Treatment and Management Goals of Dyslipidemia (Lipids)

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LIPID MANAGEMENT

Lowering LDL‑C is the main goal of treatment; once
the LDL‑C goal is reached, other lipid and non-lipid
risk factors can be treated. Therapeutic Lifestyle
Changes (TLC) are first-line therapy; reserve drug
therapy for higher risk patients. ContinueTLC for
≥3mos before starting drug therapy; use drug therapy
with—not instead of—TLC.

If there is evidence of coronary heart disease (CHD)
or CHD risk equivalents, do lipoprotein analysis.

If there is no evidence of CHD, but there are 2 or
more major risk factors for CHD other than LDL‑C, use
Framingham scoring system to identify those with a
10-year risk.

See www.nhlbi.nih.gov for worksheets to
determine 10-year risk.

LDL‑C GOALS
Risk Category LDL‑C goal LDL‑C
level
to start
TLC
LDL‑C level
to consider
drug therapy

CHD or risk equivalents (10-year risk >20%)

  • ≥45yrs male; ≥55yrs female

  • Smoking

  • HTN or taking HTN therapy

  • HDL ≤35mg/dL

  • Diabetes

  • Family history of CHD

<100mg/dL
(optional goal
of <70mg/dL)
≥100mg/dL ≥100mg/dL

<100mg/dL: consider initiating or intensifying LDL‑C lowering therapy, treat other risk factors, or use other lipid-modifying drugs (nicotinic acid or fibrates) if high TG or low HDL‑C

2+ risk factors
(10-year risk 10−20%)
<130mg/dL
(optional goal
of <100mg/dL)
≥130mg/dL ≥130mg/dL

100−129mg/dL: consider initiating LDL‑C lowering therapy optional

2+ risk factors
(10-year risk <10%)
<130mg/dL ≥130mg/dL ≥160mg/dL
0−1 risk factor
(10-year risk assessment not necessary)
<160mg/dL ≥160mg/dL ≥190mg/dL

160−189mg/dL: drug therapy optional; consider if single severe risk factor, multiple life-habit and/or emerging risk factors, or 10-year risk nearly 10%

LDL‑C vs. NON-HDL‑C GOALS

In high-risk persons, consider drug therapy to achieve non-HDL‑C goal. The non-HDL‑C goal can be achieved by intensifying therapy with an LDL‑lowering drug or by cautiously adding nicotinic acid or fibrate.

Non-HDL‑C = Total-C − HDL‑C

Risk Category LDL‑C Goal Non-HDL‑C Goal
CHD and CHD risk equivalent
(10-year risk >20%)
<100mg/dL <130mg/dL
2+ risk factors and
10-year risk ≤20%
<130mg/dL <160mg/dL
0−1 risk factor <160mg/dL <190mg/dL
MANAGEMENT OF LOW HDL‑C

Low HDL‑C (<40mg/dL) is a strong independent predictor of CHD. The primary target of therapy is LDL‑C. There is not a specific goal for raising HDL‑C; after LDL‑C goal is reached, emphasize weight reduction and increased physical activity, and modifying non-HDL‑C if TG is also elevated.

If triglycerides are <200mg/dL (see below), consider using drugs to raise HDL‑C (fibrates or nicotinic acid).

MANAGEMENT OF ELEVATED TG

Elevated serum triglycerides (TG) is an independent risk factor for CHD. For all patients with high TG, the primary goal of therapy is to achieve the target goal for LDL‑C.

Classification Serum TG
level
In addition to achieving
target LDL‑C goal:
Normal <150mg/dL
Borderline-high 150−199mg/dL

Reduce weight and increase physical activity

High 200−499mg/dL

Non-HDL‑C is secondary target (intensify LDL‑C lowering therapy or add nicotinic acid or fibrate cautiously)

Very High ≥500mg/dL

Initial aim is to prevent acute pancreatitis through TG lowering by using very low fat diets, weight reduction, increased physical activity, and a TG lowering drug (fibrate or nicotinic acid). After TG levels ≤500mg/dL, focus on lowering LDL‑C.

REFERENCES

Adapted from the Third Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III), NIH pub no. 110:227–239, July 2004. All rights reserved.

(Rev. 7/2015)

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