How is risk stratification performed in patients with dyslipidemia?

Risk Stratification of Dyslipidemia

Risk stratification for patients with dyslipidemia should be performed using validated risk assessment tools that categorize patients into distinct risk levels based on clinical factors, with treatment intensity tailored according to the patient's calculated cardiovascular risk. 1

Risk Assessment Tools

Different guidelines recommend specific risk assessment tools:

• European Society of Cardiology/European Atherosclerosis Society (ESC/EAS): Uses the SCORE (Systematic Coronary Risk Estimation) calculator to estimate 10-year risk of fatal cardiovascular disease 1
• American College of Cardiology/American Heart Association (ACC/AHA): Uses the Pooled Cohort Equations (PCE) to estimate 10-year risk of atherosclerotic cardiovascular disease 1
• Canadian Cardiovascular Society (CCS): Uses the Framingham Risk Score (FRS) to estimate 10-year risk of total cardiovascular events 1

Risk Categories

The ESC/EAS guidelines define four distinct risk categories 1:

1. Very High Risk:

   • Documented cardiovascular disease (clinical or unequivocal on imaging)
   • Type 2 diabetes with target organ damage or ≥3 major risk factors, or type 1 diabetes with >20 years duration
   • Severe chronic kidney disease (eGFR <30 mL/min/1.73m²)
   • Calculated SCORE ≥10% for 10-year risk of fatal CVD
   • Familial hypercholesterolemia with ASCVD or another major risk factor

2. High Risk:

   • Markedly elevated single risk factors (e.g., familial dyslipidemia, severe hypertension)
   • SCORE ≥5% and <10% for 10-year risk of fatal CVD

3. Moderate Risk:

   • SCORE ≥1% and <5% for 10-year risk
   • Many middle-aged individuals fall into this category

4. Low Risk:

   • SCORE <1%

Risk-Modifying Factors

Several factors can modify risk assessment and should be considered 1:

• Imaging findings: Coronary artery calcium (CAC) score >100 can reclassify patients to higher risk
• Biomarkers: Elevated apoB, Lp(a), triglycerides, hs-CRP, albuminuria
• Comorbidities: Obesity, chronic inflammatory disorders, HIV, psychiatric disorders, atrial fibrillation, LVH, CKD, obstructive sleep apnea, non-alcoholic fatty liver disease
• Family history of premature cardiovascular disease
• Social factors: Deprivation, physical inactivity, psychological stress

Treatment Goals Based on Risk

Treatment goals are directly tied to risk categories 1:

• Very High Risk: LDL-C <55 mg/dL (1.4 mmol/L) and ≥50% reduction from baseline
• High Risk: LDL-C <70 mg/dL (1.8 mmol/L) and ≥50% reduction from baseline
• Moderate Risk: LDL-C <100 mg/dL (2.6 mmol/L)
• Low Risk: LDL-C <116 mg/dL (3.0 mmol/L)

Special Considerations

Severe Hypertriglyceridemia

• Triglyceride levels ≥500 mg/dL require immediate intervention primarily to prevent pancreatitis 1
• For patients with triglycerides >200 mg/dL, non-HDL-C becomes a secondary target after LDL-C goals are achieved 1

Atherogenic Dyslipidemia

• Characterized by low HDL-C and elevated triglycerides 2
• Often associated with insulin resistance, obesity, metabolic syndrome, and type 2 diabetes
• May require combination therapy (statins plus fibrates) in high-risk patients 2

Age-Specific Considerations

• For patients >75 years, recommendations for primary prevention are weaker (class IIb) 1
• Risk assessment tools may overestimate risk in elderly populations 1

Practical Implementation

1. Initial Assessment:

   • Complete lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides)
   • Calculate non-HDL-C (total cholesterol minus HDL-C)
   • Assess for secondary causes of dyslipidemia (diabetes, hypothyroidism, kidney disease)
   • Document all cardiovascular risk factors

2. Risk Calculation:

   • Apply appropriate risk calculator based on regional guidelines
   • Consider risk-modifying factors that may reclassify risk

3. Risk-Based Treatment:

   • Set appropriate LDL-C goals based on risk category
   • For very high-risk patients, consider intensive statin therapy from the outset
   • For moderate-to-high risk patients with atherogenic dyslipidemia, consider combination therapy

Common Pitfalls to Avoid

• Underestimating risk: Failing to consider subclinical atherosclerosis or family history
• Overestimating risk: Some risk calculators may overestimate risk in certain populations 1
• Focusing only on LDL-C: Not addressing atherogenic dyslipidemia (low HDL-C, high triglycerides) in high-risk patients
• Neglecting non-lipid risk factors: Not addressing modifiable risk factors like smoking, hypertension, and diabetes
• Inadequate follow-up: Not reassessing risk and lipid levels after initiating therapy

Risk stratification is essential for appropriate management of dyslipidemia, as it guides the intensity of treatment and helps clinicians focus resources on patients most likely to benefit from intervention 3.