To effectively assess and manage dyslipidaemia in patients with established atherosclerosis, a structured approach involving initial assessment, lifestyle modifications, pharmacological treatment, and ongoing monitoring is recommended.
Assessment of Dyslipidaemia
Initial Lipid Measurement: Measure both total blood cholesterol and high-density lipoprotein (HDL) cholesterol to get the best estimate of cardiovascular disease (CVD) risk NICE NG238. A full lipid profile, which includes total cholesterol, HDL cholesterol, and triglyceride levels, is used to calculate non-HDL cholesterol and LDL cholesterol; a fasting sample is not mandated NICE NG238.
Exclude Secondary Causes: Before considering specialist review, exclude common secondary causes of dyslipidaemia such as excessive alcohol intake, uncontrolled diabetes, hypothyroidism, liver disease, and nephrotic syndrome NICE NG238.
Assess for Familial Lipid Disorders: Use clinical findings, a full lipid profile, and family history to judge the likelihood of a familial lipid disorder, rather than relying solely on strict lipid cut-off values NICE NG238. Refer to NICE's guideline on familial hypercholesterolaemia to determine if familial hypercholesterolaemia should be suspected and how to treat it NICE NG238.
Specialist Referral Criteria: Arrange for specialist assessment if a patient has a total blood cholesterol level over 9.0 mmol per litre or a non-HDL cholesterol level over 7.5 mmol per litre, even without a first-degree family history of premature coronary heart disease NICE NG238. Refer for urgent specialist review if a triglyceride level is over 20 mmol per litre and is not due to excess alcohol intake or poor glycaemic control NICE NG238. For triglyceride levels between 10 mmol and 20 mmol per litre, repeat the measurement with a fasting test within 2 weeks, review for secondary causes, and seek specialist advice if the level remains above 10 mmol per litre NICE NG238.
Management of Dyslipidaemia
Lifestyle Modifications: Encourage and discuss dietary and lifestyle changes NICE NG238. Advise and support all patients who smoke to stop NICE NG238. Offer appropriate interventions for patients who are overweight or obese NICE NG238. Provide advice on physical activity and alcohol consumption NICE NG238. Do not advise patients being treated for secondary prevention to take plant stanols or sterols to prevent CVD NICE NG238.
Statin Therapy: For patients stable on a low-intensity or medium-intensity statin, discuss the benefits and risks of changing to a high-intensity statin during medication reviews and agree on any necessary changes NICE NG238. High-intensity statins include atorvastatin 20 mg to 80 mg and rosuvastatin 10 mg to 40 mg NICE CG71. Do not stop statins due to an increase in blood glucose level or HbA1c NICE NG238. Remind patients to restart statins if they stopped due to drug interactions or intercurrent illnesses NICE NG238.
Other Lipid-Lowering Treatments: If lipid levels are not at target, consider alternative or additional lipid-lowering treatments such as alirocumab, bempedoic acid, evolocumab, and inclisiran NICE NG238.
Treatments Not Routinely Offered: Do not routinely offer fibrates, nicotinic acid (niacin), or bile acid sequestrants to prevent CVD NICE NG238. Do not offer coenzyme Q10 or vitamin D to increase statin adherence NICE NG238. Omega 3 fatty acid compounds should not be offered to prevent CVD, with the exception of icosapent ethyl when used as described in NICE guidance for patients with raised triglycerides NICE NG238. Do not offer combination treatment of a statin with a bile acid sequestrant, fibrate, nicotinic acid, or omega 3 fatty acid compound (except icosapent ethyl) NICE NG238.
Monitoring and Review
Blood Tests: Measure liver transaminase and a full lipid profile 2 to 3 months after starting or changing lipid-lowering treatment NICE NG238. Measure liver transaminase at 12 months, and then only if clinically indicated NICE NG238.
Muscle Symptoms: Advise patients on statins to seek medical advice for unexplained muscle symptoms (pain, tenderness, or weakness) NICE NG238. If this occurs, measure creatine kinase NICE NG238. If creatine kinase is less than 5 times the upper limit of normal, reassure the patient that symptoms are unlikely due to the statin and explore other causes NICE NG238. Do not measure creatine kinase in asymptomatic patients on statins NICE NG238.
Annual Medication Review: Provide annual medication reviews for patients on lipid-lowering treatment NICE NG238. Offer an annual full lipid profile to inform discussions about secondary prevention of CVD NICE NG238. During the review, discuss and encourage medication adherence, dietary and lifestyle changes, and address other CVD risk factors NICE NG238.