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Complete Summary

GUIDELINE TITLE

Treatment of hyperlipidaemia: aims and selection.

BIBLIOGRAPHIC SOURCE(S)

  • Finnish Medical Society Duodecim. Treatment of hyperlipidaemia: aims and selection. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2007 Feb 9 [Various].

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Strandberg T, Vanhanen H. Treatment of hyperlipidaemia: aims and selection. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2005 Jun 10 [various].

COMPLETE SUMMARY CONTENT

 
SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Hyperlipidaemia

GUIDELINE CATEGORY

Prevention
Risk Assessment
Treatment

CLINICAL SPECIALTY

Cardiology
Family Practice
Internal Medicine

INTENDED USERS

Health Care Providers
Physicians

GUIDELINE OBJECTIVE(S)

Evidence-Based Medicine Guidelines collects, summarizes, and updates the core clinical knowledge essential in general practice. The guidelines also describe the scientific evidence underlying the given recommendations.

TARGET POPULATION

Individuals with hyperlipidaemia, especially those with atherosclerotic disease, ischaemic heart disease (IHD), or non-insulin-dependent diabetes mellitus

INTERVENTIONS AND PRACTICES CONSIDERED

  1. Assess and modify risk factors
  2. Rule out secondary hypercholesterolaemia (measure serum thyroid-stimulating hormone, fasting blood glucose, urine test)
  3. Change living habits of patients
  4. Diet therapy; counseling on healthy diet
  5. Investigate lipid levels of relatives
  6. Drug therapy
  7. Monitor serum total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides

MAJOR OUTCOMES CONSIDERED

  • Efficacy of treatment for hyperlipidaemia on serum levels of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides
  • Incidence of ischaemic heart disease or atherosclerotic disease
  • Mortality

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence reviewed was collected from the Cochrane database of systematic reviews and the database of abstracts of reviews of effectiveness (DARE). In addition, the Cochrane Library and medical journals were searched specifically for original publications.

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

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
  1. 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
  1. 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
  1. 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

METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses
Systematic Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Basic Rules

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

Serum cholesterol (mmol/L) LDL cholesterol (mmol/L) Risk of disease progression Action
4.5 or higher 2.5 or higher Greatly increased Improve diet, change living habits, control cholesterol levels in 1 to 2 months. Reduce risk by modifying other risk factors. Drug therapy is always indicated if target levels are not reached.

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

Serum cholesterol (mmol/L) LDL cholesterol (mmol/L) Risk of disease progression Action
8.0 or higher 6.5 or higher Greatly increased Assess risk factors. Improve diet and change living habits. Control cholesterol levels in 1 to 2 months. Drug therapy is indicated if values near the target levels are not reached. The probability of an inherited disorder is high. Relatives should be investigated.
6.5 to 7.9 5.0 to 6.4 Moderately increased Assess risk factors and start dietary therapy. Control cholesterol levels in 2-4 months. Further measures (drug treatment) according to outcome of dietary therapy and other risk factors. Hereditary disorders of lipid metabolism are possible (and should be treated in the same way as patients with serum cholesterol above 8 mmol/L).
5 to 6.4 3.0 to 4.9 Slightly increased Counselling on healthy diet and assessment of risk factors. Further measures according to other risk factors. Control of serum cholesterol after about 5 years.

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
  1. 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
  1. 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
  1. 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

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

REFERENCES SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Concise summaries of scientific evidence attached to the individual guidelines are the unique feature of the Evidence-Based Medicine Guidelines. The evidence summaries allow the clinician to judge how well-founded the treatment recommendations are. The type of supporting evidence is identified and graded for select recommendations (see the "Major Recommendations" field).

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

  • Secondary prevention of ischaemic heart disease
  • Decreased risk of atherosclerotic arterial disease

POTENTIAL HARMS

Not stated

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Getting Better
Living with Illness
Staying Healthy

IOM DOMAIN

Effectiveness
Patient-centeredness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • Finnish Medical Society Duodecim. Treatment of hyperlipidaemia: aims and selection. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2007 Feb 9 [Various].

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2001 Jan 4 (revised 2007 Feb 9)

GUIDELINE DEVELOPER(S)

Finnish Medical Society Duodecim - Professional Association

SOURCE(S) OF FUNDING

Finnish Medical Society Duodecim

GUIDELINE COMMITTEE

Editorial Team of EBM Guidelines

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Primary Authors: Timo Strandberg; Hannu Vanhanen

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Strandberg T, Vanhanen H. Treatment of hyperlipidaemia: aims and selection. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2005 Jun 10 [various].

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

None available

PATIENT RESOURCES

None available

NGC STATUS

This summary was completed by ECRI on August 28, 2001. The information was verified by the guideline developer as of October 26, 2001. This summary was updated by ECRI on December 9, 2002, April 2, 2004, June 15, 2004, February 18, 2005, August 7, 2006, and most recently on January 8, 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

DISCLAIMER

NGC DISCLAIMER

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