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
| Risk Category | Criteria | Treatment Goal | Consider Drug Therapy |
|---|---|---|---|
| Non-HDL-C mg/dL LDL-C mg/dL | Non-HDL-C mg/dL LDL-C mg/dL | ||
| Low |
| <130 <100 | ≥190 ≥160 |
| Moderate |
| <130 <100 | ≥160 ≥130 |
| High |
| <130 <100 | ≥130 ≥100 |
| Very High |
| <100 <70 | ≥100 ≥70 |
For patients with ASCVD or diabetes mellitus, consideration should be given to use of moderate or high-intensity statin therapy.
bFor patients with diabetes plus 1 major ASCVD risk factor, treating to a non-HDL-C goal of <100 mg/dL (LDL-C <70 mg/dL) is considered a therapeutic option.
cFor patients with chronic kidney disease (CKD) stage 3B (glomerular filtration rate [GFR] 30-44 mL/
min/1.73 m2) or stage 4 (GFR 15-29 mL/min/1.73 m2) risk calculators should not be used because they may underestimate risk. Stage 5 CKD (or on hemodialysis) is a very high risk condition, but results from randomized, controlled trials of lipid-altering therapies have not provided convincing evidence of reduced ASCVD events in such patients. Therefore, no treatment goals for lipid therapy have been defined for stage 5 CKD.
dIf LDL-C is ≥190 mg/dL, consider severe hypercholesterolemia phenotype, which includes familial hypercholesterolemia (FH). Lifestyle intervention and pharmacotherapy are recommended for adults with the severe hypercholesterolemia phenotype. If it is not possible to attain desirable levels of atherogenic cholesterol, a reduction of at least 50% is recommended. For FH patients with multiple or poorly controlled other major ASCVD risk factors, clinicians may consider targeting even lower levels of atherogenic cholesterol. Risk calculators should not be used in such patients.
eHigh-risk threshold is defined as ≥10% using Adult Treatment Panel (ATP) III Framingham Risk Score for hard CHD (MI or CHD death), ≥15% using the 2013 Pooled Cohort Equations for hard ASCVD (MI, stroke or death from CHD or stroke), or ≥45% using the Framingham long-term (to age 80) cardiovascular disease (MI, CHD death or stroke) risk calculation. Clinicians may prefer to use other risk calculators but should be aware that quantitative risk calculators vary in the clinical outcomes predicted (eg, CHD events, ASCVD events, cardiovascular mortality), the risk factors included in their calculation, and the time frame for their prediction (eg, 5 years, 10 years, or long-term or lifetime). Such calculators may omit certain risk indicators that can be very important in individual patients, provide only an approximate risk estimate, and require clinical judgment for interpretation.
fEnd organ damage indicated by CKD (eGFR <60 ml/min/1.73 m2), increased albumin/creatinine ratio (≥30 mg/g), or retinopathy.
Lifestyle
...ifestyle...
...t 1. Nutritional Recommendation...
...ert Panel supports a cardioprotectiv...
...otective eating pattern should limit cho...
...e individuals who are hyper-responde...
...pert Panel recommends any of the f...
...alcohol is consumed as part of a healthy...
Dietary saturated fat may be partia...
...of 5-10% body weight is generally recommended...
...ns that contain a moderate quantity of carbohyd...
...nt sterols and stanols (~2 g/day) are recommended...
...nts with TG levels ≥150 mg/dL, lifestyle therapy...
...r patients with TG levels ≥1000 mg/d...
...c dosages of EPA + DHA for TG-lowering...
...mary and secondary prevention of ASCVD, c...
...with known ASCVD, suggestive, but not co...
For patients with heart failure, 1 g/day of E...
...n alpha linonelic acid intake of 0.6...
...sumption of at least three 1-oz. eq...
Consumption of ≥ 4 servings/week (1 oz. pe...
...tein foods are one source of plant...
...on education/MNT by a registered dietitian...
...Changes from Baseline Lipoprotein Lipid Level...
.... Predicted Effects of Macronutrien...
...ercise/Physical Activity Recommendations...
...d minimal quantity of exercise for supporting card...
...ance the effects on TG and HDL-C, an...
...exercise is also recommended to play a s...
Management
...anagemen...
General Manag...
...3. Patient Adherenc...
...rovider should assess adherence to both lifestyle...
...linary health care team (such as the patien...
...ulti-faceted approach should be employed by clin...
...hart 4. Team-Based Collaborative Care...
...care teams for optimal lipid and ASCVD risk m...
...h care team members should coordina...
...ed collaborative care may be incorpor...
Hypertriglyceridemia
...ertriglyceridem...
...G is not a specific target for therapy ex...
...e 4. Evaluation of Hypertriglyceridemia...
...igure 1. Clinical Algorithm for Screening an...
...ble 5. Nutrition Therapy for Very High...
Children and Adolescents
Children and Adolescen...
...lthough ASCVD events rarely occur in childre...
...Children and Adolescen...
...lipid screening of all children, regardless...
...ild or adolescent patient is screened an...
...ren ≥2 years of age with the following charac...
...ould be regularly screened for major risk fac...
...n target levels during treatment are a...
...e screening and reverse cascade screen...
...nate treatment goal for pediatric FH pati...
...lifestyle interventions, including increased...
...¥8 years of age are potential candi...
...s and bile acid sequestrants are pharmaco...
...ould be given to measurement of pret...
...al side effects with lipid-altering pharmacoth...
...ptable, Borderline-high, and High Plasma Lipopr...
.... Major Risk Factors and Conditions...
...gure 2. Dyslipidemia Algorithm Targ...
Table 8. International Diabetes Federation’s...
Special Populations
Special Populati...
...ed ASCVD risk is associated with geograp...
Women's Heal...
...rt 6. Women's...
...n general, women should be treated according...
...irst-line cholesterol-lowering drug therapy, u...
...drug therapy with cholesterol absorption inhibi...
...taking statins may be at increased...
...hart 7. Pregnancy to Menopau...
...screened for dyslipidemia before pregnancy or...
...ng lipid-lowering medications prior...
...uld be educated on the importance o...
...l-C and TG levels in women with normal...
...ypercholesterolemia during pregnancy and...
...ay be treated with LDL apheresis durin...
...(≥500 mg/dL) may be treated during pr...
...S is a high-risk condition for dyslipidemia, met...
...risk stratification and atherogenic cholesterol t...
...management of dyslipidemia in PCOS should focus...
...ntraceptive choice affects dyslipidemia. Combin...
Sex HT should not be used for preven...
...sex HT is an option for treatment of...
...able 9. Lipid Lowering Agents and Pregnancy Cat...
...ble 10. Criteria for Diagnosis of PC...
Older Patients
...hart 8. Older Pat...
...ry prevention strategies in patients...
...ients age ≥65 to
...ry prevention in patients ≥80 years of age,...
...ulators such as the C/AHA Pooled Cohort Risk ca...
...revention patients who are statin-eligible sho...
...imary prevention patient is unable to achieve at...
...scoring may be useful to further assess risk in...
...atin intolerance is an issue, consideration...
...hnic Groups...
...9. Hispanics/Latinos...
...ents of Hispanic/Latino ethnicity should be...
...ans should be aware that Hispanics/Lati...
...panics/Latinos tend to have a greater prevalence...
...anics/Latinos have higher prevalence of type 2...
...ovascular risk equations (e.g., Framingha...
...10. African Americans (AAs)...
...neral, AAs should be treated according to...
...hould be aware that AAs as a group are at increase...
Because attributable ASCVD risk in AAs is...
...ower incidence of metabolic syndrome th...
...race/ethnicity is included in the 2013 C/AHA...
...a) levels tend to be higher in AA patients, measur...
...linicians should not withhold statin therapy from...
...1. South Asians (SAs)...
..., patients of SA ethnicity should be trea...
...ould be aware that SAs (including individual...
...descent in the United States have a gr...
...creased prevalence of metabolic syndrome compared...
...nicians should be aware that risk assessme...
...to the possibility of genetic variation in dru...
...are at increased risk for diabetes, vigilan...
...art 12. American Indians/Alaska Natives (AI...
...ld be aware that AIs/ANs have higher...
...clinicians should screen for and manage dyslipi...
...uld generally assess risk in AI/AN pa...
...ncurrent Conditio...
...art 13. HIV-Infected P...
...should be aware that patients with HIV are at i...
...lipid panel should be obtained in all...
...primary prevention of ASCVD, HIV inf...
...ation is based on the NLA Recommendations...
...and LDL-C goals described in the NLA Pa...
...d TG ≥500 mg/dL that is refractory to lifest...
...n therapy is first-line for elevated LDL-C and...
Table 11. Interactions Between ART and Statins...
...atients with Rheumatoid Arthritis (RA)...
...ould be aware that patients with RA ar...
...iation between RA and ASCVD risk is independ...
...y prevention of ASCVD, RA may be counted as an add...
...tification is based on the NLA Recomm...
...hould be vigilant in ensuring that RA patients are...
...ins are generally the first-line tr...
...atherogenic cholesterol treatment goals for pat...
...patient has had lipid levels checked during...
...Treatments with Manufacturer Packag...
Residual Risk After Statins and Lifestyle Modification
...idual Risk After Statins and Lifestyle...
...y more intensive lowering of low-density li...
...ble 13. Significant Risk IndicatorsHaving trouble...
...14. Recommendations
...es and prescription omega-3 fatty a...
...patients with elevated TG (200–499 mg/dL)...
...nts not at goal atherogenic cholesterol levels o...
...d statin combination therapies to consider f...
...cular outcomes trials are completed with PCSK9 in...
..., PCSK9 inhibitora use may be conside...
...9 inhibitora use may also be considered in s...
...PCSK9 inhibitor NOT recommended for ch...
...le 15. Statin Combination Therapies (clini...
Figure 3. Statin Combination Therapy