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Dyslipidemia

Definition
Dyslipidemia is a disorder of lipid metabolism characterized by elevated LDL cholesterol, decreased HDL cholesterol and/or increased triglycerides, which contributes to the development of atherosclerosis.
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Pathophysiology
Primary dyslipidemia is due to genetic abnormalities, whereas secondary dyslipidemia is multifactorial, and is associated with obesity, physical inactivity, high-carbohydrate and high-fat diets, smoking, alcohol use, uncontrolled diabetes mellitus, hypothyroidism, renal failure, cholestatic liver disease, nephrotic syndrome, and various drugs (corticosteroids, progestogens, androgenic steroids, thiazide diuretics, beta blockers, oral estrogens, retinoic acid derivatives).
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Epidemiology
In the US, an estimated 53% of adults have at least one lipid abnormality: 27% have elevated LDL cholesterol, 23% have decreased HDL cholesterol, and 30% have increased triglycerides.
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Disease course
Lipid abnormalities contribute to the formation of atherosclerotic plaque, leading to an increased risk of CVD, stroke, and PAD.
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Prognosis and risk of recurrence
Treatment with statins is associated with a relative reduction in the risk of major adverse vascular events of 22% in men and 16% in women for every 1.0 mmol/L (38.6 mg/dL) reduction in LDL cholesterol.
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Key sources
The following summarized guidelines for the evaluation and management of dyslipidemia are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2023), the National Lipid Association (NLA/PCNA/ASPC/ACC/AHA/ACCP 2023), the American Diabetes Association (ADA 2023), the Canadian Pediatric Cardiology Association (CPCA/CCS 2022), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the Canadian Cardiovascular Society (CCS 2021; 2018; 2016), the European Society of Cardiology (ESC 2021), the European Society of Cardiology (ESC/EAS 2020), the Endocrine Society (ES 2020), the United States Department of Defense (DoD/VA 2020), the American College of Preventive Medicine (ACPM/ADA/PCNA/ABC/ASPC/AAPA/AGS/AHA/ACC/APhA 2019), the U.S. Preventive Services Task Force (USPSTF 2016), and the Society of Cardiovascular Computed Tomography (SCCT 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening, adults, CCS
Obtain non-HDL-C or ApoB over LDL-C as the preferred lipid parameter for screening in any patient with triglycerides > 1.5 mmol/L.
A
Measure lipoprotein(a) level once in a person's lifetime as a part of the initial lipid screening.
A
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  • Indications for screening (pediatrics)

2.Classification and risk stratification

Risk assessment: as per ESC 2020 guidelines, obtain total risk estimation using a risk estimation system such as SCORE in asymptomatic patients > 40 years old without evidence of CVD, diabetes mellitus, CKD or hypercholesterolemia, or with LDL-C level of > 190 mg/dL (> 4.9 mmoI/L).
B
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3.Diagnostic investigations

Lipid profile, tests, EAS/ESC: obtain LDL-C as the primary lipid analysis method for screening, diagnosis, and management.
B
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  • Lipid profile (fasting state)

  • ApoB

  • Lipoprotein(a)

  • Screening for hypothyroidism

  • Screening for anabolic steroid use

  • Coronary CT

  • Arterial ultrasound

4.Medical management

Treatment targets: as per ESC 2020 guidelines, consider targeting LDL-C level of < 116 mg/dL (< 3.0 mmol/L) in low-risk patients.
B
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  • Statins

  • Ezetimibe

  • PCSK9 inhibitors

  • Icosapent ethyl

  • Fibrates

  • Bile acid sequestrants

  • Niacin

  • Bempedoic acid

5.Nonpharmacologic interventions

Dietary modifications: as per VA 2020 guidelines, advise following a dietitian-led Mediterranean diet for primary and secondary prevention of CVD.
B

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  • Physical activity

  • Smoking cessation

  • Omega-3 fatty acid supplements

  • Other supplements

6.Specific circumstances

Female patients: as per CCS 2021 guidelines, obtain screening with a complete lipid panel in the late postpartum period in female patients with a pregnancy complication such as the following as they have a higher risk of premature CVD and stroke with onset 10-15 years after index delivery:
hypertensive disorders of pregnancy
gestational diabetes
preterm birth
stillbirth
low birth weight infant
placental abruption.
B
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  • Elderly patients

  • Pediatric patients (screening)

  • Pediatric patients (clinical assessment)

  • Pediatric patients (genetic testing)

  • Pediatric patients (lifestyle modifications)

  • Pediatric patients (statin therapy)

  • Pediatric patients (management of hypertriglyceridemia)

  • Pediatric patients (treatment targets)

  • Pediatric patients (indications for referral)

  • Patients with obesity

  • Patients with severe hypercholesterolemia

  • Patients with hypertriglyceridemia

  • Patients with familial hypercholesterolemia (screening)

  • Patients with familial hypercholesterolemia (diagnosis)

  • Patients with familial hypercholesterolemia (CVD risk stratification)

  • Patients with familial hypercholesterolemia (management)

  • Patients with familial hypercholesterolemia (homozygous FH)

  • Patients with ASCVD (general indications)

  • Patients with ASCVD (chronic coronary syndrome)

  • Patients with ASCVD (acute coronary syndrome)

  • Patients with ASCVD (ischemic stroke)

  • Patients with ASCVD (PAD)

  • Patients with aortic valvular disease

  • Patients with HF

  • Patients with diabetes mellitus

  • Patients with CKD (management)

  • Patients on hemodialysis

  • Patients with inflammatory diseases and HIV

  • Patients with solid organ transplants

  • Patients with endocrine disorders (evaluation)

  • Patients with endocrine disorders (thyroid disease)

  • Patients with endocrine disorders (Cushing's syndrome)

  • Patients with endocrine disorders (adult GH deficiency)

  • Patients with endocrine disorders (acromegaly)

  • Patients with endocrine disorders (PCOS)

  • Patients with endocrine disorders (testosterone deficiency)

7.Patient education

Shared decision-making: as per AHA 2019 guidelines, promote shared decision-making when initiating lipid-lowering therapy, and discuss the potential benefits and adverse effects of treatments, as well as the potential for drug-drug interactions.
B
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8.Preventative measures

Fat intake
As per WHO 2023 guidelines:
Consider limiting total fat intake to ≤ 30% of total energy intake to reduce the risk of unhealthy weight gain in adults.
C
Advise consuming primarily unsaturated fatty acids with ≤ 10% of total energy intake coming from saturated fatty acids and ≤ 1% of total energy intake coming from trans-fatty acids.
A

9.Follow-up and surveillance

Monitoring for adherence to treatment: as per VA 2020 guidelines, consider offering intensified patient care (such as phone calls, emails, patient education, drug regimen simplification) to improve adherence to lipid-lowering medications.
C

More topics in this section

  • Monitoring for adverse effects of statins