What are the targets for managing hyperlipidaemia?

Management of Hyperlipidaemia Based on Targets

The management of hyperlipidaemia should be based on risk stratification with LDL-C as the primary target, aiming for <1.8 mmol/L (70 mg/dL) in very high-risk patients and <2.6 mmol/L (100 mg/dL) in high-risk patients, or a reduction of at least 50% from baseline if these targets cannot be achieved.

Risk Stratification and Target Setting

Risk assessment is the first step in determining appropriate lipid targets:

1. Very High Risk 1:

   • Documented cardiovascular disease (CVD)
   • Diabetes with target organ damage
   • Moderate to severe chronic kidney disease (GFR <60 mL/min/1.73m²)
   • SCORE ≥10% for 10-year risk
   • Target: LDL-C <1.8 mmol/L (70 mg/dL) or ≥50% reduction if baseline is 1.8-3.5 mmol/L

2. High Risk 1:

   • Markedly elevated single risk factors (e.g., familial hyperlipidaemias, severe hypertension)
   • SCORE ≥5% and <10% for 10-year risk
   • Target: LDL-C <2.6 mmol/L (100 mg/dL) or ≥50% reduction if baseline is 2.6-5.1 mmol/L

3. Moderate Risk:

   • SCORE ≥1% and <5% at 10 years
   • Target: Consider LDL-C <3.0 mmol/L (115 mg/dL)

4. Low Risk:

   • SCORE <1%
   • Target: Consider LDL-C <3.0 mmol/L (115 mg/dL)

Secondary Targets

While LDL-C is the primary target, other lipid parameters should also be monitored 1, 2:

• Triglycerides: Target <150 mg/dL (1.7 mmol/L)
• HDL-C: Target >40 mg/dL (1.0 mmol/L) in men and >50 mg/dL (1.3 mmol/L) in women
• Non-HDL-C: Secondary target in patients with diabetes
  • Very high risk: <2.6 mmol/L (<100 mg/dL)
  • High risk: <3.4 mmol/L (<130 mg/dL)

Special Populations

Diabetes Patients 1, 2:

• Type 1 diabetes with microalbuminuria/renal disease: LDL-C reduction of at least 50% regardless of baseline
• Type 2 diabetes with CVD or CKD: LDL-C <1.8 mmol/L (<70 mg/dL)
• Type 2 diabetes without additional risk factors: LDL-C <2.6 mmol/L (<100 mg/dL)

Familial Hypercholesterolaemia 1:

• Suspect in patients with:
  • CHD before age 55 (men) or 60 (women)
  • Family history of premature CVD
  • Tendon xanthomas
  • Severely elevated LDL-C (>5 mmol/L or 190 mg/dL in adults)
• Require aggressive treatment with high-dose statins, often in combination with ezetimibe

Treatment Approach

1. First-line therapy 1, 3:

   • Statins at the highest recommended or tolerated dose
   • High-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for very high-risk patients
   • Assess LDL-C as early as 4 weeks after initiation

2. If targets not achieved 1, 2, 4:

   • Add ezetimibe 10 mg daily (provides additional 15-25% LDL-C reduction)
   • Consider PCSK9 inhibitors for very high-risk patients not achieving targets despite maximally tolerated statin plus ezetimibe

3. For elevated triglycerides 1, 2:

   • Optimize glycemic control in diabetic patients
   • Consider fibrates if HDL is low and LDL-C at goal

Monitoring and Follow-up

• Check lipid levels 4-12 weeks after initiating or changing therapy 2
• Monitor liver enzymes 8-12 weeks after starting statin therapy
• Once target levels achieved, annual lipid profile monitoring is recommended
• Assess for muscle symptoms at each follow-up visit

Common Pitfalls and Caveats

1. Statin intolerance: Often overreported; consider rechallenge at lower doses or different statin before abandoning therapy
2. Drug interactions: Be cautious with statin-fibrate combinations due to increased myopathy risk
3. Pregnancy: Statins are generally not recommended during pregnancy
4. Elderly patients: Benefit from statins similar to younger patients; treatment decisions should be based on risk assessment rather than age alone
5. Acute coronary syndrome: High-dose statins should be given early after admission regardless of baseline LDL-C values

The most recent evidence strongly supports an aggressive approach to lipid management based on cardiovascular risk assessment, with LDL-C as the primary target and statins as the cornerstone of therapy.