What are the current guidelines for the assessment and management of dyslipidemia?

Dyslipidemia Guidelines: Assessment and Management

Risk Stratification Framework

The cornerstone of dyslipidemia management is risk-based stratification using the SCORE system (Europe) or validated risk calculators, with treatment intensity tailored to absolute cardiovascular risk rather than lipid levels alone. 1

Very High Risk (SCORE ≥10%)

Patients in this category require the most aggressive intervention and include: 1

• Documented CVD by any modality (coronary angiography, nuclear imaging, stress echo, carotid plaque on ultrasound) 1
• Previous MI, ACS, coronary or arterial revascularization procedures, ischemic stroke, or peripheral arterial disease 1
• Type 2 diabetes or Type 1 diabetes with target organ damage (microalbuminuria) 1
• Moderate to severe CKD (GFR <60 mL/min/1.73 m²) 1

LDL-C target: <1.8 mmol/L (<70 mg/dL) or ≥50% reduction from baseline 1, 2

High Risk (SCORE ≥5% and <10%)

This category includes: 1

• Markedly elevated single risk factors including familial dyslipidemia and severe hypertension 1
• Calculated 10-year fatal CVD risk between 5-10% 1

LDL-C target: <2.6 mmol/L (<100 mg/dL) or ≥50% reduction 2, 3

Moderate Risk (SCORE ≥1% and <5%)

Middle-aged individuals typically fall here, with risk further modified by: 1

• Family history of premature CAD 1
• Abdominal obesity (waist ≥94 cm men, ≥80 cm women) 1
• Low HDL-C, elevated triglycerides, elevated hs-CRP, Lp(a), or apoB 1

LDL-C target: <2.6 mmol/L (<100 mg/dL) 3

Low Risk (SCORE <1%)

Lifestyle advice to maintain low-risk status 1

Screening Recommendations

Screen all men ≥40 years and women ≥50 years or post-menopausal, with earlier screening for those with additional risk factors. 1

Mandatory screening populations regardless of age: 1

• Any evidence of atherosclerosis in any vascular bed 1
• Type 2 diabetes (all patients) 1
• Family history of premature CVD 1
• Arterial hypertension with metabolic disorders 1
• Central obesity (BMI ≥25 kg/m²) 1
• Autoimmune inflammatory conditions (rheumatoid arthritis, SLE, psoriasis) 1
• CKD (GFR <60 mL/min/1.73 m²) 1
• Clinical signs of genetic dyslipidemia (xanthomas, xanthelasmas, premature arcus cornealis) 1
• Offspring of patients with severe dyslipidemia (FH, FCH, chylomicronemia) 1

Laboratory Assessment

Baseline lipid panel must include: TC, TG, HDL-C, calculated LDL-C (Friedewald formula if TG <4.5 mmol/L or <400 mg/dL), non-HDL-C, and TC/HDL-C ratio. 1

• Friedewald formula: LDL-C = TC - HDL-C - TG/2.2 (mmol/L) or TC - HDL-C - TG/5 (mg/dL) 1
• Alternative: apoB and apoB/apoA1 ratio 1

Treatment Algorithm

Step 1: Initiate Lifestyle Modifications (All Patients)

All patients require therapeutic lifestyle changes as the foundation, regardless of whether pharmacotherapy is indicated. 3, 4

• Saturated fat <7% of total calories 3
• Dietary cholesterol <200 mg/day 3
• Weight reduction of 5-10% if overweight 3
• Physical activity ≥150 minutes/week moderate-intensity aerobic exercise 3
• Smoking cessation (halves risk) 1

Step 2: Pharmacotherapy Decision

For very high-risk patients, initiate statin therapy immediately alongside lifestyle changes. 1, 3

For high-risk patients, start statins if LDL-C goals not achieved after lifestyle modification trial. 3

In patients with acute MI or ACS, initiate high-dose statin therapy immediately regardless of baseline LDL-C levels. 1

Step 3: Statin Selection and Dosing

Statins are first-line pharmacotherapy with the most robust evidence for LDL-C lowering and ASCVD prevention. 5, 4

• Moderate-intensity statin: atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily 3
• High-intensity statin for very high-risk patients: atorvastatin 40-80 mg or rosuvastatin 20-40 mg 1
• Target at least 30-50% LDL-C reduction 2, 3

Step 4: Monitoring and Intensification

Reassess fasting lipid panel 6-12 weeks (or 8±4 weeks per European guidelines) after initiating or adjusting therapy. 2, 3

If LDL-C target not achieved: 3

• Intensify statin dose, OR
• Add ezetimibe (10 mg daily) 1
• Consider PCSK9 inhibitors for refractory cases 6

Non-HDL-C serves as secondary target, set 30 mg/dL (0.8 mmol/L) higher than LDL-C goal. 3

Special Population Considerations

Diabetes

All Type 1 diabetes patients with microalbuminuria/renal disease require LDL-C lowering ≥50% with statins regardless of baseline LDL-C. 1

Type 2 diabetes with CVD/CKD or age >40 with additional risk factors: LDL-C target <1.8 mmol/L (<70 mg/dL). 1

Chronic Kidney Disease

Stage 3-5 CKD patients are high or very high CV risk; use statins or statin/ezetimibe combination. 1

Do not initiate statins in dialysis-dependent CKD patients without established atherosclerotic CVD. 1

Peripheral Arterial Disease

PAD is a very high-risk condition requiring statin therapy to achieve very high-risk targets. 1

Stroke Prevention

Intensive statin therapy is mandatory for secondary prevention in patients with non-cardioembolic ischemic stroke or TIA. 1

Familial Hypercholesterolemia

FH patients require intense-dose statin, often combined with ezetimibe, initiated early. 1, 5

Family cascade screening is mandatory when an index FH case is diagnosed. 1

Test children from age 5 years, or earlier if homozygous FH suspected. 1

Critical Pitfalls to Avoid

In older patients, use clinical judgment rather than automatically treating based on age-driven high SCORE alone—prioritize lifestyle measures like smoking cessation first. 1

Do not withhold statins due to concern about diabetes risk in prediabetes—the ASCVD reduction benefit far outweighs the small diabetes risk. 6

Do not use statins for heart failure without other indications—they are not harmful but provide no benefit. 1

Do not use statins for aortic stenosis without CAD or other indications. 1

Never initiate hormone replacement therapy for lipid management or cardiovascular prevention—treat dyslipidemia with standard statin therapy regardless of HRT status. 2

Measure lipids before HRT initiation and monitor response appropriately. 2