Diagnosis
- Patients > 40 should have their CVD risk estimated annually (Qrisk2) and full formal risk assessment if prediction 10% or more (though not suitable if eGFR < 60)
- Qrisk underestimated in those taking drugs causing dyslipidaemia (Bendroflumezide, Olanzepine), and the immunocompromised, and those that have quit smoking
- Use clinical findings, lipid profile and Fx to judge likelihood of familial lipid disorder rather than absolute cut-offs
Investigation
- Measure both total Cholesterol and High Density Lipoprotein for best CVD risk estimate
- Take full lipid profile prior to starting therapy: in addition triglycerides and non HDL cholesterol (fasting not necessary)
- Specialist review if TC > 9.0 mmol/l or TG > 20 mmol/l
Management
Conservative:
- Smoking strongly discouraged
- Diet: total fat < 30 % of total energy intake, saturated fat < 7% total, total cholesterol intake < 300 mg/day and unsaturated fats (olive oil, rapeseed oil) replacing saturated fat; 5 portions fruit and vegetables a day; 2 portions fish (one oily) per week
- Exercise: 30 mins a day 5 days per week of moderate intensity (bouts > 10 mins as effective as longer sessions) OR to your maximum safe capacity
- Alcohol men 3-4 units a day; women 2-3 units
- Weight: appropriate advice and support
Pharmacological
If lifestyle modification ineffective:
- Perform baseline before commencement per the following list: Alcohol consumption, BP, BMI, full lipid profile, eGFR, AST, TFT, HbA1c
- Primary prevention: 20 mg Atorvastatin if have > 10% Qrisk2, and all adults with T1DM > 40 or diabetes > 10 yrs or established nephropathy, and all patients with CKD
- Secondary prevention: those with CVD 80 mg Atorvastatin, lower dose if risk of side effects, 20 mg for those with CKD
- Before starting if generalised unexplained muscle pain, measure creatinine kinase, and if 5 x upper limit of normal do not start
- Measure liver transaminases (ALT, AST) before commencement and at 3 mths and 12 mths. Only stop therapy if raised > 3 x baseline
- Ezetimide: consider for those with primary hypercholesterolaemia