What is the initial workup and management for hyperlipidemia?

Latest Hyperlipidemia Guidelines Workup

The initial workup for hyperlipidemia should include a fasting lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides), assessment of secondary causes, and evaluation of cardiovascular risk factors to guide treatment decisions. 1

Initial Laboratory Assessment

• Fasting Lipid Panel:

  • Total cholesterol
  • LDL cholesterol
  • HDL cholesterol
  • Triglycerides
  • Non-HDL cholesterol (calculated)

• Additional Laboratory Tests:

  • Fasting glucose or HbA1c
  • Liver function tests (AST, ALT)
  • Renal function (creatinine, eGFR)
  • Thyroid function (TSH)

Evaluation for Secondary Causes

Secondary causes of hyperlipidemia must be identified and treated before initiating specific lipid-lowering therapy 2. Common secondary causes include:

• Endocrine disorders:

  • Diabetes mellitus (uncontrolled)
  • Hypothyroidism
  • Cushing's syndrome

• Renal disorders:

  • Chronic kidney disease
  • Nephrotic syndrome

• Liver disease:

  • Obstructive liver disease
  • Non-alcoholic fatty liver disease (NAFLD)

• Medications:

  • Thiazide diuretics
  • Beta-blockers
  • Estrogens
  • Corticosteroids
  • Isotretinoin
  • Antiretroviral protease inhibitors
  • Antipsychotics
  • Immunosuppressants

• Lifestyle factors:

  • Excessive alcohol intake
  • Poor diet high in saturated fats
  • Physical inactivity

Cardiovascular Risk Assessment

Risk stratification is essential for determining treatment goals and intensity 1:

1. Very High Risk:

   • Established ASCVD
   • Diabetes with target organ damage
   • Severe CKD (eGFR <30 mL/min)
   • SCORE ≥10%
   • LDL-C Target: <70 mg/dL or ≥50% reduction from baseline

2. High Risk:

   • Markedly elevated single risk factors
   • Diabetes without target organ damage
   • Moderate CKD (eGFR 30-59 mL/min)
   • SCORE ≥5% to <10%
   • LDL-C Target: <100 mg/dL or ≥50% reduction from baseline

3. Moderate Risk:

   • Young patients with diabetes
   • SCORE ≥1% to <5%
   • LDL-C Target: <115 mg/dL

4. Low Risk:

   • SCORE <1%
   • LDL-C Target: <115 mg/dL

Family History Assessment

• Screen for premature CVD in first-degree relatives (men <55 years, women <65 years)
• Evaluate for familial hypercholesterolemia patterns:
  • Heterozygous FH: LDL-C typically >190 mg/dL
  • Homozygous FH: LDL-C typically >500 mg/dL
  • Family history of premature ASCVD

Special Populations Considerations

Children and Adolescents

• Initial screening at age ≥2 years if family history of early CVD exists 1
• Without family history, screen at puberty (≥10 years) 1
• Optimal goals: LDL-C <100 mg/dL, HDL-C >35 mg/dL, triglycerides <150 mg/dL 2

Diabetic Patients

• Screen when initial glycemic control has been achieved and annually thereafter 2, 1
• Consider less frequent screening (every 2 years) for patients with consistently low-risk lipid values 1

Patients with Chronic Kidney Disease

• Assess lipid profile at diagnosis and annually
• Consider more aggressive treatment targets due to higher cardiovascular risk 2

Management Algorithm

1. Lifestyle Modifications (First-line for all patients):

   • Heart-healthy diet (reduced saturated fat <7% of calories)
   • Reduced dietary cholesterol (<200 mg/day)
   • Elimination of trans fats
   • Weight management if overweight/obese
   • Regular physical activity
   • Smoking cessation
   • Limited alcohol intake

2. Pharmacological Therapy:

   • Moderate Hyperlipidemia:

     • Statins as first-line therapy (high-intensity for high-risk patients)
     • Consider ezetimibe as add-on therapy if LDL-C goals not achieved

   • Severe Hypertriglyceridemia (>500 mg/dL):

     • Fibrates are first-line treatment to reduce pancreatitis risk 2
     • Consider omega-3 fatty acids as adjunctive therapy
     • Reduce dietary fat and simple carbohydrates

   • Familial Hypercholesterolemia:

     • High-intensity statins
     • Consider combination therapy with ezetimibe
     • PCSK9 inhibitors for those not achieving targets 2

Monitoring

• Check lipid levels 4-12 weeks after initiating or changing therapy 1
• Monitor liver enzymes 8-12 weeks after starting statin therapy
• Assess for muscle symptoms at follow-up visits
• Annual lipid profile monitoring once target levels are achieved 1

Common Pitfalls to Avoid

1. Failing to identify secondary causes before initiating lipid-lowering therapy
2. Not assessing overall cardiovascular risk when determining treatment intensity
3. Inadequate monitoring of response to therapy and potential side effects
4. Overlooking familial hypercholesterolemia in patients with very high LDL-C levels
5. Using statins alone in patients with severe hypertriglyceridemia (>500 mg/dL)
6. Discontinuing therapy due to minor side effects without attempting dose adjustments or alternative medications

By following this structured approach to hyperlipidemia workup, clinicians can effectively identify patients at risk, determine appropriate treatment goals, and implement evidence-based management strategies to reduce cardiovascular morbidity and mortality.