Dyslipidemia is a major risk factor for heart attacks and strokes, which are leading causes of death. Guidelines for treating dyslipidemia have evolved over time. The latest guidelines (ATP IV) focus on reducing cardiovascular risk through intensive statin therapy rather than targeting specific LDL-C levels. They broaden treatment indications to include cardiovascular disease beyond just coronary heart disease. All adults over age 21 with LDL-C over 190mg/dl should be treated, as should adults aged 40-75 with diabetes. Screening for dyslipidemia should begin at age 25 for men and 35 for women if risk factors are present, or at age 35 for men and 45 for women without risk factors.

1. Dyslipidemia
By: Shima Ghavimi, MD

2. dyslipidemia
MI is the most common cause of death in the
U.S
Stroke is the third common cause of death in
the U.S
There is significant overlap in the risk factors
for stroke and MI and among these RF one of
them is hyperlipidemia

3.  The first set of cholesterol guidelines (ATP I) focused on the primary prevention of
CHD, outlining a strategy for cholesterol lowering goals in individuals with high
cholesterol and two or more cardiovascular risks. At that time, an LDL-C of greater
than 160 was chosen as abnormal because cardiovascular risk increased steeply above
this level (as a result, 25% of the population was labeled with "high cholesterol"). The
second set of guidelines added goals for secondary prevention in patients with
established CHD. ATP III (and the revised ATP IIIR) combined the assessment of
risk factors for CHD (including prior CHD or CHD "risk equivalent" conditions) with
aggressive lipid lowering goals. An LDL-C of less than 130mg/dl was defined as
"desirable" and an LDL-C of less than 100mg/dl was "optimal". An even more
aggressive target LDL-C of less than 70mg/dl was defined for those at highest risk.
Based on the number of cardiovascular risks or risk-equivalent conditions, goal LDL-C
was defined as less than 130mg/dl, less than 100mg/dl, or less than 70mg/dl
according to the amount of risk for an individual. Many have referred to this
management principle of ATP guidelines as "treat to target". With ATP III/IIIR
guidelines, many began to default to the management principle that "lowest is best",
assuming that additional CVD benefit would result from attaining the most aggressive
lipid lowering goals.

4.  ATP I-IIIR built an increasingly aggressive argument for lipid management.
ATP IV similarly builds on the foundation of prior guidelines, but also
represents a significant change in management of hyperlipidemia. Gone is the
concept of "treat to target". Treat to target was abandoned because of the
lack of evidence of a specific target and lack of comparison data on different
targets. In its stead, the intensity of lipid lowering becomes the focus. Also
new: broadening of the guideline focus from coronary heart disease (CHD) to
atherosclerotic cardiovascular disease (ASCVD)(i.e., including coronary artery
disease, cerebrovascular disease, and peripheral artery disease); broadening of
risk assessment for primary prevention; definition of new treatment benefit
groups. Gone from ATP guidelines are lipid lowering targets and metabolic
syndrome treatment targets. Finally, included in ATP IV are considerations of
the potential adverse effects of therapy.

6. Statin benefit groups

7. ASCVD
Acute coronary syndrome
Prior myocardial infarction
Stable/unstable angina
Prior coronary or arterial revascularization
Stroke
Transient ischemic attack
Peripheral arterial disease presumed to be of
atherosclerotic origin

8. asymptomatic atherosclerosis noted incidentally
on imaging the presence of an abdominal aortic
aneurysm is not included.

9. +
+
LDL-C >190mg/dl
Individuals with very high LDL-C
(i.e., >190mg/dl) are known to be at significant
risk of an ASCVD event regardless of other risk
factors. As a result, primary LDL-C
elevations >190mg/dl are an indication for
statin treatment in all individuals 21 and older;
there is no need to calculate ASCVD risk in this
group. Before initiating treatment, secondary
causes of LDL-C should be excluded.

10. Secondary causes of
hyperlipidemia

11. Diabetes
All patients aged 40-75 with diabetes benefit from lipid lowering
therapy. Decisions on lipid lowering therapy in younger and
older individuals outside this age range should be made on an
individual basis. Although all diabetic patients aged 40-75 should
be treated with lipid-lowering therapy, the intensity of treatment
is determined by their 10-year risk of an ASCVD event.
Therefore, in patients with diabetes between 40-75, we always
calculate the 10-year risk of ASCVD to determine the intensity
of management.

12.  As a reminder, we do not need to perform this
ASCVD risk calculation in those with clinical ASCVD
or LDL-C>190mg/dl, but do use this calculation in
other patients, including those with diabetes. The
guidelines limit their recommendations in this group to
those aged 40-75, leaving to individual judgment the
role of risk calculation for younger and older
individuals. The only statin benefit group with specific
recommendations on younger individuals is those with
LDL-C>190mg/dl, in whom we start treatment at age
21.

13. There were two clinical groups in whom the
benefit of lipid lowering therapy was not
demonstrated: those with New York Heart
Association (NYHA) Class II-IV heart failure
and those who were receiving hemodialysis. The
benefit of lipid-lowering drugs in these groups
remains unclear.

18.  When evaluating for screening, we consider patients to be
at higher risk if they have more than one risk factor
(hypertension, smoking, family history) or a single risk factor that
is severe. We then decide whom to screen based on risk factors,
age, and sex
 •In primary prevention patients who are at higher risk, we
suggest screening for lipid abnormalities starting at age 25 in
male patients and age 35 in female patients
 •In primary prevention patients who are not at higher risk, we
suggest screening for lipid abnormalities starting at age 35 in
male patients and age 45 in female patients.

19. In patients where lipid measurement is indicated, we
suggest repeating measurements every five years in
patients whose prior lipid measurement places them
clearly below an appropriate threshold for treatment. In
patients near a threshold for treatment (whether based
on total CV risk or an LDL-C goal), we suggest
repeating measurements every three years. We also
repeat measurements at least every three years in those
found to be at increased CV risk based on their lipid
measurements