Management of Dyslipidemia for Cardiovascular Risk Reduction (Lipids)

Publication Date: May 31, 2020
Last Updated: March 14, 2022

Recommendations

Primary Prevention: Screening and Assessment of Cardiovascular Risk

For primary prevention in patients over age 40 and not on statin therapy who have not developed new cardiovascular risk factors (e.g., diabetes, hypertension, tobacco use), we suggest against offering a cardiovascular disease risk assessment more frequently than every five years.
Weak Recommendation against
6731
For primary prevention in patients not on statin therapy, we suggest against routinely ordering a lipid panel more frequently than every 10 years.
Weak Recommendation against
6731
For cardiovascular risk assessment in primary prevention, we suggest using a 10-year risk calculator.
Weak Recommendation
6731
We suggest against the routine use of coronary artery calcium testing.
Weak Recommendation against
6731
We suggest against the routine use of additional risk markers (e.g., high-sensitivity C-reactive protein, ankle-brachial index, coronary artery calcium) when assessing cardiovascular risk.
Weak Recommendation against
6731

Pharmacotherapy, Supplements, and Nutraceuticals

Primary Prevention

For primary prevention, we recommend offering a moderatedose statin in patients with a >12% 10-year cardiovascular risk or low-density lipoprotein cholesterol >190 mg/dL or diabetes.
Strong Recommendation
6731
For primary prevention, we suggest offering a moderate-dose statin for patients with a 10-year cardiovascular risk between 6% and 12% following a discussion of risks, limited benefit, and an exploration of the patient’s values and preferences.
Weak Recommendation
6731
For primary prevention in patients on moderate-dose statins, we suggest against maximizing the statin dose due to the lack of evidence proving added cardiovascular benefits and the risks of higher dose statins.
Weak Recommendation
6731
For primary prevention, there is insufficient evidence to recommend for or against using ezetimibe with or without statins.
6731
For primary prevention, we recommend against offering PCSK9 inhibitors due to unknown long-term safety, inconclusive evidence for benefit, and high cost.
Strong Recommendation
6731

Secondary Prevention

For secondary prevention, we recommend using at least a moderate-dose statin.
  • Statin doses listed as “moderate” are equivalent to moderate intensity; statin doses listed as “high” are equivalent to high intensity.
Strong Recommendation
6731
Secondary Prevention
  • For secondary prevention in higher risk patients** who are willing to intensify treatment, we suggest offering high-dose statins for reducing non-fatal cardiovascular events after discussion of the risk of high-dose statins and an exploration of the patient’s values and preferences.
Weak Recommendation
6731
  • For secondary prevention in higher risk patients** who are willing to intensify treatment, we suggest adding ezetimibe to either moderate- or high-dose statins for reducing non-fatal cardiovascular events following a discussion of the risks, additional benefits, and an exploration of the patient’s values and preferences.
Weak Recommendation
6731
  • For secondary prevention in higher risk patients** who are willing to intensify treatment, we suggest offering a PCSK9 inhibitor in addition to a maximally tolerated statin dose with ezetimibe for reducing non-fatal cardiovascular events following a discussion of their uncertain long-term safety, additional benefits, and an exploration of the patient’s values and preferences.
Weak Recommendation
6731
Higher risk patients include those with (1) MI or ACS in past 12 months; (2) recurrent ACS, MI, or CVA; or (3) established CVD and with additional risk factors (e.g., currently smoking, DM, PAD, or CABG/PCI).

Other Medications, Supplements, and Nutraceuticals

For primary or secondary prevention, we recommend against using niacin (i.e., supplements or prescriptions).
Strong Recommendation against
6731
For primary or secondary prevention, we suggest against adding fibrates to statins.
Weak Recommendation
6731
There is insufficient evidence to recommend for or against using bempedoic acid with or without statins for either primary or secondary prevention.
6731
For primary prevention, there is insufficient evidence to recommend for or against icosapent ethyl in patients on statin therapy with persistently elevated fasting triglycerides.
6731
For secondary prevention, we suggest offering icosapent ethyl in patients on statin therapy with persistently elevated fasting triglycerides >150 mg/dL to reduce cardiovascular morbidity and mortality.
Weak Recommendation
6731
For primary or secondary prevention, we suggest against the use of omega-3 fatty acids as a dietary supplement to reduce cardiovascular disease risk.
Weak Recommendation against
6731
There is insufficient evidence to recommend for or against the use of fiber, garlic, ginger, green tea, and red yeast rice supplements to reduce cardiovascular risks.
6731

Monitoring and Adherence

We suggest against the routine monitoring of lipid levels in patients taking statins.
Weak Recommendation against
6731
For patients who cannot tolerate a statin, we suggest a washout period followed by a re-challenge with the same or a different statin or lower dose, and if that fails, a trial of intermittent (nondaily) dosing.
Weak Recommendation
6731
We suggest offering intensified patient care (e.g., phone calls, emails, patient education, drug regimen simplification) to improve adherence to lipid-lowering medications.
Weak Recommendation
6731
For primary and secondary prevention of cardiovascular disease, we suggest a dietitian-led Mediterranean diet.
Weak Recommendation
6731
For primary and secondary prevention of cardiovascular disease, we suggest regular aerobic physical activity of any intensity and duration.
Weak Recommendation
6731
We recommend a structured, exercise-based cardiac rehabilitation program for patients with recent occurrence of coronary heart disease (i.e., myocardial infarction, diagnosis of coronary artery disease, coronary artery bypass grafting, or percutaneous coronary intervention) to reduce cardiovascular morbidity and mortality.
Strong Recommendation
6731

Recommendation Grading

Overview

Title

Management of Dyslipidemia for Cardiovascular Risk Reduction (Lipids)

Authoring Organization

Veterans Health Administration / Department of Defense

Publication Month/Year

May 31, 2020

Last Updated Month/Year

April 1, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Prevention, Management

Diseases/Conditions (MeSH)

D050171 - Dyslipidemias, D002318 - Cardiovascular Diseases, D014493 - United States Department of Veterans Affairs, D058014 - Veterans Health, D014728 - Veterans

Keywords

cardiovascular disease, dyslipidemia, Cardiovascular Risk

Source Citation

O'Malley PG, Arnold MJ, Kelley C, Spacek L, Buelt A, Natarajan S, Donahue MP, Vagichev E, Ballard-Hernandez J, Logan A, Thomas L, Ritter J, Neubauer BE, Downs JR. Management of Dyslipidemia for Cardiovascular Disease Risk Reduction: Synopsis of the 2020 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2020 Nov 17;173(10):822-829. doi: 10.7326/M20-4648. Epub 2020 Sep 22. PMID: 32956597.