Screening and management of hyperlipidemia.

The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Age > 18 Years and Older

Risk Assessment

Screening: Initial fasting lipid profile (i.e., total, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], triglycerides); if normal repeat at least every five years [D]
Treatment is based on LDL-C, major risk factors, and presence of coronary heart disease (CHD) or equivalent.

Major Risk Factors

Cigarette smoking
Hypertension (blood pressure [BP] >140/90)
On antihypertensives, regardless of current BP levels
HDL-C: <40 (HDL-C >60 = negative risk factor)
Family history (first degree) of premature CHD (men <55 years; women <65 years)
Age (men >45 years; women >55 years)

CHD Risk Equivalents

Other clinical forms of atherosclerotic disease (e.g., peripheral arterial disease, abdominal aortic aneurysm, and/or symptomatic carotid artery disease)
Diabetes
Multiple risk factors confer a 10-year risk for CHD >20%
CHD and CHD risk equivalents give a >20% risk of a CHD event within 10 years

LDL-C >100

Risk Stratification

Calculate short-term risk for patients with 2+ risk factors using the Framingham projection of 10-year absolute risk [D]:

Categorical Risk	Goal for LDL-C
CHD or CHD risk equivalents 10-year risk: >20%	<100 mg/dL
2+ risk factors 10-year risk: <20%	<130 mg/dL
0-1 risk factor	<160 mg/dL

Education and Risk Factor Modification

Educate patient/family regarding Therapeutic Lifestyle Changes (TLC).

Reduce saturated fats and cholesterol [A], increase plant stanols/sterol (e.g., cholesterol-lowering margarines), increase viscous soluble fiber (e.g., oats, barley, lentils, beans).
Decrease weight and increase exercise to moderate level of activity for 30 minutes most days of the week [A].

Pharmacologic Interventions

TLC and/or drug therapy may be initiated based on the LDL-C level and/or presence of CHD risk or CHD risk factors.
Initiate statin therapy for patients with atherosclerotic CHD or when the LDL-C is not at goal by 6 to 8 weeks after TLC has begun in earnest.
Statins are the most commonly used lipid-lowering agents. Liver function test monitoring is recommended for 12 weeks following treatment initiation, or dosage increases, of any statin.
Evaluate and adjust drug therapy at 6 to 8 week intervals.
For patients who do not reach LDL-C goal, consider referral to lipid specialist.

Definitions:

Levels of Evidence for the Most Significant Recommendations

Randomized controlled trials
Controlled trials, no randomization
Observational studies
Opinion of expert panel

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