Dyslipidemia Management: Detection, Classification, and Treatment

Posted on Jan 3, 2025 in Physical Education

Other Preventive Interventions: Dyslipidemia and Pharmacological Approaches

Preventive Strategies: Prevalence of Hypercholesterolemia in Spain

The prevalence of hypercholesterolemia in Spain is 23%.

Detection and Confirmation of Dyslipidemia

Frequency of screening: Starting at age 75, or earlier if not previously done. Determine total cholesterol every 5 years until age 75, at least once before age 35 in males and before age 45 in females.

If total cholesterol (TC) is ≥ 240 mg/dL, a complete lipid profile (TC, HDL, TG, LDL-C) is required. Repeat if:

  • Triglycerides (TG) > 200mg/dl
  • TC ≥ 240 mg/dL
  • HDL < 40mg/dl

LDL-C = TC – TG/5 – HDL-C. Two determinations should be done between 1 week and 2 months after the first, using average values for reference.

Study and Classification of Dyslipidemia

Clinical Classification:

  • Hypercholesterolemia (without vascular disease): TC ≥ 250mg/dl
  • Hypercholesterolemia (with vascular disease): TC ≥ 200mg/dl
  • Mixed hyperlipidemia: TC ≥ 200 mg/dl and TG ≥ 200 mg/dl
  • Borderline hypercholesterolemia: TC 200-249 mg/dl
  • Hypertriglyceridemia: TC < 200 mg/dl and TG ≥ 200mg/dl

Primary or Secondary Dyslipidemia:

  • Primary Dyslipidemia:
    • Familial hypertriglyceridemia (normal or decreased TC and very high TG; dominant inheritance)
    • Polygenic familial hypercholesterolemia (elevated TC and normal TG; polygenic inheritance)
    • Familial combined hyperlipidemia (increased TC and TG; dominant inheritance)
    • Monogenic familial hypercholesterolemia (very high TC and normal TG; dominant inheritance)
    • Hyperchylomicronemia (high TC and very high TG; recessive inheritance)
    • Familial dysbetalipoproteinemia (high TC and TG; recessive inheritance)

Referral to specialized care is advised for resistant dyslipidemias, suspected primary atherogenic dyslipidemia, or when triple drug therapy is needed.

Assessment and Stratification of Vascular Risk

Risk stratification (low, moderate, high) and level of prevention (primary, secondary) are crucial.

Process of Vascular Risk: Therapeutic Aims

Lipids:

  • Primary Prevention:
    • High Risk (> 20% at 10 years): LDL < 130mg/dl, drug treatment if LDL ≥ 160mg/dl
    • Moderate Risk (10-20% at 10 years): LDL < 160mg/dl, drug treatment if LDL ≥ 190mg/dl
  • Secondary Prevention: LDL < 100mg/dl

Adaptation to the Spanish and European Guidelines for Cardiovascular Prevention

Lipids:

  • Primary Prevention:
    • High Risk (≥ 5%): LDL < 115mg/dl, consider drugs if LDL ≥ 130mg/dl
    • Not High Risk (< 5%): Consider periodic reassessments, LDL < 130mg/dl
    • In Diabetes: LDL < 100mg/dl

Preventive Interventions for Individuals with Dyslipidemia

Non-drug interventions are effective (regular aerobic exercise, low-fat diet, Mediterranean diet, weight loss). These measures should be maintained in dyslipidemic patients. First therapeutic intervention should be lifestyle changes based on lipid-lowering strategies.

Treatment Objectives:

(Primary prevention: low, moderate, high risk / secondary prevention), based on calculated LDL values.

Benefits of Hypolipidemic Treatment

Randomized clinical trials have demonstrated that reducing LDL cholesterol decreases mortality and the incidence of cardiovascular disease (CVD) and coronary events (CI).

Prevention Goals

  • Secondary Prevention: LDL-C goal 100-129mg/dl: drug treatment not indicated for 3 months, ≥ 130mg/dl: drug treatment.
  • Primary Prevention:
    • High Risk (> 20%): LDL goal < 130mg/dl, drug treatment if ≥ 160mg/dl after 3 months.
    • Moderate Risk (10-20%): LDL goal < 160mg/dl, drug treatment if 160-189mg/dl after 6 months, ≥ 190mg/dl: assess drug treatment.
    • Low Risk (< 10%): LDL-C goal < 190mg/dl, drug treatment is exceptional (near 10% risk, LDL > 190mg/dl, other cardiovascular risk factors).

Hypolipidemic Drug Choices

Statins are the most recommended drugs, but resins and fibrates can also be used.

  • Primary Prevention: pravastatin, atorvastatin, gemfibrozil, lovastatin. Use drugs if diet control is not possible.
  • Secondary Prevention: simvastatin (first choice), gemfibrozil, pravastatin.

Other Pharmacological Preventive Interventions

Primary Prevention:

Antiplatelet therapy with low-dose ASA (if high risk at 10 years, men > 50 and women > 65, and in the prevention of coronary disease). Assess patient preferences. In hypertensive patients with good blood pressure control, ASA can be used; otherwise, other antiplatelet drugs may be considered.

Secondary Prevention:

  • Antiplatelet therapy: ASA (75-150mg/dl) indefinitely, clopidogrel (75mg/day) for allergy or intolerance.
  • Beta-blockers: Atenolol (for patients who have suffered AMI).
  • ACEI: (for patients who have suffered AMI, with or without left ventricular dysfunction) and ARB if intolerance.