This document discusses guidelines for managing dyslipidemia from several organizations. It summarizes that the ATP III guidelines from 2001 focused on multiple risk factors and modified lipid classifications. It describes risk stratification groups from different guidelines and LDL and non-HDL cholesterol goals. It also discusses management of elevated triglycerides, the metabolic syndrome, and medications and lifestyle changes used to treat dyslipidemia.

1. MANAGEMENT OF
DYSLIPIDEMIA

2. Presentation Objectives
• State the major goals of the Adult Treatment
Panel (ATP) III Guidelines.
• Describe the new risk stratification process,
low density lipid (LDL) goals and the
Framingham assessment.
• State the major medications used to lower
cholesterol and their common side effects.
• Describe the management of low high
density lipids (HDL), elevated triglycerides
(TGs) and the metabolic syndrome.

3. National Cholesterol
Education Program (NCEP)
• Adult treatment Panel I (1988)
– primary prevention in those with high LDL
• Adult treatment panel II(1993)
– reaffirmed the above, plus emphasis on
intensive management of LDL in those
with established coronary heart disease
(CHD)
• Adult treatment panel III (2001)

4. New features of ATP III
• Focus on multiple risk factors
• Modification of lipid and lipoprotein
classification
• Support for implementation

5. Risk Group AACE 2020 NLA ESC/EAS 2019 CCS 2018 IAS
Extreme LDL-C < 55 mg/dl
NON-HDL-C < 80
mg/dl
Very high LDL-C < 70 mg/dl
NON-HDL-C < 100
mg/dl
LDL-C < 70
mg/dl
NON-HDL-C <
100 mg/dl
LDL-C < 55 mg/dl
(< 1.4 mmol/l)
NON-HDL < 80
mg/dl (< 2.2
mmol/l)
LDL-C < 2.0
mmol/l).Non-HDL
< 2.6 mmol/l
LDL-C < 70 mg/dl
NON-HDL-C < 100
mg/dl
High LDL-C < 100
mg/dl
NON-HDL-C < 130
mg/dl
LDL-C < 100
mg/dl
NON-HDL-C <
130 mg/dl
LDL-C < 70 mg/dl
(< 1.8 mmol/l)
NON-HDL < 100
mg/dl (<2.6
mmol/l)
LDL-C < 2.0
mmol/l).Non-HDL
< 2.6 mmol/l
LDL-C < 100
mg/dl
NON-HDL-C < 130
mg/dl
Moderate LDL-C< 100 mg/dl
NON-HDL-C < 130
mg/dl
LDL-C < 100
mg/dl
NON-HDL-C <
130 mg/dl
LDL-C < 100 mg/dl
(< 2.6 mmol/l)
NON-HDL < 130
mg/dl (< 3.4
mmol/l)
LDL-C < 2.0
mmol/l).Non-HDL
< 2.6 mmol/l
LDL-C < 100
mg/dl
NON-HDL-C < 130
mg/dl
Low LDL-C< 130 mg/dl
NON-HDL-C < 160
mg/dl
LDL-C < 100
mg/dl
NON-HDL-C <
130 mg/dl
LDL-C < 116 mg/dl
(< 3 mmol/l)
Secondary
Prevention
Primary
Prevention
Classification of LDL cholesterol

6. Management of Specific
conditions
• ATP III Classification of elevated
triglycerides:
• <150 normal
• 150-199 borderline high
• 200-499 high
• >500 very high

7. Management of specific
conditions
• Treatment of elevated triglycerides:
– when TGS > 500 then need to lower triglycerides
first to prevent pancreatitis.
– Otherwise need to reach LDL goal first, then non-
HDL goal (LDL goal + 30 for VLDL).
– Increase physical activity, intensify weight
management first, then use fibrates or nicotinic
acid to reduce VLDL and triglycerides.

8. The Management of Specific
Conditions
• Any three of the following:
– 1. Abdominal Obesity
• Waist circumference ( >40 in M, >35 in F)
– 2. Triglycerides >150mg/dl
– 3. HDL Cholesterol
• <40 mg/dl in M, <50mg/dl in F
– 4. Blood Pressure >130/>85 mmHg
– 5. Fasting Glucose >110mg/dl
4. The Metabolic Syndrome:

9. Treatment of the Metabolic Syndrome:
• Recognized as secondary target of risk
reduction therapy after LDL cholesterol.
– 1. Treat underlying causes
• intensify weight management
• increase physical activity
– 2. Treat risk factors if they persist after
lifestyle therapies.
• Treat HTN, Use ASA for CHD, Treat increased
triglycerides &/or Low HDL.
The Management of Specific Conditions

10. Interventions to Improve
Adherence
• Simplify medication regimes.
• Use good counseling techniques with patients.
• Involve patients and their families in their
care.
• Increase visits / access to achieve goals.
• Reinforce and reward compliance.
• Multidisciplinary approach within the clinic.
• Physician reminders to prompt attention to
lipid management.

11. THE USE OF OMEGA-3 (EPA
+DHA) IN
HYPERTRIGLYCERIDEMIA,
ESC 2019

12. Skulas-Ray AC et al. Circulation 2019 Aug 19
Prescription n-3 FAs (EPA+DHA or EPA-
only) at a dose of 4 g/d (>3 g/d total
EPA+DHA) are an effective and safe
option for reducing triglycerides as
monotherapy or as an adjunct to other
lipid-lowering agents.
All prescription agents appear comparably
effective, but head-to-head comparisons
are lacking
AHA ScienceAdvisory

13. AHA Science Advisory 2019
Concerns have been raised that DHA-containing prescription agents
may raise LDL-C in patients with HTG. We identified 9 trials of
patients with HTG that reported effects on LDL-C with 4 g/d of DHA
containing prescription n-3 FA (8 studies of O3AEE and 1 study of
O3CA).
In 8 of these 9 studies, there was no change in LDL-C versus placebo
(4 of which used n-3 FA as an adjunct to statin therapy), whereas in 1
study, the median LDL-C was marginally increased by 3.5% versus
placebo (P=0.052).31 This is similar to the change reported in
REDUCE-IT, with a median increase in LDL-C of 3.1% from baseline
(P<0.001) for EPA-only.
Skulas-Ray AC et al. Circulation 2019 Aug 19

14. The use of Omega-3(EPA+DHA) in Hypertriglyceridemia, ESC2019

15. Take Home Messages
• Focus on Multiple Risk Factors
• New Lipid and Lipoprotein
Classification
• New recommendations for screening
• More intensive tender loving care
• New strategies for compliance

16. THANK YOU