When should I consider referring a patient with atherosclerosis for specialist assessment or intervention?

You should consider referring a patient with atherosclerosis for specialist assessment or intervention in several key situations, particularly concerning familial hypercholesterolaemia (FH) and severe dyslipidaemia.

• Healthcare professionals should offer people with FH an urgent referral to a specialist with expertise in cardiology for evaluation if they have symptoms or signs of possible coronary heart disease (CHD) which are not immediately life-threatening ¹. A low threshold for referral is recommended ¹.
• If a person with FH has symptoms or signs of possible CHD which are immediately life-threatening (for example, acute coronary syndrome), they should be referred to hospital as an emergency in line with advice for the general population ¹.
• Healthcare professionals should consider offering people with FH a referral for evaluation of coronary heart disease if they have a family history of coronary heart disease in early adulthood, or two or more other cardiovascular risk factors (for example, they are male, they smoke, or they have hypertension or diabetes) ¹.
• Upon diagnosis, healthcare professionals should offer all adults and children and young people with homozygous FH a referral for an evaluation of coronary heart disease ¹.
• In asymptomatic children and young people with heterozygous FH, evaluation of coronary heart disease is unlikely to detect clinically significant disease and referral should not be routinely offered ¹.

• Arrange for specialist assessment of people with a total blood cholesterol level of more than 9.0 mmol per litre or a non-HDL cholesterol level of more than 7.5 mmol per litre even in the absence of a first-degree family history of premature coronary heart disease ³.
• Refer for urgent specialist review if a person has a triglyceride level of more than 20 mmol per litre that is not a result of excess alcohol intake or poor glycaemic control ³.
• In people with a triglyceride level between 10 mmol and 20 mmol per litre, repeat the triglyceride measurement with a fasting test (after an interval of 5 days, but within 2 weeks) and review for potential secondary causes of hyperlipidaemia ³. Seek specialist advice if the triglyceride level remains at more than 10 mmol per litre ³.
• Exclude possible common secondary causes of dyslipidaemia (such as excess alcohol intake, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome) before referring for specialist review ³.