• The goals are:
  • Secondary prevention of arterial disease. (The most important patient group to be treated are patients with diagnosed arterial disease.)
  • Decreasing the risk of atherosclerotic arterial disease guided by the total risk (combined effect of risk factors). The assessment of the risk for arterial disease may be facilitated by the use of different risk calculators (e.g., SCORE).
    • Note that SCORE only gives the probability of death risk; the risk of arterial disease is significantly higher.
• Changing living habits is the primary target in all patients.
• Rule out secondary hypercholesterolaemia before starting drug treatment (serum thyroid-stimulating hormone [TSH], fasting blood glucose, urine test).
• The aim of treatment is to maintain:
  • Serum cholesterol under 5.0 mmol/L (under 4.5 mmol/L high-risk individuals)
  • Serum low-density lipoprotein (LDL) cholesterol under 3.0 mmol/L (in high-risk individuals under 2.5 mmol/L). (For calculation, see LDL calculator program available at the Evidence-Based Medicine [EBM] Web site.)
  • Serum high-density lipoprotein (HDL) cholesterol over 1.0 mmol/L
  • Serum triglyceride under 2.0 mmol/L
  • Serum cholesterol: serum HDL cholesterol ratio under 4.0
• The treatment of a low HDL cholesterol concentration and a high serum triglyceride concentration is probably beneficial, at least in patients with non-insulin-dependent diabetes mellitus.
• The serum triglyceride concentration should be under 10 mmol/L to minimize the risk of pancreatitis.

Patients with Ischaemic Heart Disease

• The risk of myocardial infarction or cardiac death increases sharply with rising serum cholesterol concentrations in patients with ischaemic heart disease.
• The effectiveness of drug treatment has been clearly shown in controlled studies ("Randomised trial of cholesterol lowering," 1994) [A]. The target serum cholesterol concentration is under 4.5 mmol/L (LDL cholesterol under 2.5 mmol/L). There is evidence that patients with coronary diseases benefit from even lower LDL levels (well under 2 mmol/L) (Cannon, Braunwald, & McCabe, 2004).
• See table "Hypercholesterolaemia in Patients with Ischaemic Heart Disease" below.

Table. Hypercholesterolaemia in Patients with Ischaemic Heart Disease

Patients with Other Atherosclerotic Diseases (Cerebrovascular Disease, Peripheral Arterial Disease)

• See above.

Symptomless Individuals

• The general target serum cholesterol level is under 5.0 mmol/L (LDL cholesterol under 3.0 mmol/L). When considering indications for intervention, the age and sex and total risk of the patient should be taken into account. (Those of working age are the most important group.) See table "Hypercholesterolaemia in Asymptomatic Individuals" below.
• In high-risk symptomless individuals the lipid target is serum (S)-cholesterol under 4.5 mmol/L (LDL cholesterol under 2.5 mmol/L).

Table. Hypercholesterolaemia in Asymptomatic Individuals

Elderly Patients (>80 years)

• There are no randomized prognostic studies in this age group.
• The biological age and the general prognosis should be taken into account when deciding on treatment, especially in those with arterial disease.
• The principles of treatment are the same as in younger patients.

Related Resources

Evidence Summaries

• Aerobic exercise training appears to produce small favourable changes in blood lipids in previously sedentary adults (Halbert et al., 1999) [B].
• There is little evidence that low or reduced serum cholesterol concentration significantly increases mortality from any cause other than haemorrhagic stroke. This risk affects only people with a very low concentration, and even in these the risk is outweighed by the benefits from the low risk of ischaemic heart disease, at least in patients with ischaemic heart disease (Law, Thompson, & Wald, 1994) [B].

Refer to the original guideline document for related literature.

Definitions:

Levels of Evidence

1. Quality of Evidence: High

   Further research is very unlikely to change confidence in the estimate of effect

   • Several high-quality studies with consistent results
   • In special cases: one large, high-quality multi-centre trial

2. Quality of Evidence: Moderate

   Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

   • One high-quality study
   • Several studies with some limitations

3. Quality of Evidence: Low

   Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

   • One or more studies with severe limitations

4. Quality of Evidence: Very Low

   Any estimate of effect is very uncertain.

   • Expert opinion
   • No direct research evidence
   • One or more studies with very severe limitations

References open in a new window

This guideline is included in a CD-ROM titled "EBM Guidelines. Evidence-Based Medicine" available from Duodecim Medical Publications, Ltd, PO Box 713, 00101 Helsinki, Finland; e-mail: info@ebm-guidelines.com; Web site: www.ebm-guidelines.com.

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