Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
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.
For patients with Familial Hypercholesterolaemia (FH):- 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 NICE CG71. A low threshold for referral is recommended NICE CG71.
- 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 NICE CG71.
- 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) NICE CG71.
- 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 NICE CG71.
- 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 NICE CG71.
- 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 NICE NG238.
- 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 NICE NG238.
- 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 NICE NG238. Seek specialist advice if the triglyceride level remains at more than 10 mmol per litre NICE NG238.
- 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 NICE NG238.