...
...e are individuals who are hyper-responders to di...
...ert Panel recommends any of the following...
...cohol is consumed as part of a healthy dietary p...
...saturated fat may be partially replaced...
Weight loss of 5-10% body weight is generally...
...erns that contain a moderate quantity...
...s and stanols (~2 g/day) are recommended...
...th TG levels ≥150 mg/dL, lifestyl...
...r patients with TG levels ≥1000 mg/dL (an...
...dosages of EPA + DHA for TG-loweri...
...or primary and secondary prevention of ASCVD, cons...
...th known ASCVD, suggestive, but not...
For patients with heart failure, 1 g/day of...
...linonelic acid intake of 0.6–1....
Consumption of at least three 1-oz. equivalent se...
...of ≥ 4 servings/week (1 oz. per serving)...
...y protein foods are one source of plant pro...
...cation/MNT by a registered dietitia...
Table 2. Changes from Baseline Lip...
...ed Effects of Macronutrient Replacemen...
...rt 2. Exercise/Physical Activity Recommen...
...mended minimal quantity of exercise for...
...the effects on TG and HDL-C, and produ...
...stance exercise is also recommended to play a sup...
Management
...anagement
...eral Management
Chart 3. Patient Adheren...
The provider should assess adherence to...
...ltidisciplinary health care team (s...
...d approach should be employed by clini...
...4. Team-Based Collaborative Care...
...s for optimal lipid and ASCVD risk ma...
...eam members should coordinate care su...
...based collaborative care may be incor...
Hypertriglyceridemia
...rtriglyceridemia...
...TG is not a specific target for therapy...
...uation of Hypertriglyceridemia Medical histo...
...ure 1. Clinical Algorithm for Screening a...
...trition Therapy for Very High TG (≥500 mg/...
Children and Adolescents
Children and Adolescents
...ASCVD events rarely occur in chil...
...5. Children and Adolescents...
...screening of all children, regardless of gene...
...hild or adolescent patient is screened...
...≥2 years of age with the following characte...
...be regularly screened for major risk factors and...
...sions on target levels during treatment...
...e screening and reverse cascade screenin...
...e treatment goal for pediatric FH patients in w...
...nd other lifestyle interventions, in...
...ildren ≥8 years of age are potential...
...ile acid sequestrants are pharmacologic...
...nsideration should be given to measur...
...side effects with lipid-altering pharmacother...
...le 6. Acceptable, Borderline-high, and Hi...
...7. Major Risk Factors and Condition...
...lipidemia Algorithm Targeting LDL-C from the...
...ble 8. International Diabetes Federation’s Def...
Special Populations
...ecial Populations
...ased ASCVD risk is associated with geograph...
...'s Health
...6. Women's Health...
...al, women should be treated according to the...
...line cholesterol-lowering drug therapy, un...
Non-statin drug therapy with cholesterol...
...ing statins may be at increased risk for...
...7. Pregnancy to Menopa...
Women should be screened for dyslipidemia...
...en taking lipid-lowering medicatio...
...n should be educated on the importance of p...
...and TG levels in women with normal pregna...
...rolemia during pregnancy and breast feedin...
...with FH may be treated with LDL aphe...
...ery high TG (≥500 mg/dL) may be treated duri...
...risk condition for dyslipidemia, metabo...
...risk stratification and atherogenic cholesterol t...
...erapeutic management of dyslipidemia in P...
...tive choice affects dyslipidemia. Co...
Sex HT should not be used for preven...
...usal sex HT is an option for treatment of...
...id Lowering Agents and Pregnancy Cat...
...teria for Diagnosis of PCOS...
...r Patients...
...8. Older Patients
...on strategies in patients 65–79 years of age s...
...atients age ≥65 to...
For secondary prevention in patien...
...alculators such as the C/AHA Pooled Cohort Risk ca...
...r, primary prevention patients who...
...older primary prevention patient is unable t...
...may be useful to further assess risk in older p...
...lerance is an issue, consideration s...
Ethnic Gr...
...hart 9. Hispanics/Latin...
...n general, patients of Hispanic/Latino eth...
...ians should be aware that Hispanic...
...anics/Latinos tend to have a greater prevalence...
...atinos have higher prevalence of type 2...
...lar risk equations (e.g., Framingham equat...
...frican Americans (AAs)...
...AAs should be treated according to the...
...s should be aware that AAs as a gr...
Because attributable ASCVD risk in AAs...
...r incidence of metabolic syndrome than...
...race/ethnicity is included in the...
...ause Lp(a) levels tend to be higher in AA...
...ns should not withhold statin therapy from at ris...
...t 11. South Asians (S...
...tients of SA ethnicity should be treated ac...
...uld be aware that SAs (including individu...
...ts of SA descent in the United States have a...
...have increased prevalence of metabolic syn...
...should be aware that risk assessment methods ma...
...to the possibility of genetic vari...
...se SAs are at increased risk for dia...
...ican Indians/Alaska Natives (AIs/ANs)...
...uld be aware that AIs/ANs have hig...
...eneral, clinicians should screen for and man...
...d generally assess risk in AI/AN patients using...
...ncurrent Conditi...
...rt 13. HIV-Infected Person...
...inicians should be aware that patie...
...lipid panel should be obtained in a...
...primary prevention of ASCVD, HIV infection m...
...ratification is based on the NLA R...
...d LDL-C goals described in the NLA...
Elevated TG ≥500 mg/dL that is refractory to...
Statin therapy is first-line for elevated...
...ractions Between ART and StatinsaHaving troub...
...rt 14. Patients with Rheumatoid Arthritis (R...
...linicians should be aware that patients with R...
The association between RA and ASCVD...
...r primary prevention of ASCVD, RA may be co...
...tification is based on the NLA Recommendat...
...d be vigilant in ensuring that RA pat...
...enerally the first-line treatment...
...time, atherogenic cholesterol treatment goals for...
...ient has had lipid levels checked during an RA fla...
...able 12. RA Treatments with Manufacturer Pa...
Residual Risk After Statins and Lifestyle Modification
...fter Statins and Lifestyle Modific...
...essively more intensive lowering of lo...
...Significant Risk IndicatorsHaving trouble vie...
...able 14. Recommenda...
...brates and prescription omega-3 fatt...
...th elevated TG (200–499 mg/dL) on maximum...
...patients not at goal atherogenic c...
...atin combination therapies to consider for fu...
...ular outcomes trials are completed with PCSK9...
...on, PCSK9 inhibitora use may be considered f...
...itora use may also be considered in sele...
...9 inhibitor NOT recommended for children....
...n Combination Therapies (clinical trial r...
...3. Statin Combination Thera...