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
...hart 1. Nutritional Recommendation...
...xpert Panel supports a cardioprotective eating pa...
...oprotective eating pattern should l...
...individuals who are hyper-responders to...
...anel recommends any of the following h...
...consumed as part of a healthy dietary...
...ted fat may be partially replaced w...
...eight loss of 5-10% body weight is generally...
Eating patterns that contain a moderate...
...nd stanols (~2 g/day) are recommended for c...
...ith TG levels ≥150 mg/dL, lifestyle thera...
...ts with TG levels ≥1000 mg/dL (and selected p...
...ges of EPA + DHA for TG-lowering s...
...rimary and secondary prevention of ASCVD,...
...with known ASCVD, suggestive, but not conclus...
...ts with heart failure, 1 g/day of EPA + DHA is re...
...lpha linonelic acid intake of 0.6â...
...mption of at least three 1-oz. equivalen...
...f ≥ 4 servings/week (1 oz. per serving) of n...
...oy protein foods are one source of...
...ducation/MNT by a registered dietit...
...nges from Baseline Lipoprotein Lipid...
...ted Effects of Macronutrient Replacement of...
...xercise/Physical Activity Recommendations...
...d minimal quantity of exercise for supporti...
...enhance the effects on TG and HDL-C, and produc...
...istance exercise is also recommend...
Management
Managemen...
...eral Management...
...Patient Adherence...
...e provider should assess adherence to both lifest...
...multidisciplinary health care team (such as th...
...i-faceted approach should be employed b...
...hart 4. Team-Based Collaborative...
...teams for optimal lipid and ASCVD risk mana...
...care team members should coordinat...
...-based collaborative care may be incorporated into...
Hypertriglyceridemia
Hypertriglyceridemi...
...G is not a specific target for therapy ex...
...Evaluation of Hypertriglyceridemia Medical...
...nical Algorithm for Screening and Manag...
...ion Therapy for Very High TG (≥500 mg...
Children and Adolescents
Children and Adolescen...
...ASCVD events rarely occur in childre...
...t 5. Children and Adolescents...
...d screening of all children, regardless of...
If a child or adolescent patient is screen...
...en ≥2 years of age with the following...
...ren should be regularly screened for m...
...ecisions on target levels during treatment...
...ade screening and reverse cascade screening are re...
...ternate treatment goal for pediatric FH pat...
...ifestyle interventions, including in...
...ears of age are potential candidates f...
...bile acid sequestrants are pharmacolog...
...ould be given to measurement of pretreatment fasti...
...l side effects with lipid-altering pharmacot...
...ceptable, Borderline-high, and High Plasma Lipo...
...Risk Factors and Conditions in Children...
...Dyslipidemia Algorithm Targeting LDL-C...
...nternational Diabetes Federation’s Defin...
Special Populations
...ecial Populations...
...CVD risk is associated with geograp...
Women's Health
...6. Women's Health
...en should be treated according to t...
...e cholesterol-lowering drug therapy,...
...drug therapy with cholesterol absorpti...
...n taking statins may be at increas...
...rt 7. Pregnancy to Menop...
...omen should be screened for dyslipidemia b...
...aking lipid-lowering medications p...
...uld be educated on the importance of pregnancy...
Total-C and TG levels in women with normal pre...
...percholesterolemia during pregnancy and breast fee...
...ay be treated with LDL apheresis du...
...gh TG (≥500 mg/dL) may be treated durin...
...is a high-risk condition for dyslipidemia,...
...pproach to risk stratification and atherogenic cho...
...management of dyslipidemia in PCOS sho...
...eptive choice affects dyslipidemia...
...HT should not be used for prevention or treatment...
...pausal sex HT is an option for treatment of...
...able 9. Lipid Lowering Agents and Pregnancy Cat...
...10. Criteria for Diagnosis of PCO...
...lder Patient...
...8. Older Patients...
...evention strategies in patients 65–79 years...
For patients age â...
...ndary prevention in patients ≥80 years of...
...k calculators such as the C/AHA Pooled Cohort Risk...
..., primary prevention patients who a...
...der primary prevention patient is unable...
...be useful to further assess risk in older patien...
...intolerance is an issue, consideration should be...
...ic Groups...
Chart 9. Hispanics/Latino...
...al, patients of Hispanic/Latino ethnicity...
Clinicians should be aware that Hispanics/...
...tinos tend to have a greater prevalenc...
...anics/Latinos have higher prevalence of...
...scular risk equations (e.g., Framingham equatio...
...rt 10. African Americans (AA...
...general, AAs should be treated according to...
...s should be aware that AAs as a group are at inc...
...use attributable ASCVD risk in AAs i...
...r incidence of metabolic syndrome than NHWs...
Because AA race/ethnicity is included in th...
...a) levels tend to be higher in AA...
...nicians should not withhold statin therapy fr...
...1. South Asians (SAs)
...eral, patients of SA ethnicity should b...
Clinicians should be aware that SAs (incl...
...f SA descent in the United States have...
...ed prevalence of metabolic syndrome...
...nicians should be aware that risk assessm...
...ssibility of genetic variation in drug met...
...ecause SAs are at increased risk for diabe...
...12. American Indians/Alaska Native...
...icians should be aware that AIs/ANs have...
..., clinicians should screen for and manage dyslipid...
...inicians should generally assess risk in AI/AN pat...
...current Conditi...
...HIV-Infected Persons...
...s should be aware that patients with HIV a...
...fasting lipid panel should be obtained...
...mary prevention of ASCVD, HIV infec...
...ratification is based on the NLA Recommendation...
...C and LDL-C goals described in the NLA Part 1 Re...
...‰¥500 mg/dL that is refractory to lifestyle mo...
Statin therapy is first-line for el...
.... Interactions Between ART and StatinsaHaving t...
...ts with Rheumatoid Arthritis (RA)...
...nicians should be aware that patients with RA ar...
...ion between RA and ASCVD risk is independent...
...ry prevention of ASCVD, RA may be counted...
...cation is based on the NLA Recommend...
...ians should be vigilant in ensuring...
...generally the first-line treatment for dysl...
...me, atherogenic cholesterol treatment goals for p...
...patient has had lipid levels checke...
...RA Treatments with Manufacturer Package Inserts...
Residual Risk After Statins and Lifestyle Modification
...Risk After Statins and Lifestyle Mo...
...ly more intensive lowering of low-dens...
...Significant Risk IndicatorsHaving trou...
...14. Recommendations...
...d prescription omega-3 fatty acids are first...
...th elevated TG (200–499 mg/dL) o...
For patients not at goal atherogenic cholesterol...
Recommended statin combination therapies to cons...
...ascular outcomes trials are completed with PCS...
...SK9 inhibitora use may be considered for selected...
...ora use may also be considered in selected...
...inhibitor NOT recommended for children....
...ble 15. Statin Combination Therapies (...
...3. Statin Combination Therapy...