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...
...1. Nutritional Recommen...
...he NLA Expert Panel supports a cardio...
...rdioprotective eating pattern should limit chol...
There are individuals who are hyper-respo...
...he NLA Expert Panel recommends any of the followin...
...nsumed as part of a healthy dietary pattern, this...
...rated fat may be partially replaced wit...
...ght loss of 5-10% body weight is generally...
...s that contain a moderate quantity of carbohy...
...and stanols (~2 g/day) are recommended for ch...
...ts with TG levels ≥150 mg/dL, lifestyle...
...r patients with TG levels ≥1000 mg/dL (a...
...erapeutic dosages of EPA + DHA for TG-lowering...
...imary and secondary prevention of ASCVD, con...
...ients with known ASCVD, suggestive, but not co...
...atients with heart failure, 1 g/day of EPA + DHA...
...a linonelic acid intake of 0.6–1.2% of energy...
...umption of at least three 1-oz. equivalent servin...
...≥ 4 servings/week (1 oz. per serving) of...
...in foods are one source of plant prot...
...rition education/MNT by a registered...
...nges from Baseline Lipoprotein Lipid Level...
...3. Predicted Effects of Macronutrient...
Chart 2. Exercise/Physical Activity Recomme...
...ommended minimal quantity of exercise for sup...
...o enhance the effects on TG and HDL-C,...
...sistance exercise is also recommended t...
Management
...nagement...
General Manag...
...3. Patient Adheren...
...er should assess adherence to both life...
A multidisciplinary health care team (such...
...ed approach should be employed by clinicians to...
...eam-Based Collaborative Care...
...care teams for optimal lipid and ASCVD risk m...
...am members should coordinate care support...
...borative care may be incorporated into the Patient...
Hypertriglyceridemia
Hypertriglyceride...
...G is not a specific target for therapy exc...
...Evaluation of Hypertriglyceridemia M...
...1. Clinical Algorithm for Screening and M...
...Nutrition Therapy for Very High TG (≥500...
Children and Adolescents
...and Adolescents...
...ough ASCVD events rarely occur in chil...
...5. Children and Adolesc...
...lipid screening of all children, r...
...or adolescent patient is screened and has...
...≥2 years of age with the following char...
...be regularly screened for major risk factor...
...s on target levels during treatmen...
...scade screening and reverse cascade scree...
...ternate treatment goal for pediatric FH patients...
...r lifestyle interventions, including increa...
...hildren ≥8 years of age are poten...
...le acid sequestrants are pharmacol...
...hould be given to measurement of pretreatment fas...
...al side effects with lipid-altering pharm...
...6. Acceptable, Borderline-high, and High P...
...Risk Factors and Conditions in Children and Adole...
...2. Dyslipidemia Algorithm Targeting LD...
...tional Diabetes Federation’s Defi...
Special Populations
...ial Populations...
...eased ASCVD risk is associated wit...
...n's Health...
.... Women's Health...
...l, women should be treated accordin...
...sterol-lowering drug therapy, unless contrai...
...on-statin drug therapy with cholesterol absorpt...
...g statins may be at increased risk for certa...
...7. Pregnancy to Menopaus...
...hould be screened for dyslipidemia...
...women taking lipid-lowering medicat...
...e educated on the importance of pr...
...al-C and TG levels in women with normal preg...
...esterolemia during pregnancy and b...
...n with FH may be treated with LDL aphere...
...y high TG (≥500 mg/dL) may be treated duri...
...S is a high-risk condition for dyslipidemia, metab...
...ach to risk stratification and ath...
...agement of dyslipidemia in PCOS should focus on d...
...raceptive choice affects dyslipidemia. C...
...not be used for prevention or treatment of ASCVD....
...opausal sex HT is an option for treatment of s...
...le 9. Lipid Lowering Agents and Pregnancy...
...le 10. Criteria for Diagnosis of...
...r Patients
...rt 8. Older Patien...
...mary prevention strategies in patients 65...
...atients age ≥65 to...
...ry prevention in patients ≥80 years of ag...
...calculators such as the C/AHA Poole...
...prevention patients who are statin-eligible shou...
...f the older primary prevention patient is u...
...ring may be useful to further assess risk in...
...intolerance is an issue, consideration sho...
...nic Groups...
...art 9. Hispanics/Latinos...
...n general, patients of Hispanic/Lati...
...icians should be aware that Hispanics/Latinos...
...nos tend to have a greater prevalence of high T...
...cs/Latinos have higher prevalence of type...
...ascular risk equations (e.g., Framingha...
...10. African Americans (AAs)...
...AAs should be treated according to the NLA Recomm...
...ans should be aware that AAs as a group are at in...
...butable ASCVD risk in AAs is less d...
...ve a lower incidence of metabolic syndrome...
Because AA race/ethnicity is included in...
...p(a) levels tend to be higher in AA...
Clinicians should not withhold statin...
...hart 11. South Asian...
...ients of SA ethnicity should be treated accordin...
Clinicians should be aware that SAs (including...
...SA descent in the United States have a gre...
...ncreased prevalence of metabolic syndrome...
...ns should be aware that risk assessment metho...
...to the possibility of genetic variation in drug...
...are at increased risk for diabetes...
Chart 12. American Indians/Alaska N...
...d be aware that AIs/ANs have higher...
...clinicians should screen for and manage dys...
...uld generally assess risk in AI/AN...
...ncurrent Conditio...
Chart 13. HIV-Infecte...
...nicians should be aware that patient...
...ng lipid panel should be obtained in all newly ide...
...primary prevention of ASCVD, HIV infection ma...
Risk stratification is based on the NLA Recom...
...e non-HDL-C and LDL-C goals described i...
...500 mg/dL that is refractory to lifestyle modif...
...erapy is first-line for elevated LDL-C an...
...Interactions Between ART and Statinsa...
...art 14. Patients with Rheumatoid A...
...nicians should be aware that patients w...
...ation between RA and ASCVD risk is indepe...
...ention of ASCVD, RA may be counted as an a...
...atification is based on the NLA Rec...
Clinicians should be vigilant in ensuring...
...atins are generally the first-line treatment for d...
...time, atherogenic cholesterol treatm...
...has had lipid levels checked during an RA fl...
...e 12. RA Treatments with Manufacturer Packa...
Residual Risk After Statins and Lifestyle Modification
...k After Statins and Lifestyle Modification...
...y more intensive lowering of low-densi...
...13. Significant Risk IndicatorsHaving trouble v...
Table 14. Recommendatio...
...ates and prescription omega-3 fatty ac...
...with elevated TG (200–499 mg/dL) on maximum to...
...s not at goal atherogenic cholesterol levels on ma...
...tin combination therapies to consider for further...
...ntil cardiovascular outcomes trials are completed...
In addition, PCSK9 inhibitora use may be conside...
PCSK9 inhibitora use may also be consid...
a PCSK9 inhibitor NOT recommended f...
...able 15. Statin Combination Therapie...
...ure 3. Statin Combination...