From the Guidelines
Hyperlipidemia diagnosis should primarily rely on LDL-Cholesterol (LDL-C) as the primary lipid analysis for screening, risk estimation, diagnosis, and management, as recommended by the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. When diagnosing hyperlipidemia, it is essential to consider the patient's overall cardiovascular risk factors, including familial hypercholesterolaemia or a high SCORE risk, which are a high priority for intensive advice with regards to all risk factors 1. Key factors to consider in the diagnosis of hyperlipidemia include:
- LDL-C levels, with goals of < 1.8 mmol/L (70 mg/dL) for patients at VERY HIGH CV risk, or a reduction of at least 50% if the baseline LDL-C is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL) 1
- HDL-C as an independent risk factor, included in the electronic version of SCORE, HeartScore 1
- Triglycerides and total cholesterol levels, although LDL-C is the primary target for treatment 1
- Secondary causes of hyperlipidemia, such as hypothyroidism, diabetes, kidney disease, or medication effects, which should be evaluated and addressed 1
- Regular screening is recommended, with frequency depending on the patient's risk factors and established cardiovascular disease 1. In patients with suspected familial hyperlipidaemia, diagnosis should be considered in those with CHD before the age of 55 years for men and 60 years for women, or in subjects with relatives having premature fatal or non-fatal CVD, or severely elevated LDL-C (>5 mmol/L [190 mg/dL] in adults, > 4 mmol/L [150 mg/dL] in children) 1. Lipoprotein(a) [Lp(a)] is also an emergent target for PCSK9 inhibitors, with the European Society of Cardiology (ESC) guidelines recommending measuring Lp(a) in patients at high risk of cardiovascular disease (CVD) and targeting levels below 50 mg/dL 1.
From the Research
Hyperlipidemia Diagnosis
- The primary lipid panel for hyperlipidemia diagnosis and cardiovascular risk estimation includes total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, and calculated non-HDL cholesterol 2
- LDL cholesterol is the primary target of lipid-lowering therapies, while non-HDL cholesterol or apolipoprotein B should be used as secondary therapeutic targets in patients with mild-to-moderate hypertriglyceridemia 2
- Lipoprotein (a) is included in LDL cholesterol and should be measured at least once in all patients at cardiovascular risk, including to explain poor response to statin treatment 2
Laboratory Tests for Dyslipidemia
- Measurement of serum cholesterol, triglycerides, HDL-cholesterol, and obtaining the LDL cholesterol by Friedewald equation is usually sufficient in the majority of patients 3
- Ultracentrifugation is required to determine the VLDL or LDL cholesterol in some cases, such as the diagnosis of Type III dyslipidemia and when triglycerides are > or = 400 mg/dL 3
- Lipoprotein electrophoresis can be useful in the diagnosis of Type III dyslipidemia and to detect chylomicrons 3
Treatment of Hyperlipidemia
- The combination therapy of fenofibrate and ezetimibe has been shown to be effective in improving lipid profiles and vascular function in patients with type 2 diabetes 4 and combined hyperlipidemia 5, 6
- The combination therapy has been found to reduce concentrations of LDL cholesterol and triglycerides, and is safe in long-term treatment 5